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This blog presents a collection of short articles I have written that reflect my thoughts on a broad range of topics relevant to therapy. I hope it will serve as a resource for people wanting to start psychotherapy or for those who are simply interested in the process of psychotherapy. Whether you experience anxiety or depression, or struggle with codependency, or are facing the struggles of addiction and recovery, or are grappling with the effects of early abuse and trauma, you will find articles that speak to these issues. If you are interested in the role of spirituality in the therapeutic process, or wonder about whether the gender of your therapist matters, or feel that being diagnosed is dehumanizing, I have written articles that address these sometimes complex issues as well.

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Sitting With Emotions

We’re often overwhelmed by such feelings as sadness, anger, fear, depression, anxiety and even boredom. In modern society we have an abundance of ways to avoid these unpleasant feelings. Our phones and other devices offer easy escape into games, movies, videos, texts, emails, chats, and digital interactions with friends or strangers. Distraction can play a heavier role than passing a boring or anxious period of time; there are addictive ways of escaping, such as food, alcohol, drugs, gambling, and sex, etc. Even our obsessive thinking can keep us from an awareness of deeper, more difficult emotions that lie underneath our spinning thoughts. The idea of being left alone with ourselves and our thoughts or feelings can even leave us feeling frantic.

People who have suffered from particularly painful events and situations often develop even more profound needs to get away from those memories or experiences. In cases of serious trauma, for example, people may have suffered emotional and/or physical pain that was literally intolerable and unbearable. The experiences may have been so overwhelming, disruptive, and fragmenting that they may have had to psychologically leave themselves to save themselves. Initially this is an adaptive phenomenon, but it can develop into a kind of reflexive habit that continues even when a threat is no longer present – another habit of escaping from unpleasant feelings.

Perhaps one of the most important aspects of psychotherapy is helping people sit with their own feelings and thoughts, whatever they may be. This is helpful not because there is virtue in the experience of suffering, but because it is often the only way to get through to the other side. As Winston Churchill said, if you’re going through hell, keep going. Therapy can serve as a container, a safe and non-judgmental place to make space for yourself. In therapy, you do not have to face these feelings and memories by yourself; therapy provides a sense of safety, and a sense that you are not alone. Your therapist can help you understand that your thoughts and feelings will pass, and that they needn’t be fragmenting and unbearable.

People are often afraid that if they let themselves feel their feelings, or let their thoughts go, they will become out of control. If I start crying I’ll never be able to stop. If I let myself feel all the anger I will hurt someone. If I let myself feel love, or feel gentle or vulnerable, I will be taken advantage of, or hurt. However, when people can let themselves relax and let their feelings be, they generally find that the difficulty of those feelings eventually leaves – not because they are indulged or pushed away, but because feeling states tend to be impermanent. Fighting with them keeps them present, and relaxing into them lets them pass through. Working with a therapist can help you sit with these overwhelming feelings so you can get through to the other side.

Developing the ability to notice and be with your experiences is neither about acting out your feelings, nor is it about repressing your feelings. Instead it is about maintaining an awareness of what you are feeling without having to do anything in response. It is about knowing that given space, feelings will pass.

BuddhaThere is a wisdom to the approach of acceptance which goes back centuries, is outside the tradition of psychotherapy, and often has a spiritual bent. There are a number of techniques to becoming more focused on the present moment and learning how to be with the thoughts and feelings and perceptions that arise. Buddhist meditation, for example, aims at cultivating a calm awareness of whatever is happening; its aim is the development of a clarity of mind that neither grasps nor rejects. Other techniques that many find helpful include

  • Mindfulness meditation
  • Yoga
  • Transcendental meditation
  • Guided meditation
  • Mantra meditation
  • Qi gong
  • Tai chi

A more complete description of these various techniques can be found here at the Mayo Clinic website.

Developing the ability to notice and hold your experience allows you to become conscious and develop a sense of calmness. Of course at some point it is essential that we take action, but when the action is motivated by a frantic need to change things, or an experience of fear that leads us to run away from things, the outcome is most frequently counterproductive. What works best is to act from a grounded and open perspective that allows for a flexible and creative response.

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Psychotherapy and Medication

medication and therapyIf you are suffering with emotional issues and are considering seeing a psychotherapist, you may also wonder about the use of medication. Should you seek therapy alone, try medication alone, or would it be best to try both at the same time? The answer to this question depends on a number of factors including your goal in seeking help, your feelings about the use of medication in general, and the nature of the problems you are struggling to resolve. Even your beliefs about what it means to be human are relevant.

If your goal is to shift your approach to life, understand and change destructive patterns, feel more connected to the world and integrated in yourself, and find a deeper sense of meaning, your first step might be to find a good psychotherapist who can help you rework and resolve the underlying issues that lead to pain and suffering. While feeling better is crucial, and feeling bad may be what brings you to therapy, people are often also motivated by a desire to grow, to become more open, and to feel they are fulfilling their potential. Reducing your pain is critical, but you may want more from your life. In some cases, medication may help the therapy process, but medication alone will not address the basic issues.

If your primary desire is to make your pain and suffering go away as fast as possible, and you have little interest in working on deeper issues, your first step might be to visit a psychopharmacologist. A psychopharmacologist is a psychiatrist who specializes in the use of drugs to treat emotional states and psychiatric disorders. Depending on a host of factors, it is sometimes possible to reduce anxiety or depression and improve other difficult emotional reactions through the use of medication alone. Still, even the best medications are not a silver bullet. For example, research reported in The Journal of the American Medical Association in 2010 found that the effect of antidepressant medication on mild to moderate depression may be minimal when compared to a placebo, although when used to treat very severe depression, the effects of antidepressants over placebo are substantial. Beyond the questions of efficacy, virtually all psychoactive medications have side effects, some of which may be severe and debilitating.

Medication may be useful in helping people feel well enough to begin the process of addressing deeper issues related to overwhelming inner conflict, the effects of serious trauma, and profound depression. For instance, people who feel so overwhelmed by anxiety they can’t even begin to focus on the reasons for their suffering, or so depressed they feel paralyzed and unable to begin to take any action, may not be able to start working productively in psychotherapy until these states begin to shift. Although medications may be helpful here, they are clearly not the essence of psychotherapy. To really address the confusion and pain in life, one needs to clarify and change what leads them to act and to feel the way they do. Some of these factors will be historical, and some will be related to current life circumstances; some may be conscious, and some may be unconscious. Medication may help reduce the overwhelming symptoms that get in the way of doing the work of psychotherapy, but it does not substitute for going through the sometimes difficult struggle of becoming more at ease with who you are, and more of who you want to be.

It is also important to note that a person’s decision about the use of medication can reflect their personal perspectives on spirituality, philosophy, science, and what they believe to be meaningful in life. Do you think of yourself as a bundle of chemical receptors and physiological processes — that people are basically highly complicated machines? Or do you see your feelings and experience as basic to who you are as a whole person, transcending the physical state of your body and its biological processes? Perhaps you see the entire system interacting – chemistry and mind, biology and psychology. The idea that depression is a simple effect of a biochemical imbalance has become very popular in recent years, yet this point of view is far too simplistic and is frequently not supported by the evidence.

In seeking help for emotional problems, it is important to think about just what kind of help you really want, and what you hope to achieve. Think about your world view and what you find meaningful in life. Recognize that inner change is not equivalent to the immediate reduction of emotional pain. If your instinctive approach is for a quick fix, it may be worth thinking about the bigger picture. If you have a reflexive reaction against the use of medication, you may want to consider the possibility that medication may be an aid, though it’s not the solution. Whatever your feelings are, you should expect them to be listened to carefully and respected by whomever you ask for help. There are some situations in which the use of medication is advisable, such as when a person is in imminent danger of doing serious harm to themselves or someone else. Still, those offering help have the responsibility to listen closely to your concerns and to try their best to understand you and take your concerns into account.

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Female Therapist or Male Therapist?

male female therapistsWhen people are looking for a psychotherapist, they often wonder whether to choose a male therapist or a female therapist. For some people, choosing a therapist of the same sex seems the obvious thing to do. Others may simply assume that males work best with male therapists and females work best with female therapists, based on the idea that a therapist of the same sex is most likely to ‘get it.’ On the other hand, you might feel that a psychotherapist of the opposite sex would be the best choice based on your personal history with men or women. People who had abusive or untrustworthy parents of the same sex, or have in general found people of the same sex particularly anxiety-provoking or problematic to deal with, may assume that the best psychotherapist will be of the opposite sex.

In fact, the issue is quite complex, and the best choice for you might even be counter to your assumptions. In choosing a psychotherapist, the most critical factors are feeling safe, and feeling that you can be honest about what you think and feel. Regardless of their gender, you must feel your therapist is nonjudgmental, empathetic, direct, and professional. On this point, research shows that the relationship you develop with your therapist is the most important factor, regardless of the psychologist’s training, gender, theoretical orientation, age, and other factors.

To start with, therapists do not necessarily fit gender stereotypes. A dominant cultural stereotype is that women are more empathetic, understanding, emotional, nurturing, gentle, and intuitive, while men are more direct, intellectual, goal-directed, controlling, and out of touch with their emotions. These stereotypes often don’t hold for men and women in general, and they’re less likely to be true for psychotherapists. Research has shown repeatedly that there tends to be more variation within groups of all men or all women than there is between the two groups.

A therapist of the same sex may have had some experiences in common with you, but there is a risk of over-identification. It’s common to reflexively feel one understands another person’s experience “because we have been through the same thing,” but upon exploration this assumption may be very much off-base. This problem of unchecked assumptions reminds of an experience I had with a patient. I assumed he felt as irritated as I did with a loud banging pipe in my office. In fact, upon exploration, he recalled feeling safer in his grandmother’s house than anywhere else in the world, and his grandmother’s home had banging pipes. Though I assumed the pipe was irritating him, I discovered that he actually found the sound reassuring and cozy. Also, it can be useful for a patient to have to clearly articulate the nature of their experiences to another person because it helps with integration, and helps them feel more grounded in knowing their own story. When therapists and patients assume they understand each other, it may seem less important to articulate feelings.

For people who have issues with the opposite sex but do not find these issues overwhelming, it may be particularly useful to work with a therapist of the opposite sex. Assuming you have a professional therapist who holds clear boundaries, it creates an opportunity to work on these issues as they come up between you and your therapist. In fact, it is possible that having a therapist of the opposite sex could be more helpful and produce insights that a therapist of the same sex couldn’t.

It may be important to consider the gender of a new therapist, but upon reflection, the issue can be complex. In situations where a person has had significant trauma, which may include sexual or physical abuse, a feeling of safety and security is essential and it may be important to choose a therapist who evokes the most trust and security – and this may be a therapist of the opposite sex of the abuser. On the other hand, selecting a therapist whose gender is likely to stir up some of the same feelings you are in therapy to deal with can be helpful. And finally, though it may be tempting to choose a therapist of the same sex out of a sense that they can best understand what it’s like for you, it may also be important not to choose a therapist who seems to automatically understand you, since this could get in the way of thoroughly exploring and articulating subtleties of experience that may be important to address.

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The Failure of Categories

Names have power. People who are sick tend to feel a kind of relief when their illness is named – ah, I have lupus; even though it’s a terrible diagnosis, there is relief in knowing. Having a name for the illness means others know what it is, perhaps how to treat it, and it means it’s “real,” in some way. It’s not uncommon for individuals to go from one doctor to another, to another, to another, in an effort to get a diagnosis for troubling symptoms.

Most psychologists and psychiatrists rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM) to diagnose emotional suffering. The DSM undergoes revision every few years, and those revisions reveal an important flaw in the concept of categorical labeling of emotional suffering. For example, homosexuality was categorized as a mental disorder in the DSM until 1986; political and cultural views clearly have an influence on the DSM categories.

diagnostic categoriesMore importantly, though, experience does not neatly fit into a category. If you tell me that you have been diagnosed with bipolar disorder, that communicates a list of potential criteria – mood swings, cycling, etc., but it does not tell me anything at all about your experience. I often hear therapists or counselors refer to people simply by a DSM category designation: “She’s an Axis II” (borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, etc.), or “He is a cluster B” (dramatic, emotional, or erratic) without any other description of the person as a human being. Perhaps worse, I have heard people refer to themselves that way.

This diagnostic approach to understanding people has profound implications for treatment. Most broadly, it does not involve the therapist in really getting to know you. It interferes with understanding you as a whole person, ignoring the larger context of your life and experience. When someone focuses exclusively on diagnostic criteria – your ‘symptoms’ – you become nothing more than a pathological entity. You are not merely a bundle of symptoms. These diagnostic categories serve the pharmaceutical industry and the insurance industry, not you.

Therapists who take a humanistic approach, on the other hand, try to understand the patient’s reality, rather than trying to force the patient into their own reality. Humanistic therapy is more a process of discovery, in which the patient and therapist seek to understand the person as a whole, and to understand what works and what doesn’t work. No effort is made to necessarily fit you into the ‘norm,’ which can suppress radical and creative points of view; instead, the goal is for you to understand who you are, and to find your own way of being in the world that works well for you.

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Psychotherapy: Clinical Supervision and Training

clinical supervisionClinical supervision is the primary training model for psychotherapists learning to be psychotherapists. Psychotherapists may be trained or supervised in the context of a particular theory, and trained to apply particular techniques based in that theory, but the best supervision is useful across techniques and will help a therapist gain competence regardless of his personal style or theoretical orientation. A clear exception occurs when the supervisor and therapist are invested in contradictory views of human nature and assumptions about the goals of psychotherapy: for example, if the supervisor sees the goal of psychotherapy as facilitating emotional integration and self-understanding, and the therapist sees the goal to be the control of behavior within the context of social norms.

Teaching new techniques may be helpful, but in fact the most difficult – and perhaps the most important– factors in successful psychotherapy are the subtleties around the relationship between a therapist and his patients. Therapy always takes place within the context of the relationship between patient and therapist, and the ways in which a therapist and patient experience each other are critical to understand. Issues of trust, empathy, and being direct are typically more important than theoretical orientation, or the application of techniques.

In any interaction between a therapist and patient, there are very powerful factors within both parties which affect the patient’s ability and motivation to change; these are broadly referred to as transference and countertransference. While they may be directly experienced and expressed, these factors are often unconscious and expressed inadvertently. Beyond this powerful dynamic, our assumptions and judgments always exist within a cultural context, so there will be blind spots around issues that are reflexively taken for granted by both therapist and patient.

A clinical supervisor’s primary task is to bring these factors into the therapist’s awareness. Issues for the therapist such as inadvertent guilt induction, reflexive negative judgments, people pleasing, modeling negative behavior, issues around personal boundaries, collusion with patients, and unconscious seduction can be present, and it is important to uncover and address these issues. To do this, the supervisor must be both a teacher and a kind of therapist to the therapist – not a therapist to the therapist regarding issues in general, but regarding the therapist’s mode of interaction with his patients. As in psychotherapy, supervision must be empathetic and non-judgmental as well as firm and direct. A supervisor’s interaction with the therapist provides a model for the therapist to interact with his patients. An effective supervisor will be an effective psychotherapist as well.

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Anxiety Plus Depression

anxiety depressionPeople sometimes think that feeling anxious and feeling depressed are separate emotional states. While this is sometimes true, anxiety and depression often come together and can feel like components of an overall state. The idea that you seek psychotherapy for depression vs. psychotherapy for anxiety may be the result of using overly simplistic categories.

When describing depression, people often include emotions such as hopelessness, emptiness, and despair. Although depression may be described on a continuum from mild to severe, there are experiential themes that tend to exist across the spectrum. There is often a loss of interest in daily activities, and a loss of enthusiasm for things that brought pleasure or were fun in the past. There may be a pervasive feeling of sadness and/or a sense of emptiness, and the experience of the world as a whole is darker and gloomy. It can be hard to concentrate.

People who are depressed frequently have low energy levels and feel overwhelmed by performing day-to-day tasks and maintaining their personal relationships. Life may seem simply overwhelming and black, and there may be suicidal thoughts or behavior. Sleep is often disturbed: some depressed people feel like sleeping all the time, while others have trouble sleeping at all. Many people describe a day-night reversal, sleeping all day and being awake all night. There can be a constant sense of fatigue, at the same time one is unable to sleep. Depression is a dark and lonely struggle.

When describing anxiety, experiences of fear or panic come to the foreground, along with a general feeling in the body of agitation and restlessness. Even in normal social situations, this state leads to feeling anxious or threatened, and brings the anticipation of some misfortune. The experience of panic or anxiety may come in waves, without any obvious trigger in the moment. With panic or anxiety attacks, it’s common to get into an endless circle that builds on itself. There is something wrong, my heart is beating fast, and since my heart is beating fast there must really be something wrong, leading to your heart beating faster. I am sweating and I feel flushed. I must be falling apart or going crazy. I’m hyperventilating and can’t even get my breath, Oh my god I’m dying! The anxiety escalates still more. Even without an anxious crisis like this, there may be a constant undertow of nagging worry or fear.

In fact, depression and anxiety frequently co-occur. In many cases, they may be seen as part of a single overall state of anxious depression or agitated depression. Though depression is often seen as a low energy state, this may not be true with agitated depression. A depressed person with low levels of energy may also experience considerable fear and agitation, or even terror. They may be having circular thoughts: I’m so depressed, I can’t function, I can’t sleep, I can’t take care of myself, I can barely move. I’m so paralyzed I will lose my job, lose my friends, have no money and wind up on the street. Without support from others or control of the things happening to me, my life will go downhill and I will wind up dead. These horrible thoughts alone are overwhelming, and the cycle starts again and can deepen.

There is considerable research documenting the relationship between depression and anxiety. For example, researchers found that anxiety began before or at the same time as depression in 37% of people, while depression began before or concurrently in 32% of people (Arch Gen Psychiatry 2007;64:651-660). In other words, for approximately 1 in 3 people, anxiety and depression exist together and begin at the same time.

Treatment. Most forms of anxiety and depression improve with psychotherapy and counseling. In some cases, adding antidepressant medication therapy to psychotherapy is helpful in relieving the acute symptoms, while underlying problems that trigger or contribute to a person’s anxiety and depression are addressed in psychotherapy. (It’s notable that antidepressants are used for both anxiety therapy and depression therapy.) Antidepressant medication therapy is not always necessary; for some people whose ideas about or reactions to taking medication are negative, psychotherapy alone may be the best option. In cases where the symptoms are not life-threatening, a person’s feelings about the use of medication should be respected.

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Addiction to Drugs and Alcohol: Self-hatred, Cravings, and Therapy

self hate therapyIf you have struggled with alcoholism or drug addiction, it’s likely that you have also struggled with feelings of self-loathing, self-contempt, and self-hatred. You probably found yourself doing things you wouldn’t normally do, and maybe even doing things you find abhorrent and believed you would never do. You may quickly go from looking at these behaviors to viewing yourself with moral condemnation. You might come to see yourself as worthless, bad, evil and unlovable. It all seems hopeless. With all your willpower, and all the self-hatred you feel for things you have done, you still can’t control your addiction. It seems the only way to make these unbearable feelings go away is to use again, but of course that only keeps the deadly cycle going. You want to stop but you feel you can’t stop. You feel trapped in your misery and self-hatred, with an increasing belief that things will never change.

These feelings of self-loathing are reinforced by society’s view of alcoholics and addicts, since people tend to see addiction as a personality flaw, a sign of weakness, or an example of immorality. People think nothing of going to an emergency room for a physical ailment, but if you (and others) think of addiction as sinful, and as your fault, of course the solution will be very different. Many people still believe that addicts need to be taught the “error of their ways” through punishment or religious indoctrination. This stigma can reinforce your negative view of yourself, and make it more difficult and frightening to ask for help or to get therapy.

The problem here has to do with how people conceive of drug and alcohol addiction.

Just what leads to addiction is a complex and highly-debated question. Some see addiction as a genetic or biochemical issue; others see it as a spiritual malady; some believe it is situational and reactive; and many see it as being due to historical psychological factors. In fact, addiction and alcoholism are multiply determined and include a number of interactive factors. The critical question in terms of helping people, at least early in their recovery, is not what caused it but what helps them change it. Once you take a substance into your body, it changes your biochemistry. At least from that point on, the addiction takes on a life of its own. One point of view is that the brain has been hijacked by the drug.

For most people, addiction involves feelings of overwhelming cravings, and a feeling of desperation that may be hard for you to comprehend if you are not addicted. The feelings can become so terrible that suicide can seem like an option, and it’s not uncommon for addicts either to actively or passively kill themselves. People often experience their craving as an intolerable state that will never end until they use, or die.

This experience can be so intense that addicts or alcoholics feel they can’t survive without using, while realizing that continuing to use can lead to death. This dilemma places much of their lives in the realm of survival, leading to an upended set of priorities that place the need for the substance above all other needs — more important than food or shelter, or connections to people they love. It is not that they become immoral, or now believe that doing bad things doesn’t matter; rather, the need for the drug or drink can supersede all other needs. This is why lying, cheating, and stealing often come with addiction. It is not that bad behaviors are not perceived as bad, but they become less important than stopping the intolerable feelings driven by the addiction.

Focusing on self-blame and self-condemnation doesn’t help; in fact, it can make matters worse and drive the addiction still more powerfully. This does not mean that you get a pass to indulge your addiction. You are still responsible for your actions, despite your addiction. However, it is important to understand why you behave the way you do – the addictive basis of your behavior – and not adopt a view of yourself as an inherently bad person beyond redemption, or without the ability to change.

Though part of the experience of addiction is a sense of despair and hopelessness, there are treatments that work. For people who feel lost and confused, it may be helpful to consult with a therapist who is familiar with the treatment of addiction. The best known and perhaps most effective group approaches are 12-step programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) and there are a number of studies which point to their efficacy. Still, different people benefit from different approaches, and there are a number of non 12-step treatments and therapy for addiction which have also been shown to be effective.

While this article primarily refers to substance addictions like drugs and alcohol, there are other things people may respond to with addictive-type behaviors including food, sex, emotional dependency, gambling, shopping, etc. Though these addictive-type behaviors are not based on an external substance (with the exception of food), they can shift one’s physiological state and produce the experience of a rush, the experience of cravings, and the experience of withdrawal. For some people the cravings involved are as potent as the cravings for drugs and alcohol, and can lead to similar compulsive behaviors. Just as with alcoholics and addicts there may be shame around seeking therapy. For more information on other addictive issues see the following links: CoDA, codependency, sex and love addiction, Al-Anon, ACOA, and the Caron Foundation.

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Finding the Best Therapist

best therapyWhat kind of psychotherapy is the best, and why does psychotherapy work? If you are looking for a therapist, this may be a question you ask yourself, and it’s a question that academic researchers and insurance companies ask, too. Why does it work, and can we make it work faster and be less expensive? How does it work, and can we turn it into a workbook that you can fill out at home? What are the important factors associated with effective treatment, what therapeutic approach is best, what kind of professional is best?

Ultimately, of course, the answers to those questions are individual, and determined by factors that aren’t easily defined and measured. Although Cognitive Behavioral Therapy practitioners frequently claim that theirs is the most effective treatment, a number of studies (e.g., Consumer Reports, 1995; American Psychology, 1995; American Psychological Association Monitor, 2010) indicate that this is not true.

The Consumer Reports study was a large-scale, naturalistic survey of 4,100 people. The results of that study showed that

  • no specific type of psychotherapy is better than any other, for any disorder;
  • psychotherapy alone is equally as effective as medication plus psychotherapy;
  • long-term treatment is considerably better than short-term treatment;
  • psychologists, psychiatrists, and social workers are equally effective across the board, and all are better than marriage counselors and family physicians; and
  • patients whose length of therapy or choice of therapist is limited by insurance or managed care do worse than those who do not have to work with such managed-care restrictions.

A recent meta-analysis by Shedler revealed that psychodynamic psychotherapy, which focuses self-reflection and self-examination to get at the root of suffering, is at least as effective as symptom-oriented treatments like CBT or medication. In fact, the same study notes that psychodynamic psychotherapy was about three times more effective per treatment than the most popular antidepressant medication, and the benefits of psychodynamic psychotherapy persist and even grow larger over time. Another meta-analysis conducted in 2008 (“Person-Centered/Experiential Therapies Are Highly Effective,” Elliott & Freire) showed that relationship-focused therapies tend to produce large changes for patients, and that the gains are maintained over time.

It’s important to note that the quality of the relationship between patient and therapist was not captured in any of these research studies. Relationship is an elusive concept, and not easily defined or measured in any systematic, large-scale study. It includes how the therapist and patient feel about each other, and the various ways in which their personalities match. Psychotherapy is a two-person system, and over and above what gets talked about, and the psychotherapist’s theoretical orientation, the patient-therapist relationship may itself be the most potent therapeutic agent.

Despite the difficulties measuring such elusive factors as patient-therapist interaction, there has been some research which demonstrates the importance of the ‘fit’ or the ‘match’ between the psychotherapist and the patient in successful psychotherapy. For example, Pilkonis (1984) found that differences in outcomes are more often attributable to differences among therapists, and to interactive effects between specific patient characteristics and a specific way of doing therapy. In his book on psychotherapy (Contemporary Clinical Psychology, 2004) Plante states that “factors such as warmth, empathy, honesty, and interest on the part of the psychotherapist are important and even vital to treatment outcome.” Beutler’s (2006) review of the research indicates that at least when treating substance abuse, the match between treatment style and patient is important for both short- and long-term success. Beutler also found that treatment is enhanced when therapists develop a positive working alliance with their patients.

Overall, studies show that patients benefit substantially from psychotherapy. Further, the most important factor in successful therapy may be the ways in which a therapist and patient experience each other. This may be more important than theoretical orientation, or the specific techniques applied. The implication for choosing a therapist is that feelings of comfort and connection should be taken very seriously.

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Empathy is Not Enough

empathyEmpathy can be seen as the matching of feelings or the matching of minds. It can reflect compassion, recognition and communion. It reflects an emotional understanding of another person’s feelings or problems. The ability to be empathetic can be a positive characteristic which brings people closer together.

In psychotherapy, empathy is critical. It allows the therapist to meet patients where they are, to enter their world and understand what it feels like to be them. Empathy is important in forming a bond and in starting a working alliance with a therapist. It leads to warmth, compassion, caring, and concern.

Patients need empathy. A therapist who has trouble being empathetic, whether for personal or theoretical reasons, is lacking something critical which will limit his work. When a therapist has an inability to make an emotional connection or feel empathetic, he or she will be overly detached, cold, and clinical. This provides little sense of safety, which is a prerequisite for any effective therapy to take place. A patient’s perceptions of the therapist as empathetic is necessary in helping the patient stay in treatment and feel comfortable enough to stick out the sometimes painful experiences that come up as therapy progresses.

Unfortunately, empathy alone may not be enough. While it can help a patient feel supported and understood, it does not necessarily promote change. Having a therapist with an empathetic stance may be necessary, but it is not always sufficient to help a person grow.

Take the example of someone who has had a difficult life for any number of reasons. These factors need to be recognized, appreciated, and understood. However, if in reacting to present-day problems the patient reflexively takes the stance that he is helpless, having little sense of his own role in his current distress and suffering, empathy alone may not be enough to help him change. If the therapist expresses nothing but warmth and empathy it may feel good to the patient but it can also support the problems rather than help resolve them.

Let’s say a recurring theme for the person is feeling the world is always unfair. He feels his girlfriend is always critical or his boss always blames him. Simply being empathetic may lead him to feel understood and validated, but that doesn’t necessarily lead to change. At times, it may be important to challenge patients’ view of themselves and point out ways in which they have a part in bringing about the problems that lead them to suffer. At times it is important for a therapist to stand firm, even when the patient protests. Having another person stay grounded, firm, and steady without becoming punitive may be a new experience for the person, and just what is needed in order to grow. It can also give a person the space to express suppressed angry feelings with the therapist who is grounded and steady.

Patients who have been seriously traumatized may need a long period of empathetic support to provide a corrective emotional experience. There are people who must experience what they never had in order to go on in life — for example, people who grew up in a very abusive or cold environment. Beyond this, everyone needs to feel a baseline of care and support, just not at the expense of sometimes being challenged to change.

The problem is that a compulsion on the part of a therapist to be exclusively empathetic can reflect issues with the therapist’s boundaries and reflect his or her need to be overly involved. If the therapist always has to rush in and attempt to save a person from any and all distress, it can block a person’s growth. A therapist with his own boundary issues may be too concerned with being approved or liked by his patient, and find it overly important to see himself as a caring person. This is clearly being overly enmeshed and will sometimes even recreate what led to a person’s problems, and present yet another bad model.

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