How I Think Therapy Works (Most of the Time)


Diane was 25, a new mom in a lonely struggle to survive an undiagnosed illness that left her emaciated and near death. One day, holding her baby in her car seat, she made the exhausting trek up the steps to her apartment. That’s when her body gave out. She began to collapse, nearly losing her grip on her daughter’s car seat. She had not dropped her daughter, but the idea of her baby tumbling down the concrete steps terrified her and filled her with the nagging shame that so often accompanies traumatic experiences.


Thirty years later, Diane found herself in my office in Houston. She was a soon to be empty-nester in her 50’s when I first met her. A valuable member of her community, Diane was the sort of person people came to when they needed someone to go above and beyond. She was talented, energetic and seemed endlessly willing to help. She also suffered from anxiety about a wide variety of subjects ranging from the everyday tasks she had to complete, to the welfare of her adult children, to whether she was a good person. Beneath her apparent good will, she harbored resentment toward the people who made so many demands of her, followed by intense guilt for feeling resentful. She came to me after she had felt overcome by panic and paralyzed as she prepared to do some public speaking for a community event (something she did often and very well).

She shared the story of her collapse on the steps one day, as we were exploring one of her memories using EMDR. As we reviewed a separate but related memory, she had become aware that she was clenching her right hand, a sensation that upon reflection, felt very familiar. As she noticed this sensation, she recalled the memory of her collapse and realized that she had been clenching her hand ever since that day.

This story has stuck with me for many reasons. One of them may be that it illustrates something common to most of the problems that bring people to therapy. We all spend a great deal of our lives (more than we’d like to believe) living automatically and in ways that lead us to suffer. Another word for automatic in this context is unconscious. By default, we respond to life with patterns of actions, thoughts and feelings that we don’t consciously choose.

Sometimes this is adaptive. If we had to consciously think about our every action we’d be pretty overwhelmed, in fact we’d be absolutely paralyzed. Just spend a few minutes intently focused on the process of walking. It won’t take long before you notice the constant minute adjustments your body makes to keep you in balance, taking steps that are neither too long nor too short and adjusting your gait to produce the pace you choose. If this were consciously controlled, walking would be nearly impossible.

However, there are times when what comes automatically (or unconsciously) causes more problems than it solves. It’s at times like these that consciousness becomes our friend. Despite its limitations, consciousness has the benefit of allowing for reflection, sustained attention to a problem and the ability to choose. If a golfer’s automatic way of swinging a club is causing her problems, she might see a coach who will take her through the painstaking process of becoming more conscious of her movements and how to create the sorts of movements that will lead to a better stroke. Through this process she will take an action that is automatic and unchosen-- the result of years of conditioning and the quirks of her body composition-- and turn it into a process she has, to a greater degree, chosen.

I think something similar happens in good therapy. Most people come to therapy because they feel stuck. Whether they feel stuck in a way of feeling and thinking or stuck in a way of acting, the root cause is the same. If you’re seeking out therapy you’re probably feeling stuck in a certain way of moving through the world that contributes to suffering and you’ve probably felt unable to change it despite your best efforts. All therapy focuses on getting you unstuck in one way or another. The kind of therapy I practice focuses on insight and relationship as the primary means of getting you unstuck. To explain this better, we’ll need to first explore how we get stuck in the first place.

How We Get Stuck

Let me say at the outset that I know I’m taking on a big question. There are certainly more ways of getting stuck than I can imagine or enumerate in a blog post. But perhaps we can start with some ways many eventual therapy clients get stuck. Sometimes we get stuck when:

WE ARE TORN ABOUT THE SOLUTION

If you study therapy, it won’t be very long until you get familiar with the word ambivalence. Feeling two opposing feelings or entertaining contradictory thoughts about a question or decision is a very difficult and very common condition. Many of us have had the experience of making a big decision and feeling unable to make a final choice. We can spend seemingly endless hours going back and forth between different ways of approaching each possible course of action. These moments are hard and can be temporarily paralyzing. What can be even more paralyzing is when our ambivalence is unconscious.

If we return to the example of Diane and the clenched fist, we can see her way of being stuck as a result of ambivalence. On the one hand, Diane was a woman in desperate need of rest and self-care, both in the throes of her illness and later in life when she began working with me. The impulse toward self-preservation is not easily ignored and it finds a way of announcing itself if it is ignored for too long. On the other hand, she was compelled by the overwhelming desire and moral imperative to never let go and to care for and protect those who needed her. In many ways, these competing impulses and values, which remained largely unconscious and automatic, were tearing her apart and leaving her feeling very stuck. However, as they became more conscious through the process of therapy, she was able to reflect on the virtues and pitfalls of both impulses and begin to craft a creative path forward that took both ways of living into account.

WE CAN’T (OR WON’T) REFLECT ON THE PROBLEM

If reflection and consciousness are such useful tools in solving a problem, it may be worthwhile to think about what stops people from using them. Here are some common reasons I’ve run into. Get ready for some bullet points:

  • Reflecting on some things feels scary or shameful. Sometimes our automatic ways of living, feeling and thinking don’t fit our conscious values or may lead to unknown and frightening territory. We have an extra incentive to remain unaware when we think awareness will make us feel bad.
  • It’s hard to reflect when you’re just surviving. We are often at our least reflective and most automatic when we are just surviving. If your life is in danger you don’t often reflect on the many facets of the decision at hand, you act automatically. Many of our most fixed ways of acting are born as way for us to survive early hardship. We can find ourselves, later in life, still just surviving despite the relative safety of our current circumstances. If we’re feeling under threat, we often feel we don’t have the luxury of reflection.
    Reflection is a skill not everyone was taught. We learn the skill of reflection in relationships in which someone has taken a keen interest in understanding what makes us tick, shares their understanding with us and is curious about how we understand ourselves. Ideally, that someone is a parent, setting us up for similar relationships throughout our lives. Unfortunately, not all parents provide those conditions. Fortunately, relationships later in life can still help us learn those skills.
  • Avoiding reflection is some people’s default way of getting by. Grow up in a situation where empathy is rare and safety is hard to come by and you may develop an automatic tendency to avoid. People with this tendency have learned that difficult times simply swallow them up. They imagine that reflection will only make the situation worse. Faced with these conditions, they find that their best path to some relief is to numb, distract, get busy or withdraw.
    You’re just one person and you need other perspectives. Even the most reflective and introspective people have blind spots. These blind spots often hide possible solutions to our problems. While families and close friend can often provide the perspective we need to see our problems more clearly, sometimes they can share our blind spots. Sometimes it helps to get an outside perspective.
  • You’re in a rush to DO something. We live in a culture of doers and we tend to think of problems in pragmatic terms. If we’re in survival mode or for some other reason feel a strong urge to rid ourselves of a problem RIGHT NOW, that tendency toward doing something can be even stronger. Unfortunately, our impulse toward action can keep us from reflecting on a problem and leave us repeating the same patterns.
  • You’re living with neurological conditions or differences that limit or eliminate the ability to reflect. People with limited mental capacity, certain brain injuries, dementia or autism may find it is very difficult or impossible to engage in the sort of reflection that I’ve been describing. While these people can certainly benefit from a caring and empathic relationship. They are often best served by therapies geared toward their particular set of limitations and may struggle in insight oriented therapies.


Turning our attention again to the case of Diane, we can see the many obstacles that stood in the way of reflection. Diane found herself stuck in survival mode. She was filled with shame and fear as she thought about the memory we explored and had learned getting to work as her primary way of dealing with these difficult feelings. All of these obstacles made it difficult to make the link between her harried pace in the present and the trauma of her past.

THE IMPULSE TO DO WHAT’S AUTOMATIC IS OVERPOWERING

Sometimes we can be aware of our automatic tendencies and still struggle to keep them from controlling our lives. We can be fully aware of our tendency to lash out an anger and its relationship to our difficult upbringing and still find the impulse to lash out irresistible in the moment. We might know that our urge to wash our hands is irrational and the product of some non-conscious mess up, but we may still find it nearly impossible to withstand the anxiety we face if we don’t just wash our hands.

Diane, even after making many important insights into the origins of her automatic tendencies struggled to manage the overwhelming urge to do what she had always done. With her, and many others, it takes time to gain increasing awareness in the moment when we need it and to gain the skills that allow us to reliably choose a response we like better. Sometimes in these cases we find the greatest peace by learning to accept this part of ourselves and build a better life anyway.

Some Thoughts on What Helps

I’ve already mentioned that insight and relationship are two keys to helping people who feel stuck. If you read many therapist profiles you’ll find that many of them emphasize creating a “safe” or “empathic” environment. I share a similar emphasis. It may be worth explaining why.

I’ll start with a personal example. As a psychologist in training I had the opportunity to have my work as a therapist and psychological evaluator supervised. At any given time I was required to meet with between 2 and 5 separate seasoned clinicians each week who would discuss my cases with me and help me to improve as a therapist. Although this process was different from therapy in some key ways, it also bore a certain resemblance. In supervision we devoted ourselves to noticing and understanding my automatic reactions. Often alternative courses of action were proposed. As the supervisee I had to struggle with the anxieties and difficult feelings that go along with taking a close and sometimes critical look at myself and I had to decide how much to trust my supervisor to take part in that process. My supervisors varied in their level of experience, approach to supervision, approach to therapy and approach to life. Looking back, it seems clear to me that most of those differences didn’t matter much. I grew the most in supervision when I clicked with my supervisor and when I felt safe.

One supervisor stood out in that regard. Despite being different in some key ways, he and I shared a natural rapport from the beginning of our work together. He was not the most seasoned supervisor I ever worked with and he did not claim to have the answers when it came to therapy. But he was genuinely interested in understanding how I thought and felt about doing therapy in helping me find a way to develop as a psychologist. In that environment I became less concerned about whether I was a good therapist or a bad therapist. Instead I became curious about who I was as a therapist and what made me tick. In that environment, I was able to explore my approach to therapy at a depth that would not have been possible otherwise and get unstuck from some ruts I had developed in my work.

In a similar way, good therapeutic rapport alleviates many of the biggest obstacles to reflection and change in therapy. We can face things that might otherwise scare us or make us ashamed when we know we are in an environment devoted to understanding rather than judging. We can try new ways of living and responding to our suffering when we have a safety net and a place to talk through our mess ups. If someone is really curious about us, they are bound to see things we just can’t see and we can consider those observations more seriously when we trust the source. Furthermore, when someone starts to understand us, they begin to know the best ways to help us get to know ourselves.

The best psychologist is not necessarily the one who can offer the cleverest coping techniques. He or she is not necessarily the one recommended by the internet or your friend. He or she is the psychologist that clicks with you and that gives you a chance of building a safe space where your defenses slowly lose their usefulness. I believe that it is under those conditions that you overcome your own obstacles to understanding yourself and start to make truly meaningful change.