I'm Working On It in Therapy: How to Get the Most Out of Psychotherapy

Preface

"So what am I supposed to DO? What do I have to do to change? It was shortly after I’d finished my postgraduate training when Edward, a sturdy young account manager sitting across from me in my office, asked these questions. He’d come to therapy to address his reactive anger and what he recognized as an otherwise shut-down emotional life. I told my friends I’m working on it in therapy, but to be honest, I have no bloody idea what that really means." This was his third month in therapy and we were beginning to gain insight into some of his issues. He was eager to make progress and was willing to work, but he was at a loss as to what he needed to do to make therapy effective.

I had to sit back and reflect. It seemed like it should be an easy question, one that I should be able to answer immediately. But the training and study I had done hadn’t focused on what the client needed to do; we had focused only on our role as therapists.

Thinking on the fly, I told him that his job was to bring himself—each and every part of himself—into our meetings as completely as possible, to tell me about every little scrap of joy or frustration or vulnerability or any other feeling that flashed across his screen before it got deleted by his censors. But I also wanted him to contain these feelings—not to react to them—so that we could get to know them first. I told him that he was already doing that by being direct with me about his frustration. I also suggested that we both get very curious—without judgment—about the patterns and the stories that went along with these emotions, not to get lost in the details, but to try to keep the big picture in mind so that we could challenge those stories when we needed to. I told him that there would be more he could do, but that would make for a good start.

Since then many clients have asked me what they need to do to make the process successful, and many have asked me to recommend a book to help them understand the process. I appreciate their willingness to take an active role in the work, and I try to give them some guidelines about how to make the best use of their experience in therapy. But I’ve found that anything other than the briefest instructions in session can be onerous and disruptive, and I’ve never found a book that I felt I could recommend to explain what they needed to do to make the process effective. Plenty of books tell the therapist what to do, and many other books give hints about what clients might need to talk about in therapy to deal with their specific issue. But clients are generally left with little guidance and many questions about how to actually proceed:

•   What are people doing in their sessions when things are going well?

•   How do I know if I’m making the best use of my investment there?

•   Is there anything that I need to do, or is it the therapist’s insight and empathy that will change me?

•   Should I vent or be objective and analytical?

•   Is there anything I’m supposed to do outside of the session?

When I first considered writing a book that would answer these questions, I had my misgivings. Therapy is ideally an organic process; it flows spontaneously and whatever arises in sessions serves as the basis for the work. I didn’t want to disrupt that spontaneous flow with instructions. But the more I thought about it, the more it seemed to me that a guide to psychotherapy could actually help clients to see the value of first being spontaneous and then reflecting on whatever came up, and that I could encourage them to dive in and use both.

So what does it mean to work on it in psychotherapy? This book is an answer to these questions and similar ones that I’ve heard from clients in the years since Edward first prompted my interest in the subject. I’ve written I’m Working on It in Therapy: How to Get the Most Out of Psychotherapy to demystify the client’s role in psychotherapy so that those of you who are in therapy can make the most of your experience. I’ve also written it so that those of you who are considering entering psychotherapy can get a more realistic sense of what it entails. I offer it too as a resource for other therapists, that it might enrich your work, and that it might stimulate more thinking and discussion about how we can help our clients get the most out of psychotherapy.

This book will convey the client’s role in therapy as I’ve come to understand it through twenty-five years of practicing therapy and teaching the process to advanced students. I will share stories of what clients have done to make their experience in therapy successful, and stories from literature and mythology that demonstrate what heroes and heroines have done for millennia to achieve change. I will also draw upon recent research that helps us to understand how to use psychotherapy effectively.

I hope that this book will help you to use your therapist as a guide and partner in your own process of discovery. I believe that the human psyche has an innate aspiration to heal and grow, a constructive unconscious (which I’ll describe in Chapter Three). If you and your therapist are both enlisting this natural tendency, the energy that arises will be very productive. I also believe that taking an active role in improving our lives helps us to develop a powerful sense of mastery and agency that is in itself healing.

This book describes ten tools that you can use to work on it. Once you’ve finished reading it, you will have a very good sense of what you need to do in therapy to use it effectively. If at any point in your work you feel lost or stuck, I’d suggest that you review the chapter headings and the summaries at the end of each chapter to see if there is a particular tool that you could exercise more to get things moving again.

When heroes and heroines set off on adventures of self-discovery, they’re usually given something to help them pass the trials they encounter so they can get to where they need to go: an ancient and revered weapon, a magic flute, a tiny wooden doll, a special coin to pay for the ferry across a river, a piece of wisdom, or any of a thousand other articles that symbolize methods for handling ordeals. No one can tell them exactly where they need to go or what problems they will run into, but the tools they receive are indispensable for them to navigate the challenges ahead of them. My hope is that these tools will serve you on your heroic journey into your own uncharted territory.

Introduction and a Few Things to Know Before Reading This Book

The content of therapy—the specifics of what therapists and clients talk about in sessions—varies widely from person to person, and can’t be prescribed. But the process of therapy—the how—includes essential practices that are crucial to know, whether it’s depression, anxiety, relationship issues, addictions, general well-being, or any other issues that bring you into therapy. These tools, as I’ll call them, constitute the heart and soul of working on it in therapy. Learning to use these tools consciously helps clients who have engaged in psychotherapy continue to benefit from the process long after they’ve stopped seeing their therapist.

These tools are no secret, yet they are not well known. And because they are so rarely discussed, distorted portrayals of psychotherapy have filled the vacuum.

If you were to base your idea of what you need to do in therapy on conventional conceptions, some of them found in the media, you might wait a long time for your therapist to say something insightful that would suddenly change you. Television and film generally use dramatic moments to entertain us, and the real, more incremental, work that the client does in therapy isn’t always portrayed.

Older, stereotypical conceptions of therapy portray a removed and reserved analyst sitting out of sight behind a couch making observations that enlighten you. More recent conceptions may evoke a nurturing and empathic, but not-so-challenging, therapist who sits across from you and supports you until your wounds are healed.

Either version may leave you in a passive state, believing that your therapist’s insights or nurturing will be sufficient to bring about the change you want. Misconceptions about how therapy works may keep some people from entering therapy and reaping its benefits, keep others from sticking with therapy long enough to get help they need, and keep others attending sessions long past the point of diminishing returns.

An increasing body of evidence suggests that it’s not what the therapist does, or even a particular model of therapy, that accounts for change; rather it’s the client’s involvement, participation, and contribution that actually accounts for most of the progress in therapy.¹

Psychotherapy works less like going to a guru for answers, and more like engaging in a personal and collaborative exploration, one that asks you to bring out, test, and develop your own ideas, feelings, and behavior in the sessions themselves. It’s less like massage and more like physical therapy, which requires a fair amount of stretching and effort on your part.

The reality is that it’s difficult to achieve significant personal change and that it does take work. If, as therapists, we let you believe otherwise, we’re misleading you, and any therapist that does mislead you that way should be tarred and feathered. Therapy is a heroic venture that requires both initiative and receptivity, neither of which is easy. The very nature of the work requires us to go to the places that scare us most, and it can feel incredibly difficult at times to remain open and persevere.

But the good news is that psychotherapy does make change possible. There is accumulating research evidence (see Appendix C) that demonstrates the enduring efficacy of psychotherapy. We now know that therapy literally changes the neurological wiring in our brains.²

Understanding your role in accomplishing that change is key to gaining the maximum benefits of the process and in maintaining those benefits once you’ve stopped attending sessions.

TEN TOOLS

I’ve organized the work of therapy into ten tools, ten overlapping ways to use the process effectively, and described each of them in a separate chapter. I’ve tried to lay these out in an order that bears some resemblance to when you might experience them in your process, but they really aren’t so distinct, and you don’t need to exercise them in a particular sequence in your actual work. However, it will be most helpful to read the chapters in order, because my explanations do build on each other.

Following are the ten tools. But before you read them, I’d suggest you take a few minutes to list the things that you believe you need to do to make psychotherapy work for you. This could come in handy later in discussions with your therapist.

  1.   Get real: Take off the mask and show your many faces.

  2.   Channel the flow of feeling: Have your feelings without your feelings having you.

  3.   Enough about them: Look deeply within for the sources of change.

  4.   Don’t hold back: Forge an authentic connection with your therapist.

  5.   Be curious, not judgmental: Observe yourself honestly without attacking yourself.

  6.   Carry only your fair share: Differentiate when to take responsibility and when not to.

  7.   What’s your story? Identify the recurring themes and fundamental beliefs that guide your life.

  8.   It ain’t necessarily so: Build a better narrative and choose your beliefs consciously.

  9.   Do something! Continue your psychological work outside of sessions.

10.   Into the fire: Use the challenges of your life as opportunities for growth.

A FEW THINGS TO KNOW BEFORE READING THIS BOOK

I’ve included condensed case examples of typical situations in order to give you a clearer idea of how these tools work. In order to protect my clients’ privacy, these examples are composites that don’t disclose material that would identify particular people. I don’t want any of my clients to ever worry—or hope—that their unique personal information will show up in my writing, so that they don’t feel that there is an audience of readers in the session with us.

Because human growth and healing predates the advent of psychotherapy one hundred years ago, we have thousands of examples from the lives of heroes and heroines from literature, mythology, film, and fairy tales that demonstrate the processes of healing and growth. We’ll utilize these stories as another way, a more imagistic and poetic way, to feel into these ten tools.

We’ll also look at psychological research that indicates what may be most helpful in therapy. While there is no research that proves exactly what will work specifically for you, we do have studies that reveal psychological patterns that suggest effective directions for your work. The work of therapy involves a weaving together of heart and head, feeling and thinking. I hope to demonstrate this weaving in the content and process of the book, and that describing these tools from different angles will allow readers with different styles different ways to grasp and absorb the material.

YOUR THERAPIST’S ROLE

Your therapist’s efforts are instrumental in activating your healing. Without her insight into what’s happening unconsciously inside of you, her perception into what’s going on in the back of your head, you could wander aimlessly for a long time. But ideally, through a combination of her training and her use of her personal experience of you, she can give you feedback about what may be going on unconsciously that causes you trouble.

While it may look like your therapist is just sitting there nodding her head, there’s an awful lot of processing going on inside: processing both your feelings and the feelings she has about you, connecting your past with your present, and all the while watching not just what is said, but also what isn’t said. Just as important as her insight is her empathy. Without it there would be little healing. Your therapist’s understanding and personality interrupt your repetitive patterns in a way that frees you to try to live differently. It’s not all your responsibility and you’re not alone in the process.

THE TEMPO OF THERAPY

Deep, lasting change takes time to achieve, and this is true for just about everyone. It would be a rare individual who was able to do everything that I suggest in this book right away. Use of some of the tools I describe may come easily to you; others may feel very uncomfortable at first because they’re unfamiliar and undeveloped. The challenge of learning these tools is no different from the challenges that determine the quality of our lives. And exploring what makes each of these tools difficult to use constitutes the work of psychotherapy. Finding your own tempo in using them is in itself an important part of the process. Further, please don’t take these suggestions as shoulds, or as hard-and-fast rules; take them rather as opportunities to enhance your work with your therapist when and as you are ready.

Psychotherapy is a very individual process. You may use some of these tools more than others, and you may use tools that I don’t discuss in this book. My goal is not to be exhaustive or technical, but to be concise and clear, describing what is most often helpful to most clients in their efforts to grow. If you see these tools as possibilities rather than obligations, they will be much more beneficial to you.

The suggestions in this book are intended for people who want to make changes in their lives, changes in how they think, feel, and behave. Many people use therapy to sustain and support themselves in a difficult time, and do not set goals to make changes. For those of you in this situation, some of these tools may not apply. There is no harm in such an approach, but it would be best to clarify what your goals are with your therapist.

The type of therapy that I will describe tends to be long-term, though I’ve seen plenty of people get a great deal out of it in the first few months. Part of the reason I’ve written this book is so that your therapy doesn’t go on longer than it needs to. But this doesn’t mean I am suggesting that you sprint through the process or that we create another form of short-term therapy. Psychotherapy is not a drive-through activity: research suggests that longer treatment correlates with better outcome.³ I suggest that you settle in and reside there for a while, rather than having one foot out the door, like a tourist ready to drive on to the next sight.

To use a different metaphor, I don’t believe that we can fast-forward the process of psychotherapy. But I do think that learning what you can do in the process will help you to remove the commercials, the periods when the therapeutic action seems stalled or irrelevant. The examples I’ve used in this book are by necessity all condensed; the process may appear to be on fast-forward, but actually takes some time.

WHAT TYPE OF THERAPY IS THIS ABOUT?

The tools that I describe here have proved their value in a wide variety of therapies used to help individual adults. The overarching term for this type of therapy is psychodynamic psychotherapy, which, on the face of it, would appear to be useless technical jargon. However, unpack it and it says a lot: psychodynamic refers to a mind or soul that’s vigorous, purposeful, active, and changing. Part of that mind is unconscious—it’s powerful but not easily seen. A therapy that is psychodynamic is one that works with this subterranean energy, and the therapeutic relationship, to bring about healing.

Included within this overarching field of psychodynamic psychotherapy are depth psychotherapy, insight-oriented therapy, expressive therapy, and psychoanalytic psychotherapy (Freudian, Jungian, interpersonal, object relations, and self-psychology). They are all designed to bring about lasting personality change by understanding unconscious processes, and by exploring what happens with the therapist in the sessions themselves. The tools in this book are drawn from the clinical wisdom accrued in over one hundred years of an evolving approach to self-understanding, healing, and growth that these therapies have honed.

While some of these tools are used in the newer forms of therapy known as cognitive and behavioral therapies, the tradition that I have drawn from is much less structured, and typically longer-term than cognitive and behavioral therapies. Cognitive and behavioral therapies tend to focus on the removal of specific symptoms, tend to be shorter-term, and include very specific instructions about the client’s role.

The work I am describing in this book is holistic in that we work with the entire personality of the client, trying to understand root causes rather than focusing exclusively on symptoms such as anxiety or depression. It also tends to be nondirective, personalized, and spontaneous; we don’t impose a structure on the process, and we usually have the client begin the session. In cognitive and behavioral therapies there is less emphasis on unconscious process and the therapeutic relationship.

These tools may be used in work with psychologists, social workers, psychiatrists, nurses, and counselors, none of which are bound to a particular sort of therapy.

I briefly explore the decision of which type of therapy you might find most helpful in Appendix A: Starting Therapy, and briefly describe research demonstrating the efficacy of psychodynamic psychotherapy in Appendix C. My purpose in this book is not to argue the benefits of one type of therapy over another. However, I believe that this book will demonstrate the extensive benefits of a therapy that leaves enough time and space to use these ten tools flexibly and organically, that takes into account unconscious processes, and that uses the therapeutic relationship, all for deep, lasting change.

* * *

You may notice that the terms healing and growth are seldom seen separately in this book. The two belong together; healing leads to growth and growth leads to healing. I think that I can safely speak for many therapists that our hope for our clients is not just to remove a problem, but to move you beyond the problem to a more fulfilling way of living. The issues that bring people into therapy often lead them to more positive change than they had initially hoped for. I hope that