How Does Change Occur in Psychotherapy?
I think it will be helpful to me and to prospective and beginning clients to try to provide an overview of how I think about psychotherapy and discuss a common question: ‘How does change occur in psychotherapy?’
I first want to identify who I am talking to or about. When a person lands in my office and depicts chronic and distressing personal problems, I take it for granted that this de facto announces a psychologically damaging background that has produced enduring psychological injuries. The obverse of the foregoing is that people who have not been psychologically damaged in the course of growing up do not have enduring, chronic, seemingly intractable personal problems’”they have situation-specific and transitory personal problems. People in the latter category rarely wind up in my office. Psychological injuries incurred during the course of living, especially incurred due to maltreatment during the course of growing up, should not be confused with impersonal medical conditions. For example, fear of ridicule, exposure, humiliation, etc. should not be called social anxiety in the spirit of recognizing and naming an impersonal ‘psychiatric disorder.’ And so on. Obfuscation doesn’t actually help anyone. I recognize that not everyone that depicts long term personal problems has been damaged during the course of growing up. Life outside the family beyond the growing up years can be very injurious. But usually the core problem is injuries sustained within the family during the course of growing up. Such injuries do not magically disappear after age 21. Rather, they are brought into adult life and undermine it.
It is not uncommon for a person entering therapy who complains of chronic difficulties in living to report a positive family history. It mostly turns out that such people have never had a long, candid, thoughtful discussion about their family history with a person who is prepared to listen attentively and take note of and be responsive to hints or much more than hints concerning maltreatment (maltreatment is an omnibus term; the idea is to explicate specific noxious conditions and practices on a case by case basis). During the course of growing up in a family virtually everything that occurs seems unremarkable at the time because no broader evaluative frame of reference exists. Later in life the old situation may look dramatically different, but some people manage to not look back evaluatively and simultaneously avoid prolonged and candid discussion about their personal family history. Not fully recognizing something is greatly aided by avoiding candid discussion on the matter with an attentive and well-informed interlocutor.
I am often asked what my specialty is, in the spirit of inquiring of a physician about his specialty. Thirty five years of American psychiatry pushing the idea that people can be sorted on the basis of specific clinical conditions makes such a question appear both natural and eminently reasonable. After all, isn’t a drug addict a drug addict, a person with eating disorder a person with eating disorder, etc.? The real question to ask is not what is the single most conspicuous deviation from an abstract conception of normalcy but rather what is actually the matter? There may well be a highly conspicuous problem, but people who know the individual in question well realize that the most conspicuous problem is hardly the end of the matter, e.g., drug addicts have far more problems than wanting to use their favorite drug. The most conspicuous problem is not the problem; it can more usefully be thought of as a sign pointing to the presence of psychological injuries and impairments that are not visible in the same sense that seeking drugs and being intoxicated or high are visible. Drug addiction is the result of a person’s desperate efforts to cope with/adapt to his psychological problems. It isn’t the problem itself any more than thirst and weakness is the problem in a case of diabetes. I’m just making reference to drug addiction to make a general point. We could just as well be talking about depression, etc.
The actual problem that must be addressed if there is going to be hope of enduring improvement concerns precisely those psychological traits and capacities that were developmentally derailed due to noxious circumstances that allow other people to avoid chronic, seemingly intractable personal problems during the course of living. What most stands out to me in this regard is positive self-feeling, the capacity to self-comfort and self-soothe (by drawing on inner resources and important personal relationships), and realistic trust in other people (which makes sociability, connection, friendship, and intimacy possible and desirable). This is a short list, but impairment in any item on this list has massive inner and social/interpersonal consequences. It is probably obvious that the three items hang together in the sense of resulting from being brought up in a secure, nurturing, etc. family environment. I submit that virtually all enduring personal problems can be attributed to impairments on this list (or the consequences of impairments on this list).
What is to be done? To put this another way, what actually might be salutary and enduring (I mention enduring because the goal of therapy is to have an enduring positive effect’”it’s not much help if your good feeling after a session is like your good feeling after a massage, namely very transitory). As I see it, trying to enduringly help a person with chronic personal problems by adopting an approach that aims at altering how the person thinks is essentially useless. You can’t think your way to resolving your chronic personal problems and no one can provide you with thoughts, information, instructions, etc. that will help you much. The reason is that you acquired your negative self-feelings and so on via direct, gripping, personal experience, and nothing outside of direct, impactful, personal experience will or can have much effect on what you acquired via direct personal experience. Your mother repeatedly beat you growing up because you were ‘bad.’ Your father left you and your mother and began another family to which he was loving and devoted while practicing indifference to you. Gripping stuff. It created a deep and abiding psychological legacy that globally affects how you feel and how you live. You can’t be talked or instructed or educated out of it. Thus the question what can be done that might actually be salutary?
What occurs in therapy obviously is a lot of talking, but putting it that way obscures the more important and potentially salutary features of what is occurring: social interaction, relating, and relationship development. It is crucial to be able to discuss what goes on in therapy in a manner that emphasizes direct personal experience rather than in a manner that puts the spotlight on cognition and related matters (instruction, education’¦). Think of a couple on a date. There is a good deal of talking but emphasizing talking has the effect of downplaying other features, for example, each person has an experience of how interested and attentive the other is being. In this case one might say talking is only one of the ways that each person is conveying their degree of interest and attention to the other person. A transcript of what was said on the date would probably not reveal that much about how each person felt about the other’s level of interest and attentiveness. The point is that conversing with another person is never devoid of personal experience and some conversations are experienced as enormously important and impactful (I’m sorry but I’ve found someone else). Talking may not even be a part of the most impactful things that have happened to you (e.g.,dad leaves without any explanation and you do not see him again for a long time).
I have been trying to prepare the ground for saying that it is the experience of the relationship with the therapist rather than his insights, cogent observations, advice, instructions, etc. that actually make a difference over time. Advice, instructions, suggestions, etc. make little or no impact on what I think is really the matter, namely negative self-feeling, underdeveloped ability to self-comfort and self-soothe, and basic mistrust and fear of other people and of being vulnerable. This is why advice, suggestions, etc. have such little effect over time and why the recipients of advice, instructions, etc. fail to follow them for very long.
It is one thing to tell a person he is worthy of respect, quite another to consistently treat a person respectfully over time. In the first case the enduring impact will probably be nil; in the second case the impact over time may be significant, even if’”this is important’”no one ever mentions respect. Respect is just a word. Telling someone he is worthy of respect is just an utterance. Being treated with respect over time is a direct personal experience. The only way you can show a person that you respect him is to treat him respectfully over time. Treating a person respectfully includes what you say but also your overall manner. Language and paralanguage operate together. This is obvious and not really the point. The point is that what is psychologically impactful is direct personal experience. If the aim is to alter what is already well-established about a person (negative self-feelings, etc.), then the emphasis must be on what is impactful experientially.
Since therapists are only too happy to provide positive regard and say nice things, it might seem that altering the troika would be a simple, quick, and straightforward matter. Experience in living as well as experience as a therapist reveals that this is anything but the case. Two considerations stand out: 1. formative developmental experiences organize the mind such that later encounters with the world tend to be perceived and reacted to in a manner that confirms the already existent organization. Thus core personality traits are powerfully self-preserving and self-perpetuating over time. When core personality traits are self-harmful, we can speak of a self-perpetuating vicious circle; 2. Direct personal experience is automatically ordered on a gradient of importance and relevance. So, for example, if the server in a restaurant or the check out person in a supermarket is pleasant to you, it has little (deep, enduring’¦) impact on how you perceive and feel about self and others. By contrast, how people who are really important to you treat you is highly salient to you and may have some impact on how you perceive and feel about yourself and other people. The therapist you see may act in a positive manner towards you and say nice things to you, but how important is that to you? How emotionally connected to and invested in the therapist are you? If the therapist is not emotionally important to you, then how he treats you and what he says has low salience, significance, and impact.
It is possible that the lived/felt experience of your relationship with your therapist over time can have a beneficial impact on the troika if the therapist becomes a very important person to you. Why the therapist? Why not your spouse? You and your spouse love each other and she is obviously a very important person to you, so why has the relationship failed to substantially alter your troika for the better? The reason is that your personal issues and hers create conflicts, tensions, etc. that act more to sustain than resolve personal issues. It’s not your spouse’s job to offer a healing relationship. In intimate relationships we hope to connect and feel satisfied and fulfilled. We don’t form an intimate relationship primarily to be of service, meanwhile keeping personal needs on the back burner and looking to get them satisfied somewhere else. I’ve just described the job of a therapist. It’s not realistic to hope your spouse will be your therapist, as just depicted. It’s precisely because a therapist is not seeking to get the kind of needs that are activated in an intimate relationship fulfilled in the therapy relationship that he can dedicate himself to offering what might serve as a healing relationship. A therapist can become very invested in a client, but not in the way one is invested in a spouse. This is critical, because the therapist must maintain focus on cultivating and maintaining what might be a healing relationship for the client.
If it is granted that self-feelings and so on are sequelae of lived/felt experience in critically important relationships, then it follows that therapy can only be a corrective emotional relationship if the therapist becomes very emotionally important’”and of course if the therapist is actually able to offer a potentially healing relationship. I don’t think old injuries can be negated or undone or emotionally neutralized in therapy. I have heard many clients lament that the past cannot be undone, and I agree. Many clients follow up with the comment that there is no use talking about what has occurred in their lives because nothing can be done about it. This seems to be a huge dilemma because there is no doubt that old psychological injuries are exerting a detrimental influence in the present and presumably will continue to do so unless something occurs to mitigate their influence. From my present vantage point I would say that although nothing can negate or undo the past, it is possible that a relationship in the present can modify core features of a person’s psychic organization (self-feelings, etc.). That indeed is the aim of psychotherapy.
What the client mostly talks about is present distress and adversity and past adversity and its consequences. That’s only natural because that’s what’s on the client’s mind and there is really no where else outside of therapy for the client to speak about highly sensitive matters freely, candidly, confidentially and at length to an interested and receptive interlocutor (I want to comment that strict confidentiality is hard-to-impossible to access outside of psychotherapy). But speaking about past injuries and present adversity does not change either one. I am reminded here of a remark by David Shapiro to the effect that the therapy task is not to help the client with his problems but rather to help the client (in the sense of ameliorating deep personal issues so that the client has fewer intractable problems). How? By being able to offer the kind of relationship that over time affects deep psychic organizational issues (bad self-feelings, etc.). There is nothing enduringly useful the therapist can do but work on developing a relationship that has the effect of altering psychic organization.Talking with the client about his past adversities and their consequences and his present stressors and challenges is the way a relationship is developed. It’s not sage remarks or advice per se that brings about alterations in ‘deep structure;’ it’s the lived/felt experience of the relationship that does it. The relationship with the therapist, if the relationship becomes a certain kind of relationship and important enough and of sufficient duration, exerts its own influence on the client’s psychic organization. You might say alterations occur automatically (think of developing a deep friendship with someone; loyalty develops automatically).
Developing an important relationship is obviously a two-way street (a co-creation). If you think of relationships that are really important to you (actual relationships, not people you admire, that you think are important, etc.), it is clear that both parties became engaged in getting involved with each other at a personal level. It doesn’t happen automatically. In therapy, it doesn’t happen just by showing up and sitting through the session. The client has a lot of difficult and painful personal material to potentially talk about (confide, reveal’¦). The relationship develops by way of the client endeavoring to talk about difficult personal material and endeavoring not to talk about it (because painful, and because life experience has shown that vulnerability is to be avoided), and by way of the therapist’s linguistic and paralinguistic reactions and offerings on a moment by moment and session by session basis. The skill on the therapist’s side lies in being responsive to what the client is saying and doing moment by moment and session by session in a manner that inspires trust rather than mistrust, openness rather than guardedness, relief at being heard and understood rather than shame, feeling that misalignments, disagreements, conflicts, etc. can be worked out via candid discussion as opposed to festering, and so on. This is skill acquired through experience. As with all high-level skills, most of what the skilled person is able to do is based on a feel for the task or activity and cannot be exhaustively spelled out (because a necessary component of a complex skill is responding skillfully to alterations in situation and context; if an activity or job requires the ability to react skillfully to alterations in situation and context, it is relatively immune to advances in computer programming and robotics. For example, spellcheck doesn’t realize you are deliberately misspelling a word to illustrate that spellcheck does not understand the meaning of the text it is checking.). For the therapist, the big picture of what he is trying to do may be conceptually clear (be accepting, respectful, etc.), but interacting is moment by moment and just what to do in response to this impasse, conflict, misunderstanding, silence, change of subject, etc. must always be a seat-of-the-pants, impromptu decision based on a holistic feel for what is occurring (for those interested in research and ‘evidence supported’ forms of treatment, there is no way to finesse, meaning standardize, what the therapist says in the moment and still retain verisimilitude. This means the therapist can be doing therapy or doing what is necessary for controlled research but not both. It is oxymoronic even to refer to well-controlled psychotherapy research as psychotherapy research.).
I should probably say explicitly that, as in all interpersonal interactions, everything counts. For example, a client told me that his former therapist was always somewhat late, never apologized, and never offered more time to make up for being late. Everything counts. A client may ask a personal question. How to handle it? Everything counts.
I suggested above that loyalty (and protectiveness, and more’¦) develops automatically in a deep friendship. There is no need to explicitly talk about it and indeed talking about it may even be counterproductive. The point is that important interpersonal and intrapsychic things happen via emotional connection and relationship with significant others. Each important relationship is unique, e.g., you might have two close friends but they are not psychologically and emotionally interchangeable. You are somewhat different with each person’”the relational you and the psycho-emotional you is somewhat different with each person. The therapist-client relationship cannot easily be characterized because it exists only in virtue of the psychotherapy profession. It is not friendship, it is not confessional, the therapist obviously is not offering to take on the duties and responsibilities of parenthood, the therapist (in private practice) declines to work without remuneration, etc. I see it as a sort of fiduciary relationship’”the therapist is committed to acting in a manner that fosters the client’s psychic repair and well-being. There are other professional relationships with fiduciary obligations, but only the psychotherapist is tasked with developing a relationship with the client that aims at fostering emotional-psychological repair.
The psychotherapist is involved with the client as a professional with fiduciary obligations. This may sound rather impersonal, but when two people meet face to face frequently genuine feelings develop, even if the reason for meeting is quite separate from the personal realm (e.g., a financial advisor and his client). This occurs inevitably and automatically in human interactions. In the case of psychotherapy of course the reason for meeting is to discuss deeply personal matters and, inevitably, also how things are going in therapy both in terms of the client’s wish to feel better and what has developed or failed to develop between therapist and client. A physician who knows a patient for a long time presumably comes to have some feeling about the person that goes beyond his job and his fiduciary responsibility. But in the usual case these days meetings are short and perfunctory from the perspective of two people getting to know each other as people. This is hardly the case in psychotherapy. Usually the therapist does not explicitly reveal much content about his personal life, but it is the nature of prolonged face to face social interactions that much about the interactant as a person is revealed’”is there to see and take in’”anyway (manner, asides, off the cuff comments, facial and bodily reactions’¦all linguistic and paralinguistic behavior is informative, actually. This is why old school psychoanalysts sat out of sight behind the patient and said little).
It is the therapist’s professional task to get to know the client very well at a deep personal level, and in the course of doing this the therapist naturally and inevitably develops personal feelings for and about the client. If the one happens, then the other happens. In other words, the therapist starts off with a professional task and professional interest, but if meetings are frequent and occur over a long period of time, the therapist naturally develops feelings about the client. And vice versa. If the relationship proceeds and deepens over time, then because the therapist remains committed to his fiduciary obligation, the relationship may positively affect the client’s psychic organization. This cannot and will not happen if the therapist does not become an important person to the client, but an inevitable parallel development is that the therapist develops extra’“professional role feelings for and about the client. Two people who meet for a long time about very deep and personal matters naturally develop a lot of feeling for and about each other. One person must, somewhat paradoxically, stay in role if the relationship is going to succeed as a corrective emotional relationship. By in role I mean the therapist must keep in mind at all times why he and the client are meeting. As a loose analogy, a parent cannot (should not, that is) ‘relax’ in the relationship to the extent that she leaves off being the parent, with all that implies.
I emphasize that it is the experience of a certain kind of relationship that may alter psychic organization rather than being offered sage remarks, good advice, insightful observations, in-session instructions on how to think rationally or any other kind of training, instruction, education, or correction. Insightful observations, for example, are just insightful observations. Even if the recipient thinks a good point has been made (‘I can see that I discount and minimize my accomplishments’), there seems to be no path from acknowledging the accuracy of the observation to altering the usual feelings, reactions, convictions, evaluations, etc. You concede the point, but you don’t really feel much different.This is because higher-level mental processes and abilities (i.e., those involved in grasping the point and validity of a comment addressed to you) played little role in creating core self-regarding attitudes and so forth. If you want to win a debate or a scholarship to college, you must draw upon higher-level mental processes and abilities. But how you basically feel about yourself etc. is not going to be altered by argument. Such (stubborn) features of your mental organization are not open to debate (argument). To the extent they are malleable at all, they can be influenced only by direct experience. You can say flattering things to yourself all day while you stare in a mirror, but it’s no use. There must be input from the outside, and it must be important enough to have an impact. Success and accomplishments won’t do the trick (this is sad) because success and accomplishments only address how you have performed in competition. Getting an A, a scholarship, a degree, a good job, etc. is about performance. It won’t erase your mom’s hostility while you were growing up. The only thing that might count is what you pick up about yourself from someone who really knows you and is important to you. This has to be the therapist because consistently trying to influence your psychic organization for the better isn’t anyone else’s job. Indeed, you complain to your therapist about your important relationships (spouse, etc.).
It’s worth reiterating two points from the preceding paragraph: 1. you need input from the outside (other people) to change your inside (psychic organization); you can’t do it by yourself (throw away those self-help books); 2. to the extent that psychic organization is malleable, it depends on mental (meaning psychological and emotional) reactions to what occurs interpersonally; thinking about yourself, how you are, and how you need to change is useless. Obviously this is bad news for people who need to change but who are very uncomfortable being a psychotherapy client. To put this another way, most people who need to change will face a situation in psychotherapy in which they are very uncomfortable and will very much want to flee. And in fact most people who begin psychotherapy do flee quickly. This seems to be a sad fact of life in the industry, although it is something of a forbidden topic among professionals. It’s much harder to be attuned to the client’s wish to be elsewhere than to what the client is saying in the moment. If a client felt comfortable and trusting interpersonally, it is highly unlikely he would wind up in a therapist’s office at all. In other words, if what I identified as really the matter is really the matter, then the client is going to be very challenged participating deeply in therapy and staying the course (how long therapy is likely to be is another uncomfortable topic for therapists’”not so much among themselves but in talking to prospective or actual clients). Most of the clients I see or have seen have previously been with other therapists. Obviously it is quite common for people who have enduring personal problems to give up on the therapist they are seeing and begin anew at a later date’”-since the enduring personal problems endure.
It’s a lot harder to be the client than the therapist. The client is the one who must try to desist from putting the other (the therapist) off in the usual self-protective manner. This is not going to come easily or quickly. The less contact with the therapist, the easier it is to relate in the usual self-protective manner. You see the problem here’”most people can’t afford to come often enough, and the insurance industry has created norms to serve itself. For the purpose of market viability, the psychotherapy industry as a whole has made out that the problem (significant and enduring personal change) is less difficult than it is.
There are two people involved in a therapy relationship. The skill required of the therapist is to use what occurs in the sessions to inculcate a certain kind of relationship’”a relationship that by its nature favorably influences the client’s real problem (the troika and its consequences). But the therapist’s skill (and good intentions) is only half the equation. The client is a real person, not a thing to be skillfully handled and molded. Real people do their best to look out for themselves. The client is distressed (unhappy, etc.) but surviving. People cling to the devil they know (how they usually cope in the world) because deviation from what they know they can survive (business as usual) is a more frightening prospect than remaining the same. Everyone knows the expression doing the same thing over and over again and hoping for a different outcome is insane. That’s a truism. From the perspective of personal reality and actual feelings, doing something dangerous and doomed to end in catastrophe is really insane (i.e., deviating from what you know you can survive). Thus resistance to change (resistance to deviating from how you survive). The client would like to feel better and do better, but he does not want to perish. He knows he won’t perish if he remains the same (he made it this far). He won’t perish if he keeps his dukes up with the therapist as he does with everyone else. The therapist wants him to put his dukes down. I’ve described the therapist-client struggle. The struggle is about letting the therapist be really important so that psychic organization can change for the better. The client doesn’t know that good things will happen if he drops his guard. Life has taught him the opposite. Even if the work together goes well and is productive, it’s necessarily a slow process. A loose analogy’”you grew up deeply prejudiced but you’re trying to change. It’s not that hard to change what you say and to some extent do. What’s hard and takes a good deal of time is changing how you feel and think on the inside. If you really want to change you probably have to live with the people you grew up prejudiced against for some time. Direct experience is what really matters.