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!


14 comments:

Sarebear said...

Very good post. I like what you have to say, and I'm particularly enjoying this series.

I feel like I kind of get to extract extra value from the 50 min sessions, because I record them on my mp3 player. So the stuff that doesn't register when I'm in there, perhaps because something he said right before it is being pondered, gets to me later on, and I can think through that, too. I kind of feel like I have a pocket psychologist that I carry around with me. Lol. This MP3 Player I got for my birthday earlier this year has been the best thing for me getting even more out of therapy! I hardly ever listen to music on it anymore. I especially like to listen to it as I exercise.

Although I am aware I shouldn't overuse it, ie, put the headphones on when hubby is peeved at me, to avoid talking about stuff.

Murky Thoughts said...

You're going to feel better having posted about this.

jw said...

"You will soon feel better." Words. Words from a man who had not understood even one concept I aimed at him.

Once I dated a Captain of Detectives. A very nice lady in a great many ways. We went to a dance once and she was wearing her service gun (I can't remember why, just that there was a good reason.) Anyways, just being with her freaked me out and badly so: It was the gun and I knew it as I liked her --quite a bit.

I talked about it with Dr. B. a psychologist, near the end of the appointment. He asked me "Did the gun turn you on?" Which is proof, proof beyond any reasonable doubt, that he had not heard & understood even one of the concepts, facts and ideas I had just spent 40 something minutes telling him about.

I remember feeling as though I was speaking Naval slang to a man who did not understand it: ie "So I said we matelots better con a pig and take a round turn and two half hitches. Then this scranbag can go strangle a baron." (We ordinary guys had better get ahold of ourselves and talk to someone in power. Then this dirty/filthy person can be pawned off on someone (on land) who doesn't know better.)

Therein --still-- remains my heart complaint.

Too often, in the past, the therapist has not even begun to understand what I was saying or why I was saying it.

To my way of thinking, talk therapy must be based on the therapist understanding the words dumped on her/him. Too often, that does not even come close to happening.

It's funny ... I'm usually the positive one, the peacemaker, the one who tries to see the bright side of the thing. Here and on the two other psych blogs, I'm always the wet rag, the one dumping the darker side of humanity.

I suppose that says something ...

NeoNurseChic said...
This comment has been removed by the author.
On the Same Page said...

Reflective, insightful patients... I vaguely seem to remember. Don't ever say I didn't quote you.

hedberg said...

I need more guinea pig pictures!!!!!!

hedberg said...
This comment has been removed by a blog administrator.
ClinkShrink said...

Ah, poor Hedberg. Perhaps a duck will do instead.

hedberg said...

AWWWW........

Sarebear said...

You just can't stop making wisequacks . . . hee hee

JR's Thumbprints said...

I found your blog thru Foo. Interesting take on psychotherapy; I believe it's always a good thing to build a rapport with your clients and to get them to recognize developing patterns.

Incidentaly, I'm a teacher with the Michigan Department of Corrections.

Catherine said...

And what if the person does not care to share anything that goes on? They just want to show up for their appointment and leave?

From a previous post you mentioned that you do have one case of med management. How did you come to that arrangement when you do not typically do that?

Anonymous said...

JW: "Too often, in the past, the therapist has not even begun to understand what I was saying or why I was saying it."


There are [in this particularly classification] three types of people in the world. Those who twist what you say into something else, those who understand what you say when you say it particularly clearly, and those who understand what you say (or help you clarify) even when you're not being particularly clear. Depending on how well you generally express yourself, most people will fall into the second category. Always select a therapist who falls into that third category.

Hannah Zaban said...

I enjoyed your description on therapy. I just wish I can go back in time before anything can get worse in the present.

There is no point in giving out medication if you're going to stop medication later if necessary.

Therapy works. The problem comes when you do not have anything to talk about.