Tuesday, August 29, 2006

What People Talk About In Therapy

[posted by dinah; part 3 in a multi-part series on psychotherapy]

This post was inspired by Carrie's post "You're Not At That Point Yet" from NeoNurseChic.

In my past ramblings on psychotherapy, I made the comment that sometimes people seem to talk about trivial things that happen in their lives --I think I used the comparative price of beef as my confabulated example for my confabulated patient-- and they still find therapy helpful. I noted that therapy can work even if the patient doesn't come every week: help is where you find it and people have different needs and extract comfort & cure in different ways.

Psychotherapy is a private endeavor, it happens behind closed doors with an intimacy-- secrecy, even-- that makes it difficult to learn and difficult to teach. It's a process that occurs over time, sometimes a lot of time, and it can be difficult to describe to a student what is to be done and how. What does the patient do that makes psychotherapy different than a conversation with a friend and what does a therapist say that effects healing?

Some patients walk in the door and they know just what to do. Maybe they've been in therapy before, maybe they've watched the right movies. Other answer questions and aren't predisposed to talking about their lives in detail. Some worry about what they discuss, others simply recount the events of their week, and some simply struggle.

I've taken to giving patients fairly specific instructions about what I want to hear, what I think will be helpful to them: I want to hear about the meaningful things that have happened in their lives since we last met. Nothing huge should be going on that's left unmentioned. People tend to write their own stories for why they do what they do and how they got to be who they are, so if the events they talk about bring up memories of the past, I want to hear about the past. If they're not thinking about their childhood, I'm not particularly interested in having patients unearth random events from long ago. Psychoanalysts may feel differently about long-forgotten memories, but I'm not sure what to do with them unless they have some relevance or hold on the present.

I like to hear about people's lives with he-said-she-said detail that puts me in the room. So if I'm told, "we had a fight," that doesn't cut it. I want to know the details of the fight, who started it, who said (or threw) what, the mitigating factors, and how it resolved. I'm not so interested in after-the-fact interpretations, I want to hear the evidence. So if a patient says "My mother uses me to make herself feel good," I follow up with "Can you give me an example?" I may well reach the same conclusion (...yup, your husband mistreats you...or whatever), but I like to get there myself.

Mostly, I listen. Often, I ask for more detail, or I find something interesting or important sounding, and will guide the conversation down a certain path. Sometimes, I'm there to offer hope and reassurance. I say, "You're going to feel better," a lot. Seven times today to three different patients--everyone else already felt better! Most people get better, almost everyone feels at least a little better, and no one (yet? I don't want to jinx myself) has ever come back and called me a liar.

Psychotherapy is often about finding and elucidating patterns for people. Have you noticed you always feel badly at this time of year? That you've been feeling worse since we stopped the medicine? How you talk about your boss the same way you talk about your mom? How you make assumptions about the reactions of strangers that keep you from even trying to get what you want? Maybe it resonates, maybe it doesn't, I can always try again.

Psychotherapy is often about pointing out things that would be difficult or painful to hear in ordinary conversation. Something about the setting makes it safe to hear hard things, to learn about oneself in a way that enables the patient to effect change.

Many books and articles have been written about psychotherapy; it's hard to imagine that I have anything new to add to all that's been said. It's fun to write about, however, so thanks for listening!