How Psychotherapy Works

by Mark Robinett, MFT
(originally printed in “The Counseling and Psychotherapy Newsletter of the Bay Area”, Sept. 1995)

How many people really know how psychotherapy works? It is a question of some importance today because people want to know; they no longer want to be kept in the dark about how therapy is going to help them with their psychological problems. The more the general public knows how therapy works and what a psychotherapist is supposed to do, the more power people will have in their ability to discern what is useful therapy and what is not. In addition, the more a person knows about how therapy works, the more she can apply herself and give herself over to the process of healing that occurs when therapy goes well.

There are over 200 different kinds of psychotherapy practiced today. The type of therapy I discuss in this article is the therapy that I believe does the deepest healing within an individual. It includes theory from four schools of psychotherapy:

The Psychology of the Self, Control-Mastery theory, Object-Relations theory and Trauma theory.

EMPATHY: The first and most important ability that a therapist needs to offer to a client is the skill of empathic attunement. A metaphor that I like to use for this tool is that of an M.D. using a stethoscope to listen to a patient’s heart while he is breathing. In the same way, the therapist needs to be able to listen to and “hear” what is emotionally in the heart of the client as he talks. Hearing what is in the client’s heart is usually more important than what he is saying verbally (unless of course he is connected with his heart). It is a matter of empathic attunement to the deeper parts of one’s being.

OPTIMAL RESPONSIVENESS: Empathic attunement is very good stuff, but the client needs to hear or “get” in some way that the therapist is empathically attuned. When a therapist is able to express what she hears or senses is going on inside of the client, and it is accurate and makes the client feel understood, we call that optimal responsiveness. Optimal responsiveness can also be being quiet on the therapist’s part, and again it is an outgrowth of empathy (a therapist’s ability to sense what will be the optimal response at the time). The therapist’s responses do not need to be optimal or accurate all of the time, but they need to be optimal enough, enough of the time, so that within a client a powerful inner experience is created of feeling understood at a deep level.

THERAPIST AS SELF OBJECT: When a client feels understood “enough” and responded to “enough”, he is able to use the therapist as a “self object”. The term self-object means that the therapist has become, for the client, a special person that is there for the “self” of the client. The self is one’s true self that resides deep within, and it holds one’s true feelings, thoughts, values and aspirations. When a person has a reliable (consistent enough) self object in the therapist, his “self” becomes able to resume any delayed, blocked or previously derailed developmental tasks due to (usually) deficits in the childhood caretakers.

What this means, basically, is that the real self can grow, and the self will grow in the areas that it needs to and wants to if it has this one most important need met; the need for a reliable, consistent enough self-object. Most of the work of therapy is facilitating new development, new growth and unsticking what got stuck earlier in life.

PASSING TESTS: Not all clients will allow a therapist to become a “self object” for themselves. Many clients require their therapist to pass certain “tests” as they go further into the process of therapy. These tests can range from something simple like the therapist starting and ending on time, not talking too much or too little, to much more sophisticated tests (often unconscious on the part of the client even though she has created the test) such as acting very weak and needing the advice of the therapist for help with very tough decisions, for example.

If the therapist doen’t recognize the test and gives the advice, the client, while seeming to enjoy getting the “special” advice of the intelligent therapist, will unconscioulsy feel disappointed and her real self will not be able to open up what it needs to to the therapist; i.e. the need for someone to help her make her own decisions because her parents made them for her. If the tests are passed successfully by the therapist, two things can happen, first, the client will open her self up to the therapist, and allow the therapist to be that certain special person that can be called a “self-object”.

This happens because the client’s deeper self believes that it is safe enough to allow this therapist to be close to it (it needs someone to have close by in order for certain parts of it to grow). Secondly, by passing the tests, the therapist may be helping the client to work through old experiences where her parents or other caretakers were not healthy or aware enough to provide this need for the person. As in the example above, the therapist will pass the test by not giving advice, and by assisting the client in making her own decisions. The long-range goal of these tests is often the unconscious design of the client to teach the therapist how to be the taylor-made healer for her real self.

WORKING WITH DEFENSES: Usually in the course of a therapy, a client’s defenses will appear in one way or another. Assisting a client in taking down unneeded defenses could be seen as similar to how the U. S. and the Soviet Union are dismanteling their nuclear arsenals. Some defenses are very necessary, and these are often called boundaries, or ways to protect oneself from noxious people and situations.
People often have other defenses, however, which block out the good things that are available in life.

For example, if a man was, in childhood, criticized alot by his father he may have formed the specific defense of not taking anything in from other men that sounds anything like criticism. Friends might notice this defense as his not listening to advice, even when it would be benefical for him to.

In therapy, a therapist might notice the defense whenever he (the therapist) makes a neutral comment such as “I noticed that when you talked about what you did at dinner yesterday, your voice became very quiet; do you know what was going on inside?”

At which point the client might say, “I don’t know!” in an angry voice.

The therapist’s job at this point would be to ask about the noticed anger:

“You seemed angry as you answered me, do you know why?”

The client may not be able to say why, and the therapist may need to suggest something like: “I had the feeling that you felt I was criticizing you when I asked you about your voice being quiet…”

Sequences like this may need to be explored and gone over again and again until the defensive pattern is worked into something more useful, such as an ability to discern what is useful feedback from a person and what is not, and how to respond to either in skillful ways.

Working with defenses can also be about working with certain patterns of being that interfere with enjoying, or simply experiencing life, i.e. patterns that actually cut off the emotional and mental experinences of living. These kinds of defenses often come from traumatic experiences which have caused a person to withdraw in some way from people and/or life. These patterns need to be talked about, explored, explained by the therapist, and empathized with, often over and over again until the patterns are dissolved. In addition, the trauma needs to come out of the person by talking about the traumatic experiences and expressing whatever feelings are associated with the experiences. Another label for this kind of work is trauma resolution.

Putting all of this together, what actually makes the wheels turn in therapy are:

(1)There first needs to be a therpaist who is able to be empathically attuned enough to the client, and is able to let the cleint know (optimally respond) that he is “tuned in”.

(2) As a client experiences being attuned to and optimally responded to, the therapist becomes a self-object, or a very important person to the cleint’s real self.

(3) Then in order for the therapist to stay in this position, he may have to pass some or many tests to prove himself worthy of being a healer for the client, and continue to be experineced as a self-object by the client. As long as the client continues to experience the therapist as a reliable “self-object”, over time she will be able to resume developing (growing) delayed or buried parts of herself. It could be thought of as a garden that hasn’t been watered for a long time, now being watered (and warmed by the sun), and all the delayed or buried parts of a client being like bulbs down in the ground waiting until enough water and warmth comes.

(4) Sometimes complications besides tests also come in the work of therapy in the form of defenses or negative behavior patterns, both usually due to trauma. With these the therapist must know how to help the client dissolve the defensive patterns and heal the inner trauma. If the therapist can do this plus all of the other things mentioned above, the wheels will turn and therapy will work.