A simple way to explain therapy

I was trying to explain how therapy worked to somebody who didn’t know much of anything about it.  He was a “thing” person, not a “person” person.  Give him something to fix and he was extremely capable. Give him a situation to fix – say a crying child – and he had no idea what to do.

So saying, “It’s a corrective emotional experience” or “You heal through the relationship” didn’t seem like it would cut it.

I went for a visualization that contained familiar things. “Think of three circles. Label one ‘trauma and pain,’ another ‘destructive ways of responding’ and the third ‘constructive ways of responding.’ Okay?” After a couple of examples of what trauma is and what are destructive and constructive ways of dealing with things are, he got it.

“If the constructive circle is really large and the destructive circle is small, a person is in good shape. That’s mental health. They may not be happy about their pain and whatever caused it, but they cope, and cope well.

“If the destructive area is large and the constructive area is small, that’s a person with problems. The therapist’s job is to coach that person on ways to shrink the destructive circle and enlarge the constructive one. You can’t just erase the destructive patterns, because even though they aren’t ideal, they are a way to cope. You have to put something in their place first.

“So why do people choose destructive ways of coping in the first place? Why don’t they go for the gold when they are kids?

“Well, maybe they were taught destructive patterns. If their parents were no good low-life scum, that’s what they had as role models. Or maybe their parents taught them destructive ways, either because it was easier on them or out of ignorance. Kids learn from the people around them. They copy what they see their parents doing.

“Also, unfortunately, destructive ways of coping are very effective in the short term. If you lose everybody you love in a car crash, you could forget the pain for a while by getting blissed out on heroin. If you are dead broke, you could try robbing a few people. Problem solved for now, but far more problems ahead.

“So therapy is teaching a person to replace poor methods of coping with better ones and of titrating awareness of the pain so that it’s not too much, so that it doesn’t overwhelm the coping mechanisms.”

For you “person” people out there, titrating means adding one liquid to another, drop by drop, until you get the balance you want.)

He got it. No magic, just plain old ordinary common sense. And it is all true!

I just thought, this might be a good way of explaining therapy or healing to a kid alter. It would be above the littlest ones’ heads, but at about eight, their thinking should be sophisticated enough to understand.

Difficulties in the Therapeutic Relationship

Now I’m going to discuss some of the things that can be suggestive of poor therapy, but which sometimes can be worked through. This isn’t a complete list — I am sure you can add lots more things.

Dual relationships. What this means is having a therapeutic relationship and also another, separate kind of relationship with the same client. Licensing boards and professional organizations are moving more and more toward banning all double relationships. Canada is looser about this, maybe because so much of Canada is rural.

Banning dual relationships is probably a good idea because it is hard to keep your client’s well-being in mind when you are simultaneously relating in another way. Certainly therapists should not have another financial relationship with their clients on the side. This means no hiring the client to paint your house or do your books, no trading lobsters for appointments, no accepting gifts. If a client wants to give a gift, it should have no monetary value – a hand-made card or a poem is fine.

In small isolated communities, it’s almost impossible to avoid dual relationships. People are spread out and there is only one therapist, one carpenter, one doctor, and so on, for miles. If a dual relationship is the only alternative to no therapy at all, it should be discussed at the beginning and some plan should be put in place to avoid pitfalls. Sometimes that’s all that is needed to set boundaries and make for a good working relationship.

There’s another circumstance that I don’t know very much about, and that’s ministers, priests, or rabbis who are also counselors. I don’t know how the different denominations ensure that the two roles stay separate. If you are considering working with a religious counselor, it would a good idea to ask about this.

Poor boundaries. The therapist asks for your help in personal matters, leans on you for comfort, or tries to be so giving that you end up being taken care of in inappropriate ways. The therapist is neither your savior nor your child – a therapist is a reliable, trustworthy coach who meets you where you are and always keeps your best interest at heart.

Flakiness. The therapist is consistently late, forgets appointments, often calls at the last minute to cancel or reschedule, or doesn’t return keep phone appointments in a crisis. Or messes up the bookkeeping. Or forgets important facts about you. Forgets to tell you about vacations. Once or twice is forgivable, but a lot? You need consistency, not chaos.

Over-stepping their knowledge. The therapist says he or she has expertise which he or she doesn’t. I’m not only talking about padding a resume; I’m talking about giving medical or legal advice or diagnosing somebody (like your parents) who they have never met. A therapist should be honest enough and confident enough to admit to not knowing something or not being qualified on a particular subject.

Suddenly changing the ground rules. Sometimes changes do need to be made, but they should be thoroughly discussed ahead of time. It’s not helpful to change the fee with no warning or to state that there will no longer be phone calls in a crisis. If you feel that the rug has been pulled out from underneath you, it will take a lot of time to rebuild your relationship.

You can see how any of these issues, if poorly handled, could prevent trust from forming in the beginning of the relationship or mess things up in the middle of therapy. You relationship with your therapist is the basis for therapy and it should be treated thoughtfully and respectfully at all times.

Transference, Counter-Transference, and Resistance in Therapy

Transference means feelings that you transfer onto the therapist. In trauma terms, it’s a feeling flashback. The therapist sneezes the way your mother did (trigger) and all of a sudden you are feeling all the emotions you used to feel around your mother. Since your mother isn’t there, you assume you are reacting to the therapist. Does this make sense?

Let’s look at an every-day example. If, in the past, you have had pleasant experiences with puppies, the next time you see a puppy you are going to think, “Aw, how cute” and want to play with it. But if dogs have been used to hurt you, you are going to shrink away and try and protect yourself. If you have seen puppies tortured, you are may feel they are fragile and delicate and you’re going to be afraid of hurting them if you touch them. And you may be puzzled why you suddenly feel sad or afraid or angry. But the “Aw, how cute” response is every bit as much of a feeling flashback as the other responses.

I’d like to add that everybody, not only trauma survivors, experiences transference and has feeling flashbacks. It’s part of the human psychological make-up. It’s just that trauma survivors have more flashbacks of terror and anger and fewer of warm fuzzy feelings. And their flashbacks are usually more intense.

Counter-transference is when the same thing happens to the therapist. In other words, the therapist has a feeling flashback. Suddenly the therapist sees you through a film of feelings about somebody else and may not be reacting to you as you really are. Doesn’t matter if the therapist had a lovely or a horrible childhood —­ he or she will experience counter-transference at some point. It’s human nature.

Many books and graduate schools teach students to concentrate on the client’s transference feelings. The assumption is that the client is “sick” and the therapist is “well.” Counter-transference, instead of being a part of life, is considered shameful. This distortion can lead to all sorts of problems in therapy.

Consider the therapist with a younger client and a teen-aged daughter. The daughter is in that lovely stage where Mom is an idiot, totally out of it. Chances are the therapist is going to be hyper-alert to put-downs from the client. So if the client says, “It’s cold in here” the therapist, rather than saying, “Yes it is. Would you like to get your jacket?” might get defensive and go on about how it isn’t her fault, the landlord controls the heat, etc etc. She’s expecting the client to act pissy, like her daughter. But since she’s been taught to look for the source of the distortion in the client, not in herself, she will probably look for “mother issues” or “authority issues” in the client. It’s confusing.

Here’s an example from my own long history in therapy. My therapist said he hadn’t received my check, and was I angry at him? We’d been working on my feelings about my father, which included a lot of anger. So he assumed I was experiencing transference. I said, well, I’d mailed it, and no, I wasn’t angry at him. He kept probing for three sessions for the source of my anger at him, by which time he had created it. I was also feeling royally mind-fucked, which was exactly the way my father made me feel. Hooray! Transference had been created.

Next session he sheepishly told me that he had made a mistake. He had received the check but had forgotten that he had. His issue was that he wanted to raise my fee and was annoyed that the check was so small. This was responsible on his part. He owned up to his mistake, and also to putting the responsibility on me, when it really belonged to him. Things got straightened out, and we proceeded. But if he hadn’t figured out his part and if he hadn’t been honest enough to ‘fess up, things would have gotten messier and messier between us.

To complicated things further, you may have feelings about the present situation and the same kind of feelings from the past transferred onto the present situation. It doesn’t always have to be either/or; it’s often both. Here’s an example. The therapist is late. The client feels hurt and unimportant. The client’s mother was habitually late, and the client felt hurt and unimportant. The therapist gets a double dose of those feelings, one from the present, one from the past.

Now if the therapist assumes it’s “all” transference, and there’s no reason for the client to be hurt by the therapist’s lateness, then that implies the therapists thinks it’s fine to be late, which it isn’t. But if the therapist can help divide it up between the past and the present, some good work can be done.

“Resistance” is another psychological concept that often gets used to put responsibility on the client for things that go wrong. If the client doesn’t get better in the way the therapist wants in the time frame the therapist wants, it’s labeled resistance. Well, what if what the therapist wants is bad for the client? What if the client isn’t ready? What if the therapist’s goals are unrealistic? What if the client doesn’t have the vaguest idea what the therapist is talking about? The therapist should assume that the client had a really good reason for not making the change and help the client to figure it out. There is no place for guilt-tripping in therapy.

I was taught that if the client wasn’t being helped, it was because the therapists didn’t know how to help. The therapist should seek supervision, read up on the client’s problem, or refer the client to somebody who knew what they were doing. No blame on either part — it’s totally normal not to know everything and to come across people you don’t understand and therefore can’t help.

Understanding transference, counter-transference, and resistance is important because misuse of these concepts is common and can lead to long frustrating periods of being stuck in therapy. Something just isn’t right, and neither person can put their finger on it. The best thing to do if this happens is to step back and take an honest look at the relationship. That’s scary, but it can be very fruitful.