Therapy has been trending.
From athletes to school systems to social media it’s hard to go anywhere without seeing some mention of mental health.
And while awareness of mental health may be a good thing, we do run the risk of diluting what’s meant by therapy, let alone great therapy, of turning something profoundly transformative into something topical and mass-produced. There are what we might call therapy mills (some with dubious practices around privacy), there’s outdoor therapy and yes (perhaps it was inevitable) text therapy.
As more people seek treatment, helping therapists’ revenues, it’s an apt time to ask: What should a great or even competent therapist provide?
‘Lives of quiet desperation’
The famous Thoreau quote about “lives of quiet desperation” could well describe many of those seeking treatment.
They come for a way out of a predicament—a divorce, a death, a deep dissatisfaction. Yet the irony is that therapy does not give them that, at least not strictly speaking.[1]Medications purportedly do and that is a significant part of what makes them so problematic.
“The work,” as it’s sometimes called, is less about eliminating problems (even though some of them may be removed) than about the therapist and the patient coming together to understand the patient.
This is a collaborative process—often the most deeply collaborative one that has had.
Simply put, therapy itself is a relationship. The patient is coming to another person for help, and this a relational act.
Beyond this fact, a patient’s foray into therapy could be her last true effort to effect change. How then should a great therapist handle this sacred endeavor?
First things first
Good therapy starts of course with listening. Great therapy involves listening on a still deeper level, taking in what’s beyond and underneath the words the patient speaks.
A therapist must practice with a profound level of sensitivity but also tolerance. Tolerance not only for what a patient reports but what she projects, and also what she keeps hidden, defended.
Just as importantly the therapist must have done his own work. This, as Freud knew, will have revealed the therapist’s own sadism and destructive impulses. These can be worked through in the therapist’s own treatment, but they can also get re-activated in the treatment.
So listening in the therapeutic session involves not just hearing the patient but continually observing one’s own inner world and motivations so that any communication with the patient is conscious rather than impulsive.[2]Non-damaging spontaneity, also known as “play,” may still occur but effective use of this is born out of years of training, of coming to know a great range of one’s impulses and … Continue reading
What else?
It is vital that the therapist refrain from a narcissistic urge to cure.
As therapists we don’t fix patients as much as we guide them to access their full selves, including those parts considered loathsome that were split off and rendered unconscious long ago. Once this new access is gained, the self is tolerated the patient and so therefore are others.
The patient makes her own conscious choices.[3]These choices may differ from what we would do if put in their position but an essential ethic of therapy is a full tolerance of this distinction between them and us. This is personal liberation.
Another essential element of treatment involves setting a frame. Patients often come to us with instability: their childhood, their relationships, their sense of self.
Showing up consistently and on time, setting a fee and ending on time help set boundaries. These are there not merely in the interest of the therapist. They provide the patient with a sense of relational reliability.
They also provide a conduit for further exploration.
What’s being communicated when the patient breaks the frame by showing up late or not at all? What unverbalized impulses and feelings might be driving that? What gets evoked when the therapist ends the session, or goes on vacation, or charges a fee for the session?
More fundamentally: What are the patient’s feelings about simply coming to therapy? And what even really is this unusual relationship?
This is all very rich terrain, an integral part of the deep relational work that can occur within psychotherapy.
Final thoughts
It’s easy to underestimate the sensitivity of patients. Much like the aspects of the frame just mentioned, what the therapist says and does, even the seemingly routine, can carry great meaning for the patient.
The therapist must be highly sensitive to this. He must be trusting of himself, and trustworthy, modeling a lived experience that conveys empathy for the gravitas of the undertaking of therapy and, when appropriate, an authentic playfulness that provides hope for a happy life to be attained.
Despite therapy’s popular ascent, great therapy is hardly an easy or common task.
Notes, etc.
| ↑1 | Medications purportedly do and that is a significant part of what makes them so problematic. |
|---|---|
| ↑2 | Non-damaging spontaneity, also known as “play,” may still occur but effective use of this is born out of years of training, of coming to know a great range of one’s impulses and what truly motivates them, of having lived an examined life. Done properly this training results in a freeing of technique rather than a restricting of it. |
| ↑3 | These choices may differ from what we would do if put in their position but an essential ethic of therapy is a full tolerance of this distinction between them and us. |