Moments of Change

An important question from Louise:

“I have a question about how to know if my psychiatrist is right for me. He appears very knowledgeable and generous, but he is never warm and never says anything positive. After a year of weekly psychodynamic psychotherapy, I feel like I am a worthless person (I did not feel like this when I started). I feel traumatized by each session and spend the following days crying. I really believe he is trying to help and I feel guilty about going to someone else.”

Answering this question is a little scary for me. Who am I to criticize another therapist knowing that I am far from perfect, myself. Then there is the danger of not knowing Louise or her therapy from direct observation, but only from her brief description. So I’ll talk in general, recognizing that the reality may be different, and that ultimately Louise will have to make her own decisions.

Let’s look at how so many well meaning and ethical therapists, by withholding feeling and feedback, end up frustrating their patients and often, in my view, reducing the effectiveness of their work by trying to follow the principle of “neutrality.”

In the dawning days of talk therapy, Freud’s idea was that gratification would kill desire. As a good 19th century scientist, he equated all the “drives” with thirst, hunger and sex. He pictured a hydraulic system where pressure builds up till we satisfy the need, then there is a release and the pressure of desire drops.

Applied to therapy, the model predicts that if the therapist withholds emotion, information, support, etc., it will increase desire and motivate the patient to reveal more and make more progress. Unfortunately the model is too simple.

Before we take a look at the complexity, we must consider the effect of shame. New therapists are taught about “neutrality.” They learn that it is not good to reveal too much or show too much feeling. Maybe the explanation is actually more rounded and complex but, when you are just beginning, what comes through is “Thou shalt not…” Students identify with the simple and powerful prohibition, even more because it is unnatural and hard to do. A senior colleague who retired and had to refer his patients, confided that  the hardest part was that his colleagues would learn the shameful truth that he had been friendly and giving. In my view, this was one of his best characteristics. You can see that neutrality has cast a huge and dark shadow on the profession of psychotherapy.

So what about the real complexity?  First, as I said in the post on Attachment to Your Therapist, the most powerful source of energy and drive to move therapy along is the need for connection. We want to feel closeness. We want to be special. We want to share a common understanding. These needs are powerful and inborn, coming from our evolutionary roots as social beings. They make us willing to reveal things to ourselves and our therapist that are hard to admit and carry painful feelings, just so we can be understood and feel close. What creates a tipping point is hope. When we have hope of getting close, we desire it more and work harder for it. When we lose hope, we give up and turn elsewhere. This is why too much deprivation turns our hope and desire off, while just enough energizes our efforts to get close.

For each individual, the tipping point between hope and discouragement is different. Perhaps Louise was traumatized in her early attachment experiences. Perhaps this is why a high degree of withholding from her therapist is actually re-traumatizing. Whatever the reason, when we lose hope of connection we lose our enthusiasm and energy. We become defensive or depressed. We lose our willingness to take risks and try new things. Think of the difference between children who feel safe and secure, versus ones who are frightened. The ones who are not afraid are full of energy. They jump and point and talk about what they see. Kids who are not feeling safe are low keyed, vigilant and quiet, or perhaps desperately active in a stereotyped and non-creative way. This is not the atmosphere you want in your therapy.

Is there a phenomenon of satiety? Does giving turn off motivation? If a therapist is more passionate and genuine, can this turn-off of desire? Moments of closeness bring a peak of good feeling, then a something of a letdown, but soon the need for closeness again asserts itself and we find ourselves driven to seek some new way to connect. There is, however, one important dynamic that can look like gratification leading to loss of motivation.

As mentioned in the post on Attachment to the Therapist, a second motivation that drives therapy is a childhood agenda of changing the therapist, motivating him or her to solve unfinished business from childhood. As therapy progresses, these “young” feelings and desires become more insistent, more explicit, and as a result, more obviously childlike. Freud learned very early in his work that there is always shame in expressing these wishes verbally and a preference for acting them out silently. This is what often makes patients want things rather than understanding. We want extra time, or special attention to our material needs. Medication is perfect for this, especially the benzodiazepines that make you feel warm and fuzzy and taken care of. These do not lead to growth. What helps people grow is the hard process of becoming aware of the long ago pain and going through the feelings in a context of safety and understanding.

Again, there is a tipping point that is unique for every individual. Too much encouragement of acting out of wishes as opposed to insisting on conscious awareness of them is sending a bad message to the patient. That therapist is, in effect, implying that he or she can fix the unfinished business from the past, which is not true. Extra time or medication can never repair the pain of an early experience of deprivation. Marvin J. Ashton said, “You can never get enough of the things you don’t need, because the things you don’t need can never satisfy.” This really applies to the things that substitute for love. So when this happens, the therapist is sacrificing real hope of growth in favor of short-term good feeling. A devil’s pact is formed where both patient and therapist are taking the easy way out, and progress stops.  This can look like Freud’s hydraulic model. It can seem as if too much gratification caused a loss of motivation. What really happened was that both patient and therapist have given up.

But there is a tipping pint. Zero willingness to give may be so discouraging that it stops progress. Early in my career, a young woman whose father had died during childhood came to session and confessed that she had forgotten to bring money for the bus fare home. Being young and trying to do the right thing, I tried to explore the possible underlying wish to have me take care of her as a father would have. In the end, she had another way home and I didn’t lend her the small amount of money she needed.  In the following weeks, the therapy lost its momentum and eventually she stopped coming. I should just have given her the bus fare.

Decisions of when and how much to be helpful are not really so hard. Parents make them every day. When a child asks to have his shoes tied even when he knows how, there are times, like after a big day, when you should tie them for him and other times when it is right to say, “You can do it.”

So, Louise, I don’t think it is good for your therapy that you feel so bad after each session. What I would strongly recommend is that you make this issue the central primary subject of your therapy. Talk about it, and see if the two of you can resolve it. He should be very willing to look at the matter, and, I hope, willing to look critically at his role in it. It is possible, even likely, that tackling it out in the open will actually help you learn about yourself and perhaps open his eyes to things about himself.

A reader submitted this wonderfull comment:

Anyway, I’ve been in therapy, on and off, for about 12 years. Dealing with “neurosis” I guess – trust issues, attachment issues, etc. Anyway, I’d love to see something about attachment, and more specifically, attachment to your therapist. I have a very strong attachment to my therapist and have come to see him as a father. I struggle with this on a constant basis, because he’s not my father, he is my therapist and is one hell of an ethical one at that and would never ever stretch the boundaries (which of course are some of the things that I wish for…). Anyway, anything on those issues, would be incredibly useful. And yes, I do talk to him about it as well, but having a more detached view of it would be really helpful for me.

The consulting room is an emotional candy store. It is a place where you are the only person in the world and it’s all about you. The therapist has no other mission but to understand you just as you are and help you heal and grow. It is as close as you can come in adult life to the one-way relationship of childhood where you receive but don’t have to give back. In the case of psychotherapy, you do give back, but in a different currency, that allows for all the feeling of being taken care of. One therapist said, “you buy my time, but the rest is free!”

So it is no wonder that patients get attached to their therapist. Is that bad? No. It would only be bad if it caused harm. Anything this powerful can cause harm, but not if it is handled right as it seems to be in our reader’s comment.  I think it is the main source of energy to drive the therapy forward. Here’s how it works.

When patients come to therapy, there are really two patients. There is the adult patient who listens dutifully while the therapist drones on on about how understanding will help you make changes and it is hard work and it is really up to the patient to want to change. Meanwhile there is a little kid who knows how things really work. The child in us all knows what he or she needs and is not interested in dull substitutes. She (or he) came in with a list of unfinished business from long ago, all the issues that she was not able to solve at the time. When they couldn’t be solved, what did she do? She saved them up for a time when conditions would be different and now it looks like conditions may just be right.

Why couldn’t she solve the problems back then? Children know that when there are problems, the ones who have the real power to solve them are the parents (or other caregivers). The child’s job is to influence the parent so the parent will take care of the problem. Let’s say a parent is depressed and totally self-preoccupied. The child needs love and attention and can’t get it. The child will invent a whole list of strategies:  Give the parent love, be unworthy so the parent will feel less bad, perform brilliantly so the parent will wake up and take notice. What they all have in common is the goal of changing the parent.

You guessed it, the child going into the psychotherapy consulting room is planning to use some of those very same strategies to get the therapist to change because that is how things get better.

Of course the therapist has another idea. The therapist thinks that the solution is for the patient (both child and adult) to accept the fact that there wasn’t enough love from the parent and to go through all the painful feelings of rage, hurt and sadness that the child knows are best avoided.

Let me digress for a moment. The power of this situation is hard to underestimate, and with so much power there are opportunities for bad outcomes. Fortunately our reader’s therapist has good boundaries and his patient is talking about what she is feeling. The key question about boundaries is whether the therapist has made or implied promises that he or she won’t be able to keep. This one rule covers essentially all the bad things that therapists can do. When that does happen, whether blatant or subtle, it is an indication that the therapist’s needs are taking precedence over the patient’s, and that is not therapeutic.

So the two go through their dance. The therapist’s humanness and real presence give the child hope and bring out young wishes and needs. On the other hand when they do come out, it is painful because they are not fulfilled. Hopefully the therapist understands this pain and, by being an empathic witness, helps it to heal. On the other hand, as the process goes on, the wishes are more and more obviously young ones. It is characteristic of childhood wishes that they don’t have limits. As they intensify, they become less realistic, less adult and more insistent. This may be embarrassing, even cause for feelings of shame, but it is exactly what has to happen. As the wishes become more intense, the frustration of the therapist responding only with understanding becomes more sharply painful. The anger, hurt and sadness are very real.

By putting off fulfillment to the future, the child was able to maintain hope and avoid the painful feelings. That is not so bad, since there was no way the feelings could be attended to back then. What the therapy has done is to force those long-avoided feelings out of hiding. Finally the situation from long ago has been recreated in the present and the feelings are palpably real. It is when feelings are actually present in the room that they can heal (see more on catharsis in the regular part of my website).

This part of the therapy process doesn’t feel like therapy at all. There is nothing as-if about it. It feels like anger and pain and sadness about life. For better or worse, that is when the most important therapeutic work gets done. Eventually the feelings heal and a more grown-up, philosophical view takes over (not the pseudo-adult one we started with, but a real acceptance). As this happens, it becomes more clear that some of the wishes actually can be fulfilled, but not by the therapist. In time, others in the patient’s outside world become more interesting than the therapist and now we are in the termination phase.

Of course, what all therapies seek is change, but change what? Most of the popular traditions focus the one way people change, but, by my count, there are seven. For both patient and therapist, knowing how each is distinct can sharpen our focus and help us see our own change processes unfold.

Neurophysiologists believe that change really occurs in the connections between neurons. They are also beginning to map out how different functions of the mind have different locations and work somewhat differently. Just as computers store information in different places such as your hard drive, a memory stick, or the volatile memory that was holding your essay when the power went out, your brain does, too.  So it is not a surprise that change processes are not all the same.

1.  The first is the transformation that happens when we tell someone about our painful feelings. It is so common that we may take this near-miraculous process for granted. People who have suffered major trauma don’t. They know that it can be the most challenging kind of change to undergo because you have to face the painful feeling and experience it’s full depth before the transformation can happen. Freud called this change catharsis, and I personally don’t think there is a better term, even though most of the time it is far from dramatic. This kind of change happens in every therapy session, not to mention every day of our lives.

2.  Stop running from your feelings. Avoidance becomes automatic. Most of the time we are barely aware that we do it. Humans are very good at avoiding the very thing we need most:  To go through feelings.  We need a therapist to hold up a mirror revealing how we have been avoiding. For example staying too busy can be one way. Rationalizing our misery is another. Even feelings like anger can cover up sadness we dread even more. The mind has any number of tricks but once we know about them, we can begin to choose to face our feelings and heal.

3. The third task is gaining knowledge of ourselves and how we manage to keep our misery intact. Changing our mind happens instantly when we are exposed to new facts, so changing our understanding and awareness should be the easiest to achieve. Unfortunately our tricks for avoidance may get in the way. As we let go of avoidance and heal painful feelings, new knowledge will begin to come into view.

4.  Changing dysfunctional values and beliefs is one of the hardest tasks. We all have values, attitudes, ideals and prohibitions. We are proud of our values, and defend them to the death. To a large extent, they form our unique identity. They also serve to help us resist temptation, which is why they are partially independent from the self and particularly hard to change. Unfortunately, we can also have values that are contradictory and even downright dysfunctional. For example, you might feel that you have to do everything perfectly. If so, there is another part of your mind that feels you should enjoy the fruits of life as much as others with lower standards. But you never arrive at perfection so you are not allowed to enjoy anything. The two values, perfection and enjoyment, are incompatible and no matter which way you go, there is a loud complaint. People who have suffered early trauma know that the experience causes internalization of negative attitudes about the self.  You have to fight to accept that you are as good as anyone else. These are two of many situations where values need to change. This kind of change requires energy, focus, hard work and time. Cognitive-behavioral therapy (CBT) specializes in bringing these “core values” to light and changing them.

5. The fifth task is to restart arrested development. In a way, humans are like plant spores. When conditions are not good, our development can be put “on hold.” More often than generally realized, we may carry some very “young” characteristics and reactions. For example caretakers sometimes give to others what they are still wishing for themselves. Fortunately, all that may be required for development to resume is a feeling of safety and connection. When this happens, as it often does in therapy, the path of psychological development can be picked up where it was left off regardless of chronological age. Just as in childhood, growth and development happen when we try out new behaviors and go through the feelings of anxiety, vulnerability and strangeness that accompany them.

6. Changing behavior patterns: As behaviors are repeated, they become habits and take on a life of their own. Even though their bad consequences are clear, it becomes automatic or nearly so to follow them again and again. These behavior patterns may be the primary impediments to change. For example, moving directly from impulse to action will consistently avoid the step of feeling. Similarly, acting habitually like a second class citizen can make a negative attitude toward the self appear to be an established fact. Behavior patterns can also include not doing something. A person who never says “thank you,” may be avoiding acknowledgement of the need for others. Lives that have been damaged by addictions and other compulsive behaviors can only begin to be repaired when the behavior is stopped.

7. Reevaluate secret wishes and dreams. This change process is the core of psychoanalysis. By age five, as I see it, we have enough grasp of time to solve the problems of the present by dreaming of a better future. Sometimes these dreams are experienced as shameful and unacceptable. They are not given up but buried, waiting for eventual fulfillment. Blocked by fear and guilt, out of conscious awareness, they wait and search for opportunity. Intensive therapy is calculated to call out these wishes and plans, which usually involve the therapist. Their coming to light is often stormy and difficult, but the end result is a chance to reevaluate goals that date back to a much earlier age, a chance to seek fulfillment of those aspects that are consistent with adult life and to let go of those that are not. This is classic “neurosis.” How do you know if you have neurosis? See my post “OMG Do I Have Neurosis?” below.

At any time in therapy, the work will be focused on one or two, maybe three of these processes or tasks. As you become more aware of just which ones you are addressing, you will be more attuned to the best tools to use and how your efforts should be directed. Furthermore, you will be able to monitor your progress by observing moments of change as they happen.

In order to help with your observation, we have developed the Scarsdale Psychotherapy Self-Test (SPST). Click the link at the right and rate the sixteen items that reflect how well your therapy is working. It is a tool for thinking about and evaluating therapies of all kinds. In addition you will be able to enter your ratings and receive a confidential report of how your therapy compares with others from our database. These seven tasks are the basis of the book I am working on, so I will value your feedback and ideas. Please use the comment link below.

Why are feelings sometimes oversized? Do you remember how big your house looked when your were a small child? Many years later when you go back to visit, you are surprised to see how modest it really was. Of course you remembered it the way it seemed at the time. Feelings are similar. The younger we are, the bigger feelings feel. When two-year-olds have a meltdown, it is real. At the time, it feels as if the world is coming apart.

Small children don’t have perspective on emotions. Now is forever and big is gigantic. When seemingly minor adult situations trigger giant feelings it is usually because they take us back to a much earlier age, perhaps when we were struggling with problems too big to master. Those feelings and problems were buried and stored away to heal some day.  When you go through the experience with someone you trust, you begin to see through the eyes of the other. Feelings get right-sized as you see from a more adult perspective. (See the main website, Psytx.com for a more extensive explanation of how emotions heal)

Dear Reader–  PsyTx.com has a new feature, a blog. That’s not all.  I am doing the blog to help with a new book on psychotherapy for both professional and general readers. The book, called, (you guessed it) Moments of Change, at least for now, will tell a lot about how therapy works and how to make it work better.

To be sure that the book responds to the things people really want to know, I would like you to give me your questions.  I will try to answer them in upcoming posts.  Not every question is guaranteed an answer, and I will be looking for themes and topics to address in a more general way.

Disclaimer:  The ideas presented here are only suggestions and may not be right for your individual situation.  They are not a substitute for the advice of a professional who knows you, so please do consult with a licensed professional of your choice regarding the application of any information obtained from this site.