Structured Interventions: Tools to Aid the Healing Process
Many of the problems which we face in day to day life have relatively straight-forward solutions. When something breaks, we find the broken part and replace it. When a road is unexpectedly closed, we look for a new route to get to where we’re going. When our income changes, we adjust our spending to compensate. This is often the case with medical problems as well. When we go to the doctor, the doctor assess our problem and prescribes solutions such as medications, physical therapy, or surgery, among other things. As a result, many people enter psychotherapy with similar expectations, however, psychological healing isn’t as simple as replacing a part in your refrigerator. As a mentor of mine used to say, “there’s no paint by numbers.”
Many therapists become specialists in using particular therapeutic techniques to treat their clients while others become technically eclectic; employing a wide variety of approaches, depending on the client and the situation. Research has shown that the particular therapy techniques that a therapist uses is statistically insignificant in influencing outcomes of therapy, that therapy works, and that the relationship between the therapist and client, among other factors, is one of the most influential elements in determining outcomes (see common factors research in psychotherapy). In other words, specialization and technical eclecticism are both valid, techniques are helpful, but they are not “paint by numbers” cures.
In addition to technique, therapists rely on theory to help them understand how human psychology works and how to help people heal and achieve their goals. Theories of psychotherapy are built upon observation, research, and the collective clinical experience of practitioners in the field since the beginning of the profession. While there are hundreds of theories of therapy, and no unified theory, a great deal of overlap exists between theories to the point that they start to appear more like different metaphors to explain the same complex phenomena that is the human experience. Theory gives the therapist a way of understanding what is happening and what the healing process is, while techniques are tools which can help get the healing process moving.
Why isn’t healing more straight-forward? It sure would be nice, if it was, but people seeking psychological help face a multi-faceted problem: we are largely driven by unconscious patterns, we may have been hurt and find it hard to build trust, and healing often requires going through discomfort. Trust takes time, especially when we have been hurt, and a good therapist will earn that trust over time by the way that they relate to you; by being empathic, genuine, and non-judgmental. That trust is necessary in order to feel safe looking inward, tolerating and opening up about uncomfortable thoughts, feelings, or experiences, or trying the techniques that your therapist suggests.
When I treat clients, I use structured techniques as tools for self-regulation, to deepen self-awareness, and to practice for real life situations. There are many great techniques for helping us feel more calm when overwhelmed, or connected when we get disconnected. Other techniques are great at helping start to notice patterns and other elements of our experience that we didn’t see well before. Still others are great ways to practice things we want to do or say in our real life that we may not know how to do or say or that we may feel anxious about doing or saying. Techniques are an opportunity to try on new ways of looking at and dealing with our difficulties. Therapy is a unique and personal process, in a healing relationship, and techniques are tools the therapist uses to help that process along.
Healing Experiences in Therapy
A great source of healing in psychotherapy comes because of the kinds of experiences, relational and otherwise, that occur during the therapeutic hour. We learn what is and isn’t acceptable, how to relate to the world, and how we expect the world to relate to us, primarily through early relationships with our attachment figures. Some learn that they aren’t safe, during traumatic experiences of various kinds. This early relational and/or traumatic conditioning is difficult to change, even when we know intellectually that the difficult times are over. Old patterns of relating to the world, ourselves, and others overtake us and repeatedly get in our way. With a therapist, we can learn new ways to relate to others, ourselves, and the world.
Therapists relate to their clients in a variety of ways, but in general, they will strive to be empathetic, non-judgmental, and genuine. Many people come to therapy having lacked such relational experiences, at least in some important way, during their early years. As a result, these individuals will expect future relationships to let them down in similar ways. Many will find themselves unconsciously pursuing new relationships with the same old dynamics which they felt trapped in growing up. Still others will find themselves automatically treating those they wish to be close to in ways that encourages the unwanted pattern to be re-created. In therapy, the client gets to learn through building a relationship with the therapist and instead of living these old patterns, having a different outcome.
Sometimes, the healing experience comes simply from expressing parts of one’s self that were treated as unacceptable, and in therapy, being accepted. At other times, it comes from getting to know yourself better because of being really listened to about something, or getting a genuine response to something, when others had not listened or not been real with you in some way. The therapeutic relationship gives opportunities to try out new ways of relating that may have felt ineffectual or unsafe in the past. Because the therapist is a person, they will at times make mistakes, have lapses in empathy, and may even temporarily fall into old patterns of relating with you. As difficult as this can be, it creates the incredible healing opportunity of having something go awry in a relationship and having that relationship repaired.
For individuals with trauma, the feeling of being unsafe is a great challenge. When the trauma is relational, being with others, including a therapist, can feel dangerous. It takes a great deal of courage to explore one’s self in therapy, and this is especially true for people with relational traumas. Repeated experiences of being safe with the therapist can increase one’s sense of safety with others. Non-relational traumas also lead to a sense of not being safe, and a therapist can help one practice various things to calm down from overwhelm, tolerate anxiety, and establish a feeling of safety again. In therapy, you learn to be in and use your body to express and take care of yourself, to trust yourself, to be with others, and live authentically in the world again.
How Therapy Heals: Non-Judgment
Research has repeatedly shown that the relationship between a therapist and client is one of the most influential factors determining the outcome of treatment. Quality relationships are important for maintaining mental health, physical health, and overall quality of life. A good relationship with a therapist differs in many ways from the relationships in your personal life; differences which are uniquely healing. One of the most important aspects of a good therapeutic relationship is that it strives to be non-judgmental.
To be non-judgmental as a therapist (sometimes referred to as having unconditional positive regard, or radical acceptance) does not mean that the therapist won’t have thoughts about whether certain patterns in your thoughts or behavior are in the best interest of yourself and/or others. It also doesn’t mean that the therapist won’t ever disagree with you, say no to a request, or feel frustrated in a difficult interaction. It does, however, mean that the therapist will not judge you as bad or shameful. In other words, what you bring to therapy, including those things about yourself that you and/or other people find difficult to accept, will be approached with curiosity, compassion, and the understanding that it all makes sense somehow, rather than with judgment.
Non-judgment from the therapist is crucial, because judgment prevents us from exploring and understanding elements of our personalities that may be getting us stuck in our lives and relationships. You can’t change something, if it needs to be changed, if you can’t even look at it for fear of being judged. The feeling that something makes us shameful or bad is powerful, because we need to know that we are safe with, belong to, and are loved by others. Shame is the feeling that we are not worthy of that love and belonging.
People often struggle with judging aspects of themselves as shameful, because they learned that aspects of themselves were not accepted by important others in their lives, in one way or another. Some people repeatedly end up in relationships with others who judge them harshly and often. An additional challenge comes, when one has also hurt others. A non-judgmental therapist makes room for all of who you are, so that what needs to heal can heal and what should not have been shut-down can be expressed freely again. It can take a long time, to stop judging the more challenging aspects of ourselves, but the encouragement, modeling, and just plain good feeling of being accepted fully by another person helps us to see that we can face whatever we need to face to live more fully and authentically.
I’ve Never Been to Therapy, What Should I Expect?
Psychotherapy is a bit of a mystery, for people who have never experienced it. Many of us are familiar with the pop culture cliche of a person laying on a couch, going on about something that is bothering them, only to have the expressionless therapist sitting across from them say something like “uh-huh… tell me about your mother.” And while your mother may be a fruitful topic for therapy, suffice it to say that this isn’t what therapy looks like in reality. Psychotherapy is a rich, collaborative exploration that varies widely across therapists, clients, and even between sessions for the same therapist and client.
A graduate school professor of mine once told me that there are over 300 recognized theoretical orientations in the psychotherapy profession (not to mention those approaches which aren’t recognized as valid)! There are also hundreds of thousands of people practicing therapy at any time, and we all bring our own individuality into our work. The wide variety of approaches, and therapists implementing them in unique ways, with unique clients, contributes to the mystery that many new clients enter into, when they decide to give therapy a try. It may sound counter-intuitive, but research analyzing the outcomes of therapy has repeatedly demonstrated that it’s not the particular modality of therapy that is important, but the relationship between the client and the therapist, and other common factors, including the authenticity of the therapist and their use of methods which they truly believe to be helpful.
One way that therapies can differ is in the amount of structure that is used in therapy sessions. Every therapist uses structure to some degree, and many will change the amount of structure to fit the particular client and the particular situation. Some therapists will introduce structure in the form of paper assessments (questionnaires) which they will ask you to fill out and perhaps discuss. Some therapists follow step-by-step protocols which they may or may not explain to you along the way. Another way that therapists can create structure is through how directive they are (e.g. giving you specific instructions in session, assigning homework regularly). On the other side of the spectrum are therapists who tend toward a more exploratory and organic approach; allowing the therapeutic process to be led by the client, the growing therapeutic relationship, and their own intuition. There are merits to using more and less structure in therapy.
When I meet with clients for the first time, I usually start by asking them something like “what would you like to get out of therapy?” What I do depends a great deal on how the person answers this question. In my work with clients, a lot of time in therapy is spent in a conversation in which I am striving to encourage a mutual exploration of the client’s experience and what is getting in the way of them having more of the life that they want. I often introduce more structure when it seems to me that the client is stuck in some way and/or overwhelmed. Sometimes, clients need a structured exercise because they are struggling to think or feel at all. In these circumstances, we will experiment together with different exercises, to see if we can get the client un-stuck and/or calm and centered.
People vary greatly in how much structure they need, in order to work through their difficulties, and the same person will have different needs for structure at different times. People also vary in the amount of knowledge that they have in regards to psychology, relationships, and their own inner experience. Some people come to therapy, knowing only that something in their life just doesn’t feel right, and they may initially need their therapist to take the reins a bit more. Other people come in with a lot of things that they wish to work on and a desire for their therapist to act as more of a facilitator. Over time, clients may come to learn that they can benefit from an ability to seek helping in relationships that is sometimes more and sometimes less structured and directive.
Some people find it difficult, at first, to sit with a therapist without knowing what is going to happen. It’s quite normal to have anxiety, when you start going to therapy, because you’re meeting a complete stranger with whom you will at some point be exploring vulnerable parts of yourself. My best advice here would be to share whatever you feel comfortable sharing about why you are coming to therapy and if this therapist is a good fit for you, your trust in the therapist and understanding of what you need will grow naturally over time. If you have questions, ask them. If you don’t want to do something, let your therapist know. If you disagree with your therapist, share your disagreement. If you feel like you should be focussing on something else, say something. Regardless of how much structure a therapist is using, therapy is first and foremost a healing relationship. Above all else, learn to trust your gut and honor your experience; a good therapist will do the same.