It’s the Relationship

Two Chairs

Many, maybe most people believe that therapists “do” something which makes patients feel better because it is hard to believe that it is the relationship between the therapist and the patient which is the healing factor.

If I go to the dentist because I have pain in my mouth and the dentist doesn’t help, I likely will seek help elsewhere, and that seems reasonable. But I look to the dentist to *do* something to make me feel better. The dentist does not usually, at least in acute situations, require of me that I do more than be cooperative and hold my mouth open. But psychotherapy is a different thing altogether. Therapists do not perform procedures upon patients in order to relieve their suffering. We might sometimes wish we could and certainly patients wish we would, but it just isn’t that way.

In any depth psychotherapy, the therapist does not tell the patient how to solve problems. The focus of treatment is exploration of the patient’s psyche and habitual thought patterns. The goal of treatment is increased understanding of the sources of inner conflicts and emotional problems. This understanding is what we call insight. Now insight without action is pretty useless. But the therapist doesn’t say to do this or that but instead might ask how this new understanding might be put into action in the patient’s life.

In order to accomplish this work of therapy, the patient and therapist must have a good working relationship, or therapeutic alliance. The patient needs to feel that the therapist is on her side, so to speak, allied with her in her desire to have a better, happier life. And in turn, the therapist needs from the patient a willingness to do the work of therapy, to put feelings into words, to talk about what she is thinking and feeling. And that includes being willing to talk about feelings of anger, disappointment or frustration about the therapy or therapist.

“For psychotherapy to be effective a close rapport is needed, so close that the doctor cannot shut his eyes to the heights and depths of human suffering. The rapport consists, after all, in a constant comparison and mutual comprehension, in the dialectical confrontation of two opposing psychic realities. If for some reason these mutual impressions do not impinge on each other, the psycho-therapeutic process remains ineffective, and no change is produced. Unless both doctor and patient become a problem to each other, no solution is found.”  C.G. Jung

Most often when I hear people saying that therapy isn’t helping, I am also hearing an expectation that the therapist will tell the person what to do in order to feel better. And  to a very limited degree, we can do some of that — like take a walk or write in a journal or try painting or some other creative outlet when having difficulty between sessions. But on the big things — like whether or not to stay in a marriage or change careers or leave home or any of many many other important life decisions, we cannot tell a patient what to do. We, as human beings ourselves, have enough trouble finding our way through the complexities of our own lives and not only cannot, but really should not presume to be in a position to make decisions for others in their lives. No matter how much the patient may want it. But talking about wanting that, being angry that therapist won’t do it — that is the stuff of therapy. Because it is the relationship with the therapist that facilitates change.

Ultimately we behave with the therapist the way we do with most important people in our lives, with the same kinds of assumptions about the therapist and about ourselves. And we do so unquestioningly. 

It is also true that it is difficult for the therapist to respond to feelings and issues that the patient does not talk about. All rumors to the contrary, we are not mind readers! This underlies the basic therapeutic dictum that the patient should say whatever comes to mind.

Now of course, this is difficult for most of us, conditioned as we are by social norms, by rules we have learned from our parents. Remember Thumper in Bambi:”If you can’t say something nice, don’t say anything at all”? Most of us operate on some version of that in our relationships and avoid saying things to another person that we think might make them uncomfortable or angry with us. But therapy is a place where Thumper’s Rule needs to be suspended. So, if you don’t tell the therapist you don’t feel cared about, there isn’t much the therapist can do to help you with that. Similarly if you are angry with the therapist, have sexual feelings toward him or her, or any of the myriad of other feelings and thoughts about the therapist you might have. It all belongs in therapy. Putting those feelings into words is a key  part of what therapy is about, after all, because that opens the doorway to understanding where they come from and how to deal with them in ways that are helpful rather than destructive in life

Therapeutic Space

In my search for how others have thought about the issue of therapeutic space, I encountered some of the writing of Yi-Fu Tuan, a geographer. Tuan wrote a very interesting little book, Space and Place: The Perspective of Experience in which he muses about how people think about space and place, home and neighborhood. One of his thoughts is that space is what we encounter when are are someplace new and unfamiliar and it becomes place as we learn its features and landmarks. This leads me to contemplate the fact that every time a new patient comes to see me, not only is the patient in a space which is not yet place, but so am I, because, though the physical features of the room are the same from patient to patient, the addition of a new person changes the space. As we begin the process of coming to know each other, we are each creating place, place which contains the other.

And I am pondering who the therapy space is for — the patient or the therapist? Or both? 

Psychotherapy in Darkness

I think often of this powerful quote from Jung on therapy:

“The principle aim of psychotherapy is not to transport one to an impossible state of happiness, but to help (the client) acquire steadfastness and patience in the face of suffering. ” -C.G. Jung

How very different this view of therapy is from what most people seek. Jung understood that suffering is a part of life, that it has meaning and that to live fully is to know that suffering will be a factor in one’s life throughout life. If I look back on my own life, I know that I have learned most from those times which were difficult and often painful, not because I wanted to but because of the choices and consequences i faced at those times. The good times, the times of great happiness are wonderful and I have celebrated and cherished them and look forward to more. But it has been in those dark times when I have had to face myself and look deeply into my life and my actions that I have grown most.

Reflecting on consolations and desolations, joys and sorrows, is a part of many spiritual practices. Matthew Fox wrote in modern terms in Original Blessings about the Via Negativa, the path that takes us into darkness. So much of post-Enlightenment culture has been about the flight from darkness that many of us have lost sight of the meaning and value of darkness. New life begins in the dark. Seeds germinate in the dark.

Therapy which acknowledges and even embraces the dark times, suffering as well as joy, opens the door to that new life and creativity that can come from them.

Millennials and Online Psychotherapy

labyrinth solid white bkgrd

A Tweet about this article caught my eye before the holidays: Millennials and the false allure of online psychotherapy. Just the term “online psychotherapy” can mean anything from Skype or FaceTime sessions to email. Not all therapists are comfortable with or accepting of therapy except when done face to face in the consulting room. So I am used to seeing articles here and there decrying therapy which occurs via telephone or Skype. And that is what I expected to read about in this article. To a degree, that is indeed what I found.

After describing factors that seem to make millennials “the most stressed out group in the country”, there is this brief bit:

With Talkspace, for just $25 per week, clients can purchase “Unlimited Messaging Therapy” that allows them to text with a therapist whenever emotional problems arise. The Web site for the app states, “just like texting with a close friend, you can now message your therapist every day, for an entire week, writing as many times as you want.” Initial sessions for In Your Corner cost as little as $25 dollars for “instant expert support when you need it.” That might include online therapy, written coaching plans and stress-reduction techniques from a meditation instructor.

I had only recently heard of these quick response options from my son, who is just starting out in private practice and considering what he might offer. When he asked my opinion, I asked him if he really wanted to work with anyone on that kind of uncommitted catch as catch can sort of basis, because in my mind, it is not therapy but more like a stop at a first aid station for a band-aid now and again. He tried to make a case for it, thinking maybe some people would want to convert over to more regular scheduled therapy. I told him that when therapy starts with such a haphazard frame and very little commitment, it doesn’t seem likely to change because in accepting it, the therapist is colluding with the patient in his or her belief that a quick fix, an encouraging word as needed is sufficient to actually deal with ongoing issues and problems. 

Years ago I had a copy of the fairy tale “East of the Sun, West of the Moon”. And there was a line in it that seems to fit the therapeutic process — the road is long and hard but when you get to the end, you will find great reward. Therapy isn’t about becoming happy or soothed but is about traveling the road inward and becoming more conscious about oneself and life experience so that a greater freedom of choice becomes a available. It isn’t a pacifier there for instant gratification. No matter how much any of us might like to have something like that.

It is ultimately, no matter the orientation of the therapist, the relationship, which can only develop over time, that heals, that fosters change. And that can’t come in texts or quick emails. And yes, it can occur over time talking with a therapist over Skype or the telephone.

Now to spend some time reflecting on how our children came to expect that “instant expert support when you need it” is the way to go.