the goal of therapy is for the person to be more whole and live their life more fully and freely what we have especially in like phd clinical psychology programs is we have like the next generation of clinical practitioners being trained by people who aren't clinicians themselves and aren't experts in what they're teaching and you know this forms the students ideas about what psychotherapy is and they just have no clue what really good therapy looks like it's not in their repertoire of experience they've never encountered it what i would consider and i think you would consider
meaningful you know real psychotherapy is less and less common therapy is more and more common in society but really meaningful therapy it's like fewer and fewer of the people who are providing therapy are providing that kind of therapy so here's how here's how i think of therapy and practice it and teach it the things that bring people to psychotherapy to psychological treatment are usually depression or anxiety and those are the psychological equivalents of fever right they're non-specific psychological responses to an enormous range of underlying things and maybe people come to therapy because they don't because
they feel bad you know well how do we feel bad what do we feel when we feel bad we feel anxious or depressed right so almost every patient walks through the door it comes in with anxiety or depression or some mix of it and that that's the starting point that's like the the surface you know the a surface manifestation of something that's wrong now we got to get into the business of what's going on psychologically that's giving rise to it there's there's really a very sharp dividing line when we talk about therapy we have go
down two different branches and one branch is we know the problem up front we have the methods up front we know what outcome we're trying to get up front and now we're gonna you know follow this instruction manual in this kind of algorithmic way right so that's one approach to what we call therapy the second approach to therapy is it's not aimed at teaching you the patient something it's aimed at finding out something discovering something about you with you it has to be a lived experience right in the therapy relationship it's not an intellectual experience
it's an emotional experience we track people's affect we track their emotions right and a lot of the work is helping the person to articulate their emotional life to put words to it in ways that they never have before and that includes you know emotional experience that they may not have words for initially they may not have paid attention to right or been aware of initially as soon as we get in the business of doing that what we find out by virtue of being human is humans have a wealth of things we have vast riches in
our ability to steer around and avoid things that are emotionally distressing in in plain english i just say you know avoidances in you know in theoretical terms we'd be talking about defense and resistance but avoidance is a perfectly fine word and you know if the person is building a wall it's the work is less about getting to the other side of the wall we get over the wall or through the wall or under the wall the work is about why is there so much wall building going on just right here just right now how is
this wall constructed why is it constructed why is it being constructed in this particular place so that the person becomes aware not just of the things that they're avoiding but of the process the third thing we do is people's lives and and internal experience is just filled with recurring themes we tend to repeat certain patterns certain themes in our lives right um they they play out again and again and we listen for the themes right so you know sometimes the person comes in and they have a pretty good idea of a repetitive theme that's causing
them trouble other times the patient has no idea they tell you what they tell you they tell you their stories but the therapist can hear the theme so we're listening for recurring themes because that's going to become the focus of the work right so we really need to understand the person systemically you know in order to have a context for understanding a particular problem that they're looking for help with we're not looking at the person at this momentary slice in time there's an understanding that what we're seeing right now at this moment in time is
you know part of an ongoing trajectory that's brought him there right so it's pretty hard to understand you know where you are let alone where you're going to go if you don't understand how you got here i'm interested in the past to the extent that it helps shed light on and understand the present right and the goal is actually not to dwell in the past the goal is actually to free the help free the person you know from from the bonds of past experience so they don't have to keep doing things in the same you
know painful and self-defeating ways the goal is to free the person from being you know controlled by the past experience right and there's an understanding that this is part of a developmental trajectory right who we are is really forged in the context of our our relationships our attachment relationships you know beginning with our first relationships you know usually with mother or father siblings right our psychological being right is is formed and shaped in the context of relationships and it plays out in the context of relationships show me somebody who comes to therapy with you know
a psychological problem of any kind right and i'll show you someone who's having some kind of difficulty in relationships either the problem is playing playing out in their relationships or it's getting in the way of having any relationships right you can't disconnect you can't disconnect the problem from the relational context in which it occurs so we're very very interested in the person's interpersonal connections and they necessarily and unavoidably bring their lenses for making sense of themselves and other people in relationships they bring those lenses into therapy it's not good or bad it just is it's
how we're constructed as people and in one way or another we begin to play out those patterns in some version with this new person in this new relationship and the thing that makes therapy therapy and just and not just you know a new person to repeat the same painful and self-self-defeating patterns with is that we don't just repeat the same patterns we pay attention to them as they're unfolding we recognize them we are we put words around them right so the relationship between the patient and the therapist is a window into what goes on in
the person's relationships in general we become very interested in the person's fantasy life their daydreams you know their their night dreams absolutely anything in the realm of the life of the mind is fair game and is open for exploration and discussion which is very very different from an agenda-driven therapy where the therapist assumes upfront a priori i know what's important to this person i know where this work should go like i already have the answers now i just need to you know sort of you know upload them into the patient's mind right it's a very
different approach and the most inter important determinant of therapy outcome is what people now call the therapeutic alliance but that actually wasn't the original term the original term was the working alliance which puts the focus on the work and it's a very very special and unusual kind of relationship right it's not feeling good about each other the way you might feel good about your friends or you know or your romantic partner it's a very very special right the quality of a very very special kind of relationship this happens all the time i uh one of
the things i do with my my students my my trainees is we look at videotapes of you know of therapy sessions and beginning students they always you know i mean they're very self-conscious understandably and they always ask the same question they're scrutinizing the therapist if if it's themselves they're scrutinizing themselves usually very self-critically and they want to know did i do the right thing the therapist say the right thing or the wrong thing and that right they're looking at the therapist and part of what i'm trying to teach them is you're looking at the wrong
person in the video if you want to know whether the therapist did said what the therapist did was helpful or unhelpful look at the patient look at the response of the patient so a master therapist has a feedback loop in real time right they're in the room they're interacting with the patient they're doing whatever they do and what they're actually gauging is how does the patient respond to it right so the patient is basically teaching us how to do therapy for that specific person it's not all sweetness and light right i mean we're going to
see the person's anger their disdain their contempt their hate right this is all the all of these things are part of being human so the test of a working alliance isn't the therapist and the patient always feel good about each other the test of a working alliance is can the patient be furious with the therapist right can they hate them and come back to talk about it and explore it and think about it together that's the test i i have never once presented this to an audience a lay audience or a professional audience of the
therapist of any orientation and where people didn't say yeah that makes sense that's what i want i want to be understood in that way when you tell people this is what we're trying to do and you say it in plain english like people you know just immediately and intuitively grasp like yeah that makes sense like how else would you do it you
