What’s Therapy Like?

This summer Netflix released the show Gypsy, which portrays a caring yet highly unethical therapist. It reminded me of how few honest, informative depictions of therapy there are available to the general public, (I think the best is In Treatment), so I thought it would be useful to give a description of how I approach therapy.

Perhaps the most fundamental lesson you learn in training to be a therapist is that there are 3 factors that contribute by far the most to successful therapy, and none of them is the technique. While technique is important, it pales in comparison to the 3 core factors: 1) The relationship between patient and therapist; 2) The patient’s expectations of improvement; and 3) the patient’s personality (we can combine #2 and #3 into the patient’s “motivation.” For a run-down of some of the more popular theoretical techniques out there, have a look at my colleague Juan’s recent blog post.

When someone walks into my office, I start from the goal of creating a relationship that helps them work for change. The process will not be identical with every person, but to create the proper relationship means building rapport, seeing the world as they see it, understanding how my strengths can be brought to bear, and what limitations may be a hindrance. If I can build an authentic connection, we have a wide-ranging discussion on the presenting problem, current stressors, important relationships, and family history. I typically find that the patient gives me all the information we need to get started by the end of the first session so that I can offer a tentative roadmap to provide encouragement for the work ahead.

The tools I use to conceptualize the treatment include REBT, Adlerian Therapy, Existentialism, and Ancient Greek philosophy. How much we work with any tool will depend on my patient’s presenting problem, goals, and temperament, but I would say that 9 times out of 10 we will work pretty consistently with Adlerian therapy and REBT quite a lot.

I take it upon myself to use my ability to break down convoluted theories, provide a wide-ranging knowledge base, and an anti-dogmatic stance to problem solving and treatment planning, and most importantly, to make sure the basic diagnosis and treatment plan makes sense and sounds promising to my patient. If I can’t explain how and why I’m pursuing a topic, suggesting a treatment plan, or assigning homework then I am not doing my job.

Many therapists prefer to be significantly more geared to listening and reassuring, and provide little if any direction. I certainly value providing empathy, but am more directive than the average therapist. I find that I can use my natural inquisitiveness and ability to frame questions to spur conversations rather than to simply coax or force my patients to do all the talking. My patients still talk probably 75-85% of the time in a session, but I find that sometimes psychoeducation and philosophical exploration require me to do a bit of the heavy lifting. (No therapist should really be telling you what to do. Sorry!). Basically, I am constantly asking myself “Where is this person?”; “What do they need?”; “Where are they stuck?”; “What is getting in the way of getting where they want to go?” But of course, it isn’t usually very useful to just bluntly ask such questions.

So let me give you a bit of an idea how Adlerian therapy works to help me answer these. (I will return to a discussion of REBT in another post). In Adlerian therapy, the fundamental stance is that all humans strive toward goals, and so all interpretations, choices, and behaviors are goal oriented. By the time we are ready to start school, we have unconsciously developed a life goal and learned a life style to achieve it. These are the major components of our personality, and deeply motivate how and to what extent we pursue social connection, overcome our perceived inferiorities, and maximize our perceived strengths. Of course, 6 year-olds aren’t very good at this sort of thing, so inevitably the goal and plan break down and people develop neuroses (sometimes worse) as the ever more complicated world pushes back on us.

So, I engage with you to help you uncover who you fundamentally are, how you frame the world, what you see as threats and aides, and really tease out the beliefs you have about what is valuable in you and the world. Then, based on your presenting concerns, we work to understand what beliefs and goals are helping and hurting you, and begin the process of reconsidering them.

Everyone who walks in my door is a fundamentally free, but goal-driven person hungry for meaning and social connection. They use lifestyles that have become less and less helpful in achieving meaning and connection, and are grappling with just how much capacity they have for making changes. This last point brings me back to what most therapists would agree is the sine qua non of successful therapy: a motivated patient. A motivated patient has the courage to dig in and understand what is holding them back, and has or is willing to develop the tenacity to work through inevitable ups and downs. We may not know immediately what getting “better” will look like beyond lowering symptoms such as anxiety and depression, but working together with respect and trust, we can get there.