Why Should I Pay to Talk to You?: Reflections on the "Process" of Psychotherapy

A recent conversation prompted me to revisit this question. This post is an edit of a 2013 post on "Content vs. Process" in psychotherapy.  

When meeting new clients (and others), I encounter a variety of comments that reflect common misconceptions about psychotherapy.  One is that the focus of therapy is for me to evaluate the client and tell them what to do.  Many people start their therapy a bit defensive because they are fearful of my judgment or correction.  Some people have mocked the process of therapy by saying that therapists never tell you what to do and only “Listen”.  Others have said to me, “Why am I paying you to listen to me when I could just be talking to a friend or family member?”  The difficulty with all of these assessments is that they assume over-activity or inactivity on the part of therapist.  People have experiences with other "advisers" in their life in which they seek advice and receive a plan on what to do for their particular problem and they expect therapy to be like that.  There are also distortions of the therapeutic process portrayed in film and television that perpetuate misconceptions.  Unfortunately, there are also a number of people in the world practicing some type of counseling who contribute to these stereotypes by their methods of practice.  The very terms we use for this type of care are also confusing – counseling, therapy, psychotherapy, psychoanalysis, etc.   (In a previous post, I commented on the technical differences in these various terms).  Many people think that seeing a therapist is helpful because the therapist is supposed to be a neutral third party.  However, what makes the process of psychotherapy different from talking with a friend or other type of helper is the attention to the process of therapy. Because this part of the relationship is often managed in subtle ways, people often perceive that the therapist is not doing much, but the reality that is that the process is rich with reflection.

Fundamentally, what makes any type of counseling or psychotherapy beneficial is the quality of the established relationship and this is true regardless of the therapist's theoretical orientation.  However, attention to this "process of therapy" is particularly meaningful to those who practice psychoanalysis, psycho-dynamic psychotherapy, and traditional Pastoral Psychotherapy. In these types of therapy, the therapist is mindful of the dynamics of the relationship, monitors these things, and uses them (hopefully) for the client’s benefit.  These types of dynamics can exist in other relationships with friends, etc, but it is more rare.  Psychotherapy is, by definition, a relationship between two (or more in the case of couple or family therapy) people for the benefit of one of them.  Everything the therapist does or says should be for the benefit of the client.  In order to do this, the therapist must be aware of many dynamics that are simultaneously at work in the counseling office.  Friendships are generally more mutual in nature.  

What is the "Process" of Therapy? 

When a person comes to therapy, the issues they wish to discuss and the struggles they have with these issues constitute the “content” of the session.   However, the forces that motivate a person’s behavior are also important.  The therapist should be reflecting on the selection of material presented and the content of the material.  After a particularly painful session of dealing with something like grief, a client may come in the next session and talk about more mundane or superficial issues.  The therapist’s job is to note the shift in tone and help bring to awareness the change.  When a client presents a memory of events, the therapist is focusing on how the person was affected and how they behaved in the events presented, but he or she is also focused on how the person seems to be feeling as they are presenting the material.  The therapist should not make assumptions about what the client felt, how they are feeling, or why they behaved in a certain way.  The job of therapist is to note that such feelings and motivations exist and to ask questions to raise the client’s awareness.  This is why it has become cliché for a therapist to ask questions like “How did you feel when that happened?”

The Therapist should monitor his or her own feelings during a session

Completely out of the awareness of the client (at least it should be) is the therapists’ reflections on another set of dynamics in the room – his or her own.  As the client is sharing, the therapist is also monitoring his or her own feelings about what is being shared.  He or she is monitoring the experience of the person and noting what they observe and hear.   The therapist is monitoring how his or her own story is connected to the client’s story.  The goal for the therapist is to be able to separate his or her own experiences from the experiences of the client.  In order to do this effectively, the therapist should have done sufficient therapy for their own personal issues and to receive adequate supervision and/or consultation on their work. The therapist becomes less effective when he or she assumes what the client will or should feel instead of allowing the client to discover what they actually feel.

Therapy is meaningful when the therapist is NOT giving advice

While the therapist may provide some education on common dynamics of interaction or personal development, their primary goal is to allow the client to discover how he or she plays out these dynamics in their own life.  Any intervention or action on the part of the therapist should be in the service of this self-discovery or to help provide an environment that contrasts the clients’ previous hurtful experiences.  By observing the clients actions, monitoring feelings, and dealing with the dynamics of the client’s relationship with the therapist, the therapist creates the opportunity for growth and healing.  The client’s experience of the resulting relationship between therapist and client can then grow beyond the walls of the therapy office to the other parts of the client’s life.  The goal for the therapist is to create independence for the client and not to foster dependence.  Advice-giving and such activities, while helpful, only keep the client dependent on the counselor.  When the therapist helps the client discover his or her own ways of dealing with things, then they are able to apply that understanding to novel situations.  The experience of this growth within a therapeutic relationship is generally experienced by client and therapist as deeply meaningful.  In pastoral psychotherapy, this growth and self-reflection will often include reflections on faith, God, and spiritual development and the process of the therapy itself can be experienced as quite spiritual or holy. 

So, far from doing nothing or doing everything for a client, the therapist works with the content of the client’s issues while monitoring the internal and relational process of therapy. The therapist should maintain a calm exterior, but should always be actively reflecting internally.  I have found this process personally, professionally, and spiritually enriching.  For most events in life, the support of a good friend or trustworthy family member is invaluable.  A good friendship can have wonderful therapeutic value and can be very helpful in many of life's difficult situations, but for me, there is no true substitute for a meaningful therapeutic relationship.