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I posed this blog topic as a question, as I think that very specific question requires huge attention;  it’s long overdue.  This question is fundamentally more topical now, as we live in a world where there is widespread misinformation, made possible by the internet, and some TV programmes, which are made for entertainment. Social media eg (Tik Tok, Instagram, Facebook) perpetuates this misinformation; we often forget that some people monetise their  content & will post anything that draws attention-clickbaits. Any one can  post anything online, and the information is not fact checked. This could be  misleading information and very harmful. I have had many clients diagnose themselves with all kinds of things- Personality Disorders, Anxiety, Autism, ADHD,  OCD, etc, after watching Tik Tok, Instagram posts, or the mighty Google. I always get them to reflect on the reliability of this information & recognise the harmfulness of it.

We live in a paradigm where people use Google, as a source of information. By simply reading someone’s advice or opinion on a particular subject, we tend to believe it, without questioning the validity, reliability, and credibility of the source of information.  There are numerous TV programmes where “individual therapy” or “couples therapy” sessions are screened. We forget that this is entertainment. I personally do not watch these programmes as the ethical issues that arise in most of them leaves me feeling very uneasy. Revolted to be frank.  Sadly, many people believe that the TV programmes of “therapy” sessions or “couple’s therapy” sessions depicts the reality of what happens in the therapy room. They don’t!  Many people are put off the idea of therapy after watching these TV programmes, while the inherent misinformation lead to some people approaching therapy with unrealistic expectations.

It’s almost impossible to know what therapy is about, unless if you have been in therapy yourself, or if you know someone who has been to therapy, who has shared their therapy experience with you.

By exploring with you why people go to therapy in this blog, l will hopefully shed some light to why people go to therapy in the first place, and highlight some of the nuances around  therapy.

The Therapist, The Human

In social settings, when asked what l do for a living, l find it easy to default into “l am a lecturer”. Why?  Because l know what kind of questions disclosing that l am a psychotherapist stimulates, which l would rather avoid & play safe.  I recognise this is something l do as a defence, as revealing that “l am a psychotherapist” or simply mentioning “therapy”, is met with a lot of questions that l don’t  feel comfortable  to answer in social settings. One question often triggers another. In short revealing that I am a psychotherapist is often met with shock, curiosity, and at times suspicion that l may have ulterior motives, and l can “read people’s minds”. That’s not what I am about; l certainly do not have the magical powers to do that. It’s not flattering at all, rather jarring.  On the contrary, another  reason why l avoid talking about therapy in social settings is that l tend to get very passionate; just like being in class with my students. So instead, I go into survival mode, which is not okay. But it makes sense in the moment.  When I have disclosed that l am a psychotherapist, two of the main questions l have been consistently asked are “what is therapy” and “why do people go to therapy”. The first question was answered in my second blog post on "Navigating the Therapy World.” It is therefore essential that we discuss why people go to therapy after all.

Why do people go to therapy?

It is difficult to answer this question without sounding simplistic, and being intentionally so. People tend to approach therapy at different stages in their lives, and with varying presenting issues.  The reasons are not universal. People are not impacted by the same things in life, and their ability to cope with certain life situations differs depending on many factors, including how we were raised in our homes, how our parents dealt with our emotions, and their emotions, which all defines the level of emotional maturity we have achieved.

Fact- people come to therapy for different reasons. Some come to therapy when they are in crisis- for example following a relationship breakdown, bereavement, job loss, or acute mental health challenges. Others come to therapy as part of their personal growth and development. Some may be aware of distressing thoughts, feelings, and repetitive patterns which are impacting on their wellbeing, and life in general.    There are some people who are more psychologically minded and will have an awareness that there were some “traumas” or pernicious experiences in their past and would like to use therapy to explore them. The notion of “working through” is used in therapy, as therapy is a process that requires confronting, and coming to terms with some parts of ourselves that may have been unconsciously split off, disavowed, denied, or felt very alien to us. In working through, we are able to create meaning out of something that may have been meaningless, and provoking distress, emotionally burdening, or stimulating disturbing feelings. Having a deeper understating of ourselves enables us to be more in control of these feelings,  make sense of them and have clarity.  Instead of being reactive or being at the mercy of them, we can embrace them with grace, compassion, understanding, and be more reflective. Many people will have had previous relationship traumas;  the new relationship experience with the therapist in the present, can effect change in many ways, for example by enabling them to learn new ways of relating,  attunement,  affect regulation, develop a secure attachment, and enhance reflective abilities.

Another concept central to why people come to therapy is “processing”. I consider this to be a form of psychological metabolism. By processing, we are able to enrich our lives with the learnings we take from the processing, and let go of what we do not need. Just like when we have a meal, the body processes  the food,  derive nutrition from it, and let go of the waste. We do the same in therapy, food symbolising our life experiences-unpack, breakdown, nourishing ourselves, & let go of what no longer serves us. A major aim of therapy is to enhance reflexive function- therapy provides one with an opportunity to explore, experience, consider and master feelings. The relationship with the therapist is central to this.

Intellectual Understanding vs Emotional Understanding

I found this very simple formulation helpful:  Some people come to therapy because they feel and need help to understand, while others understand and need help to feel.

This is so profound as it captures what therapy is about. Many people who come to therapy are very intelligent individuals and they “get it” intellectually. However, there is another level of understanding-emotional understand- which is missing. Therapy helps them develop an emotional vocabulary (naming & understanding their emotions) and integrate that to their intellectual understanding. Intellectualisation can also be a defence (Klein, 1926) which people use to keep difficult feelings at bay. Therapy is a process of slowing down and allowing an integration of cognitive understanding and emotional understanding. This requires a lot of vulnerability and trust as it means letting go of the defences that we have used throughout our lives and getting used to new ways of being.  By emotionally understanding, it means we can be more in touch with ourselves, and embrace our emotions without fear, or overwhelm. This is why and how therapy enable us to experience ourselves more wholesomely.  I fundamentally believe that having a healthy relationship with ourselves is a prerequisite to having healthy relationships with others. We cannot see, love, and accept others without firstly seeing, loving, and accepting ourselves, with all the good and the bad.

Narrative Competence

There is so much power and healing in telling our stories, in our own words. Many people find it difficult to remember or have coherence in their life experiences and the past. Their memories may be patchy, vague, jumbled, and at times completely absent-erased. This is more so when there has been past trauma, and when there has been experiences that are psychologically painful. The mind has a sophisticated way of protecting us, for its own survival. In the context of "trauma" Van Der Kolk writes a lot about how  trauma is stored and how traumatised people experience incomprehensible anxiety and numbing, and how trauma affects their capacity to concentrate, to remember, to form trusting relationships, and even to feel at home in their own bodies. Although this work is around trauma, it helps us  understand how trauma affects our ability to remember things and  how it can manifest in a somatic form. (Re-trauma, read my blog on Adverse childhood experiences). This is why at times some people  are overwhelmed by feelings, but they cannot locate the source of the feelings, which is in the past. The ability to describe one’s past, however painful clearly and coherently, without denying or censoring aspects of it, is indeed a powerful and transformative experience. This also enhances our ability to name feelings, experience them, and self sooth. This reflective and reflexive work enables one to re-evaluate the past and create personal meaning. Developing a coherent narrative enables us to integrate different aspects of our lives that may have been deemed to painful & split off or repressed. This work can only be done in a contained space- therapy. This is why the space itself has to be safe & secure enough for this work to be done. There is evidence that our minds can adapt to change, over the course of our life time, a term called neuroplasticity. This neuroplastic quality of our mind enables us to work through the past, by replacing "old experiences" with new ones that are built in the safety of the relationship with the therapist.

Do Therapists Fix People?

This question has come up very often, especially when people are approaching therapy for the very first time, with specific problems-they want to be fixed!  No, Therapists do not fix people. Therapists are human, and therapy is a process that is co-created and co-constructed by two humans. Therapists have feelings too, and clients do not often have the awareness of just how deeply they affect and change their therapists. Therapists are work in progress, like everyone else; we learn a lot from our clients. The process is not about the therapist having the answers, and telling the client what to do; rather finding the answers between us. The admirable Psychoanalyst Patrick Casement (1985) wrote an excellent book called On Learning from the Patient, dedicated to exploring how therapists creatively learn from their patients. There is a notion of therapists being all knowing, which is not true. Therapists don’t have the answers for their patients. They are there to hold the mirror for the clients to see a reflection of themselves on that mirror. They may guide or lead, or direct. However, it is fundamentally the client who is the master of their own life. Therapy gives people a voice, the ability to define themselves, and empowerment to do so. From the therapist’s perspective, it is countertherapeutic to work  from a place of omnipotence, as it simply means we are seeking to serve our own narcissistic needs by being a “great therapist”.  I myself have been a therapist for many years, and l do not consider myself some kind of guru.  In any therapy, there are two human beings, in the therapeutic space. None of them is neither superior to the other, nor better than the other. The therapist in not all knowing.

On the very notion of therapist meeting their own ego needs, Winnicott (1969) said that “ The principle is that it is the patient and only the patient who has the answers” . This is a caution against the idea of  the therapist being the fixer and giving clients, the right “tools” to “fix” things. Therapy is a journey that is taken by both client and therapist. It is not an event, or simply a meeting that takes place once weekly.  The journey itself can be precarious, and prone to having ups and downs. The ability for the therapist to “hold” the client through the journey, and through the turmoil, is what becomes successful therapy. Winnicott (1969) writes about the concept of “holding” as a mother who holds the baby in the early stages of life- providing a holding environment and psychological holding. The therapist has to have an emotional relationship with a client, but also be able to emotionally separate themselves from the client material. This is complex, and a rather contradictory place to be, where the therapist can be with the client, and bear their feelings with them, and survive it together, without contamination. The ability to survive is what the client internalises and subsequently build their own internal resources. The ability to function in this reflexive and paradoxical space, explains why therapy training is long,  and very rigorous, and why its mandatory for trainee therapists to be in analysis. Qualified and practising therapists go to therapy too. I have done, and go back to replenish when l need to.

The Relationship- Boundaries

There need to be boundaries between the therapist and client in any therapy that is therapeutic. Many clients who are new to therapy experience a degree of frustration of having to tell the therapist about themselves, and the therapist not reciprocating. It makes sense to them why this is necessary as time goes on. The relationship between therapist & client  is neither a friendship, nor is it any personal relationship where you would discuss your day-to-day shopping, fashion trends, football or other day-to-day stuff. It is unique in many ways. It is a therapeutic relationship; a deeply intimate and meaningful one. Oversharing with clients turns the process into it being about us (therapist) than the client, and takes away the attention from the client. There is an imbalance of power from the outset as the client consult the therapist who has certain accolades to qualify their position. I always remind my clients that they are hiring me, which is true, and this neutralises the power dynamic. I remind my clients to call me by my first name (Joyline), as my professional title implies a degree of authority and knowledge.  When a therapist starts disclosing and overstepping this boundary, they are creating a power dynamic, where the client becomes secondary. Social media platforms also create real issues for some therapists with regards to what they can share, and how much they can share of themselves even if it relates to wellbeing, mental health, or therapy. It is indeed very easy to breach this boundary, albeit with good intentions. Clients come to therapy because their own boundaries may have been impinged on, or they have never learnt to create boundaries. By oversharing, we are simply modelling the pathology that they need to work on and retraumatising them.  Some clients come to therapy because no one has ever given them undivided attention, or showed an interest in them, and they are neither valued nor respected and feel ignored. It’s very easy to repeat the same trauma with our clients when we step outside the boundaries of a professional relationship.

Safety and Security in the Relationship

 Safety and security are innate needs, that humans are biologically wired to seek. We are programmed to seek safety and security and without it, we defer into survival modes of fight, flight or freeze.  Just as an animal would;  that’s the essence of who we are as humans, who belong to the animal kingdom. This becomes paramount in any therapeutic encounter. There is an encounter of two strangers. Clients need to feel safe, secure, and held, not just in a physical sense but held in the mind. This is the foundation of clients working through their difficulties, knowing that the therapist is holding them in the mind, and they are safely held. The therapist act as what Winnicott terms the “auxiliary ego” for them, by being able to hold the client in the mind. Winnicott (1960) wrote about this concept hypothesising that the therapy dyad mirrors the mother and baby relationship, where the client identifies with the baby, and the therapist the mother. The mother has to be capable of holding the baby safely, by having the function of being the auxiliary ego.

Despite there being different modalities to therapy, most therapy approaches will have the following qualities:

•  Discussing presenting issues & their onset
• Discussing past experiences
• Exploring distressing thoughts and feelings
• Affect and expression of emotions
• Identifying recurrent themes and patterns
• Learning to identify and name feelings
• Developing an understanding of our emotional life
• Making some links between past and present
• Creating a definition of self
• Meaning making-creating meaning around one’s experiences

Some therapy approaches (more specifically CBT) focus on the present, and will entail a lot of behavioural experiments and homework. This is unlike most approaches to therapy which are explorative, and themes emerge naturally.

As a therapist, I have struggled with the notion that there are certain modalities that are based on the principle that  by ticking boxes, clients’ experiences can be reduced to specific diagnoses, and there are certain “proven scientific tools” applied as a form of treatment. This is what some of the contemporary and so-called evidence-based therapies purport. The basis of this approach is a medical model; applying it to something hermeneutic (therapy) is problematic.  The human experience is very complex, and multifaceted- from its bio, psychosocial, spiritual, sexual, and phenomenological contexts. While I appreciate that this approach is helpful for some acute problems- OCD, Agoraphobia, panic disorder, etc, the approach itself is reductive, and simplistic.  With these type of therapies, clients  have a prescribed set of treatment, and  they come with a set of tools and a manual. I fundamentally believe that this approach disregards the contesting and multivariate nature of what it means to be human. It also undermines the significance of the fundamental aspect of therapy which is the therapist and client’s deep and meaningful relationship, which is key to any successful therapy. The tools become the focal point, and we forget the person who is suffering and why they are suffering in the first place. This does not sit well with me. That said, I have found using this approach (tools) useful as a form of grounding for clients who are experiencing present day distress and functional  impairment, before going into therapy proper. When clients build a deep and intimate relationship with their therapist, they are also learning to build an intimate relationship with themselves and others, and to trust themselves and others. If we have an understanding of ourselves, we are likely to understand why we feel the way we do and why we do things the way we do them. When we have this awareness, we respond and not react. We experience the world in a conscious fashion; knowing something makes it less scary, less painful, and more bearable.

Therapy Metaphors

The House-Rearranging Psychic Furniture

 When thinking about therapy, I like to use the metaphor of a house to describe our psyche. If your house is  unattended, dirty, with furniture disintegrating, rubbish everywhere, paint/wallpaper falling off, lighting going off, and you keep stumbling and falling in that house, it won’t feel good, living in it. It will feel quite scary, and unsafe. Using that analogy, therapy is akin to you simply cleaning the house (psyche), rearranging the psychic furniture, and bringing everything back to life again-light switches etc. Rearranging the furniture, will entail moving things around, opening some packages & looking at what’s inside them & getting rid of what we no longer need. That’s why therapy can be a painful process, as it means confronting some of these packages that may be “foul and rotting” and getting rid of them. These may be packages that we have relied on, and deemed important. Therapy is a process of continuous loss and grieving over the loss, of the old and coming to terms with the new; what we become.  When you have a clean home, you will feel safe & in control. You will know where to find things, value your property and likely to continue taking great care of it.  This is why people who come to therapy become acutely conscious of their boundaries- it’s the psychic boundary they create after the process of  cleaning & rearranging their psychic home.

The Gym- Psychological Stretching

Therapy enables emotional stretching and expanding one’s emotional bandwidth. We go to the gym to exercise in order to strengthen our muscles & core- physique. Our emotions also need the same kind of stretching in order to maintain a certain level of robustness & stamina. Therapy enables us to do the emotional stretching & helps us to access a repertoire of emotions available to us in our emotional landscape, and understand them. Being in touch with our emotions and experiencing them fully, is what makes life meaningful, pleasurable, and rich.

Some people apologise for crying in sessions. Crying in front of the therapist is seen as a sign of weakness, and shameful. These are unhealthy internalised  notions. When you go to the gym, you sweat. By crying in session, you are simply sweating. And that’s ok. Believe me, therapists do tear up as well, when they are deeply impacted by your story. They just don’t break down and disintegrate.  We are right there with you. And l must confess, l have on many occasions been deeply affected by my clients' stories (countertransference) and shed a tear with them.  For them. And that is indeed a special and deeply intimate moment, that no words can describe. In that moment, we encounter each other as fallible humans,  and heal together. l remain human, and will always be one.

References:

Casement, P. (1985.) On learning from the patient: Tavistock Publications. London

Klein, M. (1946). Notes on Some Schizoid Mechanisms. International Journal of Psychoanalysis, 27, 99-110.

Winnicott, D. (1960). The theory of the parent-child relationship, International Journal of Psychoanalysis, 41:585-595

Winnicott, D.W. (1969). The use of an object, International Journal of Psychoanalysis, 50:711-716