What Psychotherapists Say

The therapist expressing her/his own point of view

Literally hundreds of studies have shown the importance of the therapeutic alliance to outcome. If psychotherapy is modeled on having a conversation – an activity which is ubiquitous among humans – then what may be the elements from the point of view of the therapist which will contribute to a developing trust on the part of the patient? First is listening and encouraging elaboration just described. But how to handle the patient’s efforts to engage the therapist, directly or indirectly? Psychoanalytic theory of technique decades back emphasized the importance of leaving a blank screen, so to say, for the patient to write on, and to project their innermost fantasies, fears and desires. The reason that was given for this recommendation was that the therapist should not be pulled into revealing much about her/himself, because this would obscure the patient’s own point of view. Many writers in the past forty years have challenged this technical recommendation (see Renik: The Perils of Neutrality, 1996; Hoffman: The Patient as Interpreter of the Analyst’s Experience, 1983). Recent research by the Analytic Process Scales Group, most of whom are also Directors of the Psychoanalytic Research Consortium, has shown that when the analyst expresses his or her subjectivity, the patient actually makes a better, freer contribution to the therapeutic work in the next session (click on our 2017 article included at the bottom of the home page). Sometimes, this means that a therapist confronts the patient more directly or urgently with his/her particular intervention. It can also involve the therapist presenting him/herself in a straightforward way, or expressing him/herself in a way that acknowledges his/her subjective point of view. It stands to reason that the patient will feel more comfortable and secure if (s)he experiences the therapist as someone whom (s)he can relate to, and whose point of view feels compatible. [Click here to see examples of the analyst expressing his own point of view early in the analysis of Annie]

Clarification

Patients know what their upsetting feelings are when they come for help generally, but they don’t generally understand the full origins of their feelings. Feelings of shame and guilt are painful, and people want to avoid experiencing such feelings, so they may have difficulty keeping aspects of their situations in mind. Consequently, the therapist’s effort to understand elements contributing to their unhappiness by clarifying what the patient appears to be experiencing may often be the patient’s first experience of the therapist’s ability to understand them. This can often also help the patient develop trust that the therapist understands them and has something important to add. [Click here for a definition and example of clarification. Click here for illustrations in Annie’s case.]

Interpretation

Clarification and interpretation differ in the degree to which the patient is presumably already aware of the relationship between the elements described by the therapist. [click here for further definition and description]. Clarification and interpretation can contribute to the patient’s sense of being understood and helped, or if the point made is too unwelcome, may lead to a negative reaction. If indeed the patient is initially unaware of the interpreted connection, the therapist’s tact and timing may help in avoiding overly strong negative reactions. One aspect to be considered by the therapist is the state of the therapeutic alliance at that time. The state of the alliance clearly affects whether the patient is likely to examine constructively the proffered interpretation.

Interestingly, one immediate response to an interpretation by the patient that has proved to be an indicator that the interpretation is, in fact, correct is the response, “I never thought of that.”

 [Click here for examples of Annie’s reactions to her therapist’s interpretations]. 

The single most under-emphasized aspect of understanding a patient is the importance of understanding the patient’s feelings, including those that the patient may not be aware of (see Elliott, 2018?; Greenberg ????). Inquiring about or acknowledging the patient’s feelings will often open up the conversation in directions the patient may find relieving, or distressing. If in doubt about the patient’s feelings, better to express an inquiry or offer a tentative thought, rather than being definitive. In fact, for most patients a more respectful style is to be preferred anyway. A tentative interpretation (even in the form of a question) of a feeling about which the patient is unaware can develop trust that the therapist understands aspects of themselves that they had not fully appreciated, and can provide a stimulus for patients to think more about their feelings generally and how they relate to one another..

An important issue is what is interpreted from the patient’s current life outside of the therapy, from the past, or from reactions within the therapy situation. No general principle can be claimed for the choice, although there are fine studies dating back decades showing that linking those three situations often is therapeutically effective (see Malan, 1976, for example).

Support

Patients who come to see us are suffering. Most also feel a sense of failure and being unable successfully to deal with their problems.  Accompanying feelings include guilt and shame. Consequently the first priority may not be clarifying or interpreting, but rather supportive remarks to ease the patient’s distress. Such remarks can only be based upon the therapist’s own empathic response. Being open to your own feelings in response to the patient can make offerings of support feel more timely and appropriate. [Click here for our definition and description of support, and click here, here, and here for examples from the case of Annie].

Discussing issues regarding self-esteem

For some patients more than others, and perhaps especially for patients like Annie for whom psychotherapy is a novel experience, difficulties with self-esteem become a prominent part of the conversation that develops. In order to understand why a patient seems to have a low (or even an exaggerated or inflated) opinion of him/herself, the therapist attempts to understand how the patient sees himself more generally and across a variety of different relationships and other situations. Self-esteem and the variety of feelings associated with its highs and lows tend to be related to both activities in which the patient pursues important desires and achieves a sense of accomplishment (or helpless frustration), as well as significant interactions in which the patient experiences feeling understood. Encouraging the patient to elaborate on how he/she sees himself in these contexts, and especially in the context of the relationship with the therapist, can highlight fears, needs, and injustices he/she is anticipating, as he/she regulates his/her sense of self. To understand all that affects the patient’s self-esteem, the therapist must be mindful of carefully exploring, clarifying, and interpreting feelings of triumph and abject failure, more or less urgent needs for recognition from others to feel right in him/herself, positive and negative experiences with others who might be seen as confident, capable, and helpful or else pathetically deficient and disappointing, and experiences in which there is a comforting or frightening feeling of similarity between his/her view of him/herself and his/her view of others. All of these experiences and more can affect the patient’s self-esteem, and thereby contribute to a variety of other emotional difficulties as well. In addition to discussions about more recent incidents challenging a patient’s self-esteem, understanding the antecedents to the patient’s sense of him/herself and past experiences by which he/she regulates self-esteem, the therapist can also gradually and more effectively intervene. For this reason, self-esteem is often considered of central importance.

Discussing aggressive feelings

We highlight discussing aggression with patients not because angry and aggressive feelings are more important than other kinds of painful emotions, and not because we believe intolerable conflict does not occur in the arena of love and sexuality, but rather because there is an understandable tendency in most human interaction to avoid thinking about rage and hostility. This is especially true when it pertains to a therapist with his/her patient, given that each cares about the other deeply, and given the possibility that patient and therapist may therefore unconsciously collude in order to avoid the discomfort associated with a potentially hostile. In other words, often patients and therapists can feel guilty, shameful, or even not-quite-themselves in discussing particularly intense or unpredictable anger, and this might lead both to avoid thinking about the subject altogether. Of course, angry and aggressive feelings are an important part of mental life. They are necessary in order to compete against others for something of emotional value, to make oneself seen or heard when it seems one has been rejected, criticized, or dismissed, or to respond to a perceived injury or injustice towards oneself or one’s significant others. Anger is usually an approach-related feeling that motivates the patient to get closer to another person, at the least in fantasy, in order to respond with aggression. Yet it thereby also commonly forms one component of internal conflicts that therapist and patient attempt to address. Indeed, for any relationship and for any society to function, there must be some check on hostile feelings that could become dangerous to others and/or self-destructive. The therapist’s support, encouragement of exploration, clarifications, and interpretations in discussing a patient’s aggressive feelings require tact and mindfulness of this delicate balance. At times, complicated interactions with the therapist him/herself may devolve into an angry exchange, in which the patient projects his/her own anger or guilt on the therapist, senses the therapist’s actual anger or guilt, and/or reacts accordingly. Just as when the patient describes angry feelings about others outside the consultation room, these can become important opportunities to understand where the patient’s angry feelings come from, how he/she tends to manage them, and what might be at stake in continuing to feel this way or changing his/her efforts to manage these feelings. Click here for an example from the PRC Manual of the therapist addressing a patient’s angry feelings, and click here to read about Annie’s unique exploration of her angry feelings. 

Addressing conflict

Often, patients arrive to treatment complaining of intolerable feelings of some sort. With further discussion and clarification, it sometimes turns out that these feelings are intolerable because they are felt in opposition with other important feelings. This opposition between feeling states is often termed internal conflict, which has been the subject of much theorization by psychoanalysts for years. Thus, patients often describe various degrees and versions of feeling stuck between activating, or approach-related feelings (e.g. anger, yearnings for closeness, grief) on the one hand, and inhibitory, or withdrawal-related feelings (e.g. anxiety, guilt, shame) on the other. Part of what makes this so difficult for the patient is that it makes no sense to him/her to feel both as extremely as he/she does, and it feels as though they are caught between the impulse to approach and the impulse to withdraw. Doing both seems impossible, and yet it also seems like the only way out of a conundrum and still feel oneself in the process. In many instances, the trouble is not only or even primarily that each kind of feeling is particularly intense in and of itself, but rather that the patient is caught in a confusingly incoherent mixture of the two that leaves him/her to feel unlike him/herself or make a sacrifice in which he/she cannot emotionally survive. In order to remedy the situation, patients often turn to a variety of psychological and behavioral maneuvers that allow them to either resolve the disparity through a compromise between the two, and/or become less aware of one or the other side of the conflict and hang onto a coherent sense of self. In this way, the concept of conflict is fundamentally linked with that of these protective mental maneuvers, which we call defenses (see just below). Sometimes, the therapist may clarify an internal conflict of which the patient is already aware, but has not yet linked to other kinds of situations or relationships. Other times, the therapist may highlight the more hidden side of a conflict, interpreting a conflict of which the patient is more or less unaware. Tact and good timing become important, lest the therapist mystify the patient by describing intolerably opposed feelings that he/she may not be ready to consider for a number of understandable, but highly contextualized reasons. Click here for a description of addressing defenses from the PRC Manual, and click here for an example from the case of Annie, in which the analyst interprets her conflicted feelings. 

Addressing defenses

The problems patients experience, which bring them to a clinician for help, very frequently involve painful feelings, such as anxiety or grief or guilt. Eventually, a clinician comes to appreciate patterns in how a patient manages these painful feelings in the context of his/her life and protects him/herself from them, sometimes at some emotional cost. Thus, typically they also complain of aspects of their lives that are not going well, as a result of how, on some level, they feel they must protect themselves from these painful feelings and the conflict between them. These protective maneuvers often affect intimate relationships, work difficulties, or failures to achieve career goals. Harder to identify, but also often defensive compromises at another level of complexity, are the underlying character problems that lead to the more apparent difficulties of which they complain. To address these difficulties requires tact and good timing. Yet often, if timed correctly, the patient can also experience relief from such interventions. By better understanding how one protects him/herself from painful feelings, one can sometimes become more curious about and make freer choices related to such feelings. The PRC manual example (click here) is from later in a treatment, while Annie’s therapist addresses defenses beneficially quite early in their work together (click here) {the instance when she insists that she must show respect to her parents, and the doctor points out how she does not want to criticize them, which then puts her more at ease, and causes her to elaborate further on her critical feelings toward them.} 

Addressing transference

Decades ago, therapists were cautioned not to attempt to make remarks early addressing the patient’s reaction to the therapist. Then along came  Per Høglend and colleagues, who studied talking with more troubled patients about difficulties they were having in the therapy itself. They found that conversing about difficulties in the relationship with the therapist (for example, in patients distrusting the analyst), illuminated patients’ difficulties in their lives, and thereby led to more successful treatments (2008). The conclusion is that making an interpretation that includes the patient’s reaction to the analyst (a transference interpretation, since it involves feelings presumed to be transferred from earlier relationships in the patient’s life, onto the therapist) may be beneficial even early in treatment. [Click here for description and example from our manual. Click here for example by Annie’s analyst]. In addition, careful attention by the therapist to his/her own feelings as he/she listens to the patient can also help guide tactful and timely interpretations of patients’ feelings towards the therapist.