The A-Z of Therapy: 101 Therapeutic Concepts

A

…Anger, Anxiety & Avoidance…

1. Anger

For some people anger is one of the scariest emotions to experience, whether in life or therapy. Maybe the person has had bad experiences with anger in the past: anger leading to violence or aggression, perhaps. Or maybe the inverse: they have never experienced it and so presume it must be cataclysmic if ever unleashed.

In fact, anger is an emotion which is - at least intrinsically - no better or worse than any other (sadness, happiness, relief, embarrassment) and yet for many of us it is the most fear-inducing of them all. How we personally read anger can vary wildly: for some it is synonymous with shouting or violence, for others silence is the most intimidating.

Therapy can be a great place to dare to express it; to practice allowing it out – safely and honestly – and discovering, if your therapist can help you, that it is not the same thing as violence and that its release can be just as relieving as a good cry.

2. Anxiety

Anxiety is the petrol of most therapy: the basis for seeking it, the fear of pursuing it, the recurring feeling in the early days of it (and sometimes beyond). Indeed, the act of talking to a stranger about deep, personal, under-explored material is intrinsically anxiety-inducing for some people. 

What clients often discover, though, is that navigating the anxiety with their therapist in support (“I’m feeling this” “When you said that, just then, it made me feel this”; “My heart is racing now” “My throat is tightening” “I’m finding it hard to look at you”) can, counter-intuitively, alleviate it. Anxiety is the schism between the now and the later, or between the certainty and the maybe, and is often firmly based in anticipation (“What if I say this?” “What if this happens?” “What if he responds like that?”). 

Letting your therapist encourage you to gently walk through the scary terrain, with him or her walking alongside you, knowing you can always stop or turn back if it gets too hard, is often what allows anxiety to begin to be taken control of rather than it controlling you.

3. Avoidance

It is not untypical for an exchange in a therapy session to go something like this:

Therapist:        So was your mother a good mother do you think?

Client:              She did her best.

or

Therapist:        What feelings does that bring up for you?

 Client:             It makes me think of a time when….

 or even

 Therapist:        Do you think such-and-such might be going on here?

 Client:             I’ve never thought about. Changes subject.

All of these, and thousands of others, are examples of avoiding a question. This is, of course, fine; nobody is obliged to say anything they don’t want to. But it is often important to notice oneself doing it (sometimes with the help of the therapist) and to wonder why. Is it the sort of question they would avoid with anyone? Is it a question they fear might open up an uncomfortable avenue of exploration? Does the answer, if expressed, feel dangerous in some way?

Politicians dodge questions to avoid getting into trouble, and usually do it consciously. Clients often slide away from uncomfortable questions for complicated reasons, and usually unconsciously. The motivation for the dodge is often more helpful to the therapy than the material being side-stepped.

Avoidance is a message. It is good to try and wonder, together, what it might be. 

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B

Body, Body Language, Boredom & Bravery

4. Body

Many people approach therapy with the expectation of a largely intellectual exercise: “Here are my problems, here is why, what do I do about it?” All of this is important, of course, but if someone could think their way out of their dilemmas they probably would have done so already. The real storage vessel for vital information, process and opportunity is contained in the body.

We can fool our minds into believing we’re ok quite easily; our body is a different story. As Susan Aposhyan, the brilliant articulator of the “body-mind” connection, says “The body reflects the mind and the mind reflects the body.” It remembers every experience we’ve ever encountered and often will (cough) helpfully (aka ‘confusingly’ or ‘frighteningly’) communicate a hazard light on our internal dash board saying ‘Problem”.  Maybe anxiety, heart palpitations or restlessness. Or, in some cases, maybe panic attacks.

Therapists asking “How do you feel about that?” is a hideous cliché and many of us hate using it for that reason, but it is also the most fundamental question for the therapeutic experience. Because if a therapist can encourage you to notice that (for example) the way you experience anxiety talking about your boss is quite different from that which you feel talking about sex but very similar to how you remember feeling when you got told off in a PE class fifteen years ago, then slowly but surely we can work out what your body is experiencing in those different scenarios and what we can do to release it. Often, the body is responding as if in the past tense to an experience in the present tense. What we seek to do is to disentangle those experiences.

It is no wonder that the most famous book on this subject is called The Body Keeps the Score. It does.

5. Body Language

Every one of us has particular quirks of our non-verbal communications (body language). We tend to sit in a particular way, scratch a particular area even when it’s not itching, or hold eye contact in a certain way. In therapy, body language communications can be incredibly useful, as they can sometimes reveal something different or additional that’s going on for the client than what she is communicating in words.

Why does Billy look away when he’s talking about his father? Why do Brenda’s hands go into claws when discussing her partner? Why does Bec always giggle when talking about their bereavement? Why does Bob slump in his seat?

One doesn’t want to get all Derren Brown over it (great as he is, obviously), but it’s often helpful to notice and occasionally helpful to discuss.

6. Boredom

In therapy boredom is interesting.

Very rarely in therapy is anything boring. Indeed, often it is incredibly interesting: if the narrative being expressed was put in a long-form article in a Sunday newspaper it would feel like a riveting life history. And yet the client is bored. Or, alternatively, he expresses his powerful story as if it is a total snooze.

Boredom is an escape; a way of dissociating, a way of giving a memory minimum emotional force. Unconsciously, the person under-sells it. On some level they may even hope their therapist will be bored and thus not force them to go further into an experience which is actually very difficult for them. Maybe it’s embarrassing, maybe it’s confusing, maybe it’s traumatic.

But it’s not boring.

7. Bravery

Many people come to therapy feeling scared: scared at what they can’t control, or of their responsibilities, or of their lack of clarity, or of their pasts or futures. Many people experience that. But all of them are, in fact, brave: brave at acknowledging what’s difficult, brave in seeking to do something about it, brave in sitting in a room with a therapist to try and explore, explain and change it.

For me, going to therapy is one of the bravest things a person can do for themselves. And the best therapeutic experience is one which allows us not only to acknowledge and grieve our vulnerabilities but also to identify and amplify our resilience. “Yes this happened but I survived it.” “Yes I feel this every day but still I go to work.” “Yes I can’t make ends meet but I have found a way to spend some money on making my life better.” All of that is brave.

And bravery is the foundation stone for change.

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C

Change, Childhood, Confidentiality, Contracting, Crying

8. Change

If therapy has a number one purpose it is to facilitate change.

What the change is, of course, is up to the client. It’s their life, not the therapist’s. Maybe it’s something obvious: they want to have decided whether to stay with their partner, or sleep better, or learn how to express their feelings without feeling scared. Maybe it’s something subtle: they want to feel more confident in who they are and what they need, even if nobody else notices. Either of these are changes.

What therapy isn’t, at least to me, is a space to research an essay on ourselves. Understanding ourselves is essential but insufficient. You understand why your heart races every time you hear a particular song, say: that’s great, but now what? 

Therapy is a place we go to learn how to change.

9. Childhood

Whatever style (‘modality’) a therapist works in, it is likely that a client’s childhood will arise at some point in the work. Whether you had a good, bad or indifferent upbringing, our younger years are crucial to understanding how patterns of behaviour developed, how particular understandings of the world took root, and how your way of relating to people developed.

As David Brooks summarises in his brilliant book The Social Animal (2011): “No-one is locked into any destiny during childhood. But they give an insight into the internal working models that have been created by the relationship between  parents and child, models that will then be used to navigate the world beyond.” 

Don’t be afraid of such enquiries; it usually contains great gold.

10. Confidentiality

There is no more important sentence uttered by a therapist in a first session than “Everything we talk about is completely confidential”.

Few clients would be able to make themselves as vulnerable or as honest as they need to be if they felt there was any chance of someone else knowing what they talked about. A therapist always keeps all session content confidential (with limited exceptions such as if someone’s safety is compromised); whether the client does is up to them.

Some clients go home and tell their partner or housemate everything that was discussed in a semi-verbatim blow-by-blow account. For others, nobody in the world knows that they’re seeing anyone; the idea of anyone asking “How was therapy?” would convulse them in shame. Neither response, nor any of the shades in between, is unreasonable. It’s what works for you.

But the therapist ain’t talking.

11. Contracting

‘Contracting’ is the few minutes that takes place early in a therapeutic relationship (often in the first session) in which the therapist and client agree the basic boundaries of how they will work together.

In general this involves a commitment from the client to attend every week at a set time and at a set fee paid either weekly or monthly, and the therapist committing to making that slot available only to him/her, to treat their material confidentially and caringly, and with some understanding of how absences and holidays are handled. Some therapists encourage clients to sign a written agreement, usually just a page or so; for many it’s just a verbal understanding.

Like any contract or agreement, it is crucial for both sides to know what the deal is. And then they can forget about it and concentrate on what they need.

12. Crying

If the number one expectation of therapy is that it will involve pauses (see entry 59, below) then crying has to be number two. A box of tissues is just about the only prerequisite for any therapeutic space.

Crying is a release. People cry from unhappiness, despair and grief, of course, but in my experience tears enter sessions just as often from relief, revelation or connection. The person might release via a sigh or a laugh or a blush. But crying often comes first. 

Being witnessed with our tears – whichever particular kind they happen to be – is one of the most affecting experiences in therapy. And, for many, the most life-affirming.

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D

Defences, Dependence, Dissociation, Dreams

13. Defences

Defences get a really bad press. “Oh my God he’s so defensive”, we say of our friends. Well…yeah maybe he is. And he may have a really good reason.

A psychological defence is like a shield: it protects us from incoming danger. The difference is that we don’t always realise we’re doing it and we often don’t know what caused us to start doing it in the first place.

A defence can be as obvious as someone getting angry with their therapist for asking something (“My parents were fantastic; I don’t want to talk about them”) or as subtle as not holding eye contact when talking about something which might reveal emotions. Whatever the defence, therapy can be useful in two ways.

First, if spotted, we can wonder whether that defence you just deployed is really necessary now or if, in fact, it was vital when you were 12 or with your critical uncle or your competitive colleague, but not necessary in other contexts. And we can practice lowering our shield: saying or doing something without the defence and seeing what it brings up.

The aim is for you to be able to use your shield when you need it, rather than your shield appearing to use you.

14. Dependence

For some, the idea of dependence is the ultimate safety: Daria can trust in her parents or her husband to always look after her. But for Desmond, dependence means powerlessness; he’ll always feel like a child dependent on a dominant parent.

The same mix of feelings can arise in therapy: a client seeks (often unconsciously) to depend on their therapist, for it to feel like the ultimate relationship of trust. For others, that is the nightmare scenario: “If I depend on my therapist,” Denise thinks to herself, “how will I ever leave?”

Therapy is partly about helping someone towards independence; giving them the confidence to have their own needs and make their own choices. To get there, though, often needs some level of dependence first.

As with parents, one often needs a period of dependence through which to develop the tools of independence.

15. Dissociation

To dissociate is to disconnect from the emotions held within an experience.

Someone talks about a trauma which they experienced and yet without any apparent feeling about it, almost as if it had happened to somebody else. This is a common experience. Sometimes someone might literally yawn while expressing something heavy, as if their body is too tired to connect with it. These responses are as relevant as someone becoming overwhelmed, enraged or emotional. “No response” is itself a response.

Dissociation can be even more bizarre. Someone is asked about something that happened in their childhood and suddenly they can’t remember the question, much less the answer. As if an over-ride button has been pressed, marked “Move Away Now”.

If we can understand what makes something hard to connect with we can perhaps understand what that event or emotion means for you. And, even more valuably, we can wonder what else has been ‘turned off’ when that Danger button was pressed.

16. Dreams

Daniela dreams one night of a huge lion walking through the grounds of her primary school. What might this mean? It all depends what the feelings mean for her.

Freud called dreams “the royal road to the unconscious”. Some people assign them a near-mystic power. In fact, dreams are a place in which we are able to process feelings or thoughts which would be too challenging while awake. Our minds find images or stories which best allow us to safely experience a challenging combination of feelings.

So back to Daniela. Let’s say she associates a lion with danger and her primary school with safety. In that case then perhaps the dream is allowing her to experience the sense of a lurking danger within a normally safe environment: a stranger to the family home, perhaps; a new boss taking over at work; a new teacher at school. Or maybe a lion, for Daniela, connotes strength and primary school suggests entrapment, in which case the dream is allowing her to feel that one way or another she can overpower the strictures of her school environment. After all, everything in the dream is a part of her: it’s her dream. The lion will be some part of her.

In therapy, dreams can be very useful in offering us access (maybe even a preview) to feelings which are being stirred beneath the surface but not yet accessible to us. They are always worth noting and often worth mentioning.

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E

Endings, Erotic Transference, Ethics, External Locus of Control

17. Endings

Concluding therapy is one of the most important stages of the entire experience. Whether it’s been a good or a bad relationship, a six-week problem-solver or a long-term odyssey of change, deciding to end and how to do so can inspire strong reactions – anger, grief, guilt, relief.

The way in which the client approaches this most delicate of stages is often a helpful pointer to that person’s relationship with endings elsewhere in life.

Some clients end by email – “Thanks very much for your help, I think I’m fine now” – rather than risk the difficult emotional experience of saying goodbye, perhaps fearful of hurting or offending the therapist, often determined to keep the relationship as distant and plutonic as possible. But being professional does not mean being impersonal. Other clients pursue a slow fade-out period, over several weeks or even months (particularly if they have been in therapy for a while).

I always encourage people to fade down – even if it’s only over two or three weeks – so that the relationship can be brought to a close rather than simply have the lights turned off in a way that leaves things unsaid or untouched which may later be regretted. If someone wants to leave, my role is to make that experience as helpful as I can however long or short it may be.

But in the end it’s not my decision.

18. Erotic Transference

One of the more famous clichés of how clients relate to therapists but less openly explored than it should be, erotic transference can be a dynamic at play between client and therapist for some people at some times. So how does that work?

The love, support and encouragement of the therapist feels so embracing and comforting that the feelings intersect with a client’s longing for such feelings in a romantic or sexual context (or perhaps association with having had them). The client can panic “Oh my god does that mean I am in love with my therapist?!” and it can feel like a feeling that must never be spoken for fear of being rejected. This is not true.

Love or attraction is just as valuable and challenging an experience in therapy as anger or contempt. All of it is useful to work through. But, as in personal relationships, whether to raise it or how it will be received is very challenging. Hopefully a therapist can help with that.

19. Ethics       

All qualified therapists are bound by the Code of Ethics of one of their qualification agencies, often BACP or UKCP. Such ethical obligations include duties of care, confidentiality and not pursuing any dual relationship (for instance going into business with someone with whom s/he has previously given counselling, and - obviously - no romantic or sexual relationships).

Hopefully ethical factors are largely invisible to the client in a session, but are always present for the therapist.

20. External Locus of Control

This grand-sounding phrase, first expressed by child-expert Donald Winnicott, refers to someone with a tendency to give their autonomy (power over their lives) to someone else: they will always ask their mum what they should do; they won’t act without their wife’s approval; they cannot determine whether their work is good without first hearing what others have to say.

This is not just about seeking approval; it’s about a way of being in which she does not feel she can run her own affairs.

In such cases, this is likely to manifest in the therapeutic relationship. A client will ask their therapist “How am I doing?” rather than feeling able to make a judgment for themselves in how/if they are progressing or whether anything is getting better. If spotted and explored, therapy should be able to facilitate someone to dare make such judgments and decisions for themselves.

The problem is usually not the individual decisions, but the idea of making any decisions at all.

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F

Fantasy, Fear, Fifty-Minute Hour, Fight/Flight/Freeze, Freud

21. Fantasy

You might think that therapy is the last place in the world you should be fantasising. You’d be wrong.

Therapy can be a place to imagine. Perhaps to imagine the life you want to live, the things you’d love to say to your partner, the way you’d expect to react to someone saying something to you. It’s a place to practice new feelings or confront scary ones. If you can survive it, then maybe you can take the fantasy out into the real world. If not, then you can leave it safely in the therapy room and the counsellor won’t tell anyone.

Fantasy – whether deliberate or unconscious – is an incredibly valuable tool of therapy. And that’s a fact.

22. Fear

One of the great titles of any self-help book is Feel the Fear and Do it Anyway. There’s something to that message.

Fear stops us doing, saying, thinking or acting in particular ways. Sometimes we know what we’re afraid of: rejection, anger, violence, shame. But often we don’t. Our body is telling us that to say something will bring terrible consequences, even though our mind knows that those consequences are extremely unlikely. Exploring this in therapy can lead to some interesting revelations, perhaps something like this:

Therapist:        So what does it feel would happen if you told him how hurt you felt that day?

Client:              Nothing. He’s lovely.  I’m completely over-reacting.

Therapist:        Ok. But is that what your body thinks?

Client:              No. It thinks he’ll humiliate me and I’ll never live it down.

Therapist:        Has your brother ever reacted that way?

Client:              Never. He’s not remotely that kind of person.

Therapist:        I wonder why your body is so convinced otherwise.

In such contexts the fear (or fantasy – see above) has overtaken the logic. This is very common. That’s why it’s necessary to work out what the body feels will happen, however seemingly illogical.  Sometimes people literally feel they will die if they say something: they know they won’t but they feel they will.

When we can work out why we can drain the effect of the fear and try and allow the person to respond in the real world.

23. Fifty-Minute Hour

Therapy sessions run 50 minutes in almost all cases for simple practical reasons: 50 minutes of session, 10 minutes for the therapist to collect their thoughts before their next appointment, time for one person to leave without bumping into the next person arriving early. That’s the logic. But there’s a more prosaic reason steeped in history.

Fifty minutes is how long Freud could go without needing to pee.

24. Fight/Flight/Freeze – Three Responses to Threat

You’re standing alone in the middle of a deserted country lane and out of nowhere a grizzly bear stands facing you in the middle of the road, twenty feet away. What do you do? You have three options.

You can fight. You run at full force at the bear, perhaps making a guttural roaring sound as you do so. You are ready to break its neck with your bare hands, ideally before it eats your face off with a single bite.

You can fly. You can run as fast as you can and hope to outrun the bear, which, given that its survival depends on running a lot faster than things it wants to eat, could be problematic.

Or you can freeze. You can hold very still, stare the bear down, let it approach you (if it insists) but hope that your calm cool demeanour will mean that it loses interest and moves off to find a better source of nourishment elsewhere.

The bear is “Threat”. Each response might work brilliantly and save your life, or might turn out to feed yourself to the bear. You don’t know.

Which one you pick reveals a lot about you.

Let’s say the threat, for you, is being told off. Do you ‘fight’ – turn your timidity into strength, shout back at the teacher/parent/boss and act like you’re every bit as tough as he is? Do you ‘fly’ – leave the room, change the subject, resign from the job, put as much distance between you and the threat as possible? Or do you ‘freeze’ – go very quiet, try to become invisible, sink into your chair, hope your assailant will just give up on you and leave you alone?

For most of us there is one of these three fear responses which dominates our life. We learnt that at some point.

Therapy can help us take charge of our responses to threat, rather than respond in the way we learnt decades ago.

25. Freud

Sigmund Freud was the father of psychoanalysis which begat psychotherapy. Most of what we know about the functioning of the human mind and the practice of therapy of any kind was sparked by him – whether following in his example or reacting against it. And more or less everything The Person On The Street thinks about psychology – the id, ego and superego, the Oedipus Complex, dreams, Freudian slips – comes from him.

Smart people like to bitch-slap Freud, for his God complex or his misogyny or his methods. Smarter people know he was a genius writing in a particular time and place.

Freud sits quietly in the corner of most therapeutic encounters. And I am grateful to have him.

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G

Gender, Grief, Grounding

26. Gender

The respective genders of the therapist and client are often highly relevant to the work. Here’s how.

First, different genders will have different experiences of the world and thus different sensitivities to it. The relationship can replicate this: Gaynor may believe her male therapist cannot understand what it’s like to be objectified; Griff may feel awkward talking about his masculinity to his female therapist for fear of feeling emasculated. Gerry may be nervous of meeting a cis therapist for fear of being rejected for their gender identity like they have frequently been by others.

Erotic or intimate ingredients can play out too: flirting (consciously or otherwise), attraction or a sense of courtship. For many, these feelings - far from being pleasurable - are loaded with negative associations. All of these are human responses and can be just as valuable as many other dynamics. But it can also be terrifying for the client and sometimes very uncomfortable for the therapist.

The second reason – discussed in more detail in my blog Choosing a Therapist - https://benetcattytherapy.com/thoughts-1?offset=1599606683347 – is how the choice of a particular gender of therapist is relevant to the client. Do they only feel comfortable with their own gender, or does that have challenging associations? If the client has had a repeated experience with a particular gender (being let down, or abandoned, or abused) they may ‘project’ this onto the therapist. Does a trans woman only want to see a trans therapist who may have a similar life experience, or be seeking a cis therapist who may represent the world she is trying to navigate?

There are good reasons on all sides, but it is worth nothing what your personal response might reveal.

27. Grief

Grief frequently laces the therapeutic experience, not always in obvious ways. We grieve for someone who has died, but just as often we find ourselves grieving for a relationship, an opportunity, a memory, or even ourselves – the person we hoped to be, perhaps, or the time in our lives which was stolen by a trauma in our past.

The go-to person on grief is Elizabeth Kubler-Ross, the Swiss-American psychiatrist who wrote twenty books on the subject of death, and gave birth to the widely-known Five Stages of Grief. We may pass through each of them in varying order, flip back and forth between them, or even not experience some of its stages at all.

 These five stages map what she called “grief’s terrain”.

DENIAL

Following a huge loss, our psyche decides that we cannot cope with it. We understand (usually) that the loss has taken place but we experience it as if it’s a bad dream, perhaps feeling as if the person will soon be home from work, and we are still able to go about our lives relatively well. “It is nature’s way of letting in only as much as we can handle”, Kubler-Ross tells us.

ANGER

Often illogical but frequently passionate, we feel burning anger: at the person who died (how could they leave me?), at ourselves (why didn’t I realise….?), at other people (how dare they carry on without this burden?), maybe at God (why are you punishing me like this?).

While horrible – and sometimes challenging for the people around us to experience – anger is a good sign: it suggests we feel we are safe enough to experience it and survive. It’s important. As Kubler-Ross says “don’t let anyone criticise your anger, not even you”.

BARGAINING

Bargaining is the “if only” stage; the place where “what if…” and “next time….” occupy our thoughts. It is our mind taking charge for a while: changing the past or seeking to change the future by imagining a parallel world in which something or someone isn’t lost. Ultimately, of course, we must come to the crucial but tragic realisation: it makes no difference. The person has still gone.

DEPRESSION

As with anger, depression is an emotion which many people are very bad at handling when they see it in their loved ones. They try to cheer us up or help us to “move on” (or away) from it. Whereas in fact a withdrawing of our energy - from the world and ourselves – is a completely necessary response.

Kubler-Ross says “…depression is a way for nature to keep us protected by shutting down the nervous system so that we can adapt to something we feel we cannot handle”.

ACCEPTANCE

Acceptance is not being ok with the loss, or meant to suggest “getting over it”. When we’ve lost someone or something important to us it may be unlikely that we’ll ever fully “get over” it and nor would we want to. As the late Queen Elizabeth II said following 9/11, “grief is the price we pay for love”. But acceptance is where we accept the new reality and begin to feel we can operate in a world in which that person is no longer with us, that time in our life is never coming back, this new normal is where we will be living. It’s not about liking it; it’s about accepting that we can find a way of operating within it, however much we wish we wouldn’t have to.

Grief is a fundamental ingredient of many therapeutic experiences, and finding acceptance is perhaps its biggest challenge.

28. Grounding

When we panic, or dissociate, or become overwhelmed, we can ‘float away’, get into our heads, become dizzy, tired or seasick. Our mind is working so hard that it maxes out: like a music system turned up so loud that the sound becomes fuzzy. We need to keep our feet on the ground, literally.

The answer to this, as I frequently tell clients, lies in three words: breath, bottom, feet.

To ground ourselves (to keep ourselves cool, calm and connected) we first need to breathe, as when we are overwhelmed we forget to breathe, our brain gets less oxygen and that’s what makes us feel faint.  

Having done that, we need to bring our focus to the two areas that bring us downwards and more in touch with gravity: the bottom and the feet: our bottom that rests on a chair (or should; lying down often helps add to our floatiness; sitting on something firm is much better), and our feet connected to the floor.

Activate those areas (wriggling on the chair, tapping or smearing your feet while you talk and breathe and feel) will usually, with patience, bring down your heart rate, counter-balance the energy in your head, and bring you back to earth.

You can practice this even while reading this blog. Do it now.

Breath. Bottom. Feet.

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H

Homework, Horizontalization, “How Do You Feel About That?”, Humour

29. Homework

Homework is something to do after school; it’s not a thing to ask adults to do. Absolutely not.  No no no.

Except yes, sometimes I set my clients homework.

Therapy ‘homework’ (in practice suggesting something the client might do between sessions – maybe general, maybe a specific exercise) can be a useful way of joining-up sessions or encouraging a theme to get some more attention.

Maybe Hassan has been discussing “shame”, for instance, and I’ll say “Find ten minutes this week to do a spider diagram of words/thoughts/memories/images you associate with shame and bring it along next week”. Or maybe we’ve been discussing his difficulty expressing feelings to family members and I’ll say “Try and find three occasions to use the phrase ‘I feel…” with your family this week”.

It’s a little hill to navigate, not a mighty mountain, but the hill can be worth the climb.

Whatever happens it’s always useful to see how a client responds to the challenge. Do they think of it as homework and begrudge doing it? Do they find it thrilling and beg me for more exercises? Were they struck down with fear before doing it? Whatever the response, there’s gold in them there hills.

30. Horizontalization

A word coined by the doyen of existential psychotherapy Ernesto Spinelli, “horizontalization” is where a therapist tries to put aside any judgment of what is most important to a client and tries to give it all equal weight.

Harri has a tendency to bring a lot of different strands to their therapy session with Hendrick: their mother, their work, their partner, last week’s session, their relationship with Hendrick… It might make total sense for Hendrick to ‘pick’, say, the topic of material arising from last week’s session in order to achieve some continuity, or maybe more talk about mother (as therapists just love mother talk). But by doing so he may miss something fundamental which is contained in one of the other topics. We don’t know what matters, so let’s assume it all matters equally, just not necessarily obviously.

Horizontalization also allows a session to roll where it wants to and not have a structure imposed on it which may have narrative clarity but therapeutic irrelevance. It operates on the basis that “everything contains everything” – in other words, if the issue Harri is struggling with is humiliation then we’ll probably gain access to that whether we’re talking about their mother, job, partner or anything else.

31. “How do you feel about that?”

There is no more cliched therapy question than this. And none more important.

In therapy most clients have difficulty feeling or articulating their emotions: maybe because they are overwhelming, often because they are unfamiliar. Our emotions are very adept at expressing themselves whether we want them to or not, and if we try and resist them they surge forward at full force and – sure enough – they become overwhelming. If a therapist can help you express your feelings in the moment, whether they’re big or small, obvious or subtle, present or absent, that begins a process whereby ultimately the person can run their own life rather than feeling that their emotions govern theirs.

A therapist is rarely (I hope) wanting you to say a particular thing in answer to this question. If the answer is “nothing, really” then that’s a completely legitimate response. But she does want to encourage you to notice. It’s often impossibly hard at first but, in time, with the right amount of encouragement and support, it is usually possible to gain access to them.

See my blog: “6 Therapy Cliches and Why We Need Them”

https://benetcattytherapy.com/thoughts-1?offset=1581359046712 

32. Humour

When I began training as a therapist I had two main fears: that I’d start wearing cardigans, and that I’d lose my sense of humour.

Dealing with challenging emotions is a serious business. But sometimes they need levity to express. As one client once put it to me “I can go darker when I go lighter”. Humour can be used as a block from emotion, or a distraction from the depths of the feeling. That’s why in early sessions most therapists won’t instinctively laugh at a humorous remark – we worry about unintentionally diminishing the power of its meaning by laughing along with the client’s light characterisation of a hard truth. But humour matters and, at least for me, once I feel settled-in with a client I hope laughs can be exchanged back and forth as long as it helps the building of the relationship and the accessing of the material needed to be supportive.

Humour in therapy isn’t about cracking jokes; it’s about allowing some light in which might bring further attention to the shade.

I have still never worn a cardigan to work. That would be no joke.

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I

Integration, Interpretation, Intervention, Introjection

33. Integration

On the whole, we’d all prefer not to disintegrate. The opposite of disintegration is - no kidding - integration. What does this mean, though? Well, here’s what it means to me.

Each of us has four strands of our relationship with ourselves: our thoughts, our emotions, our body, and our behaviour. Most of us are incredibly strong on one of those, maybe two. Many of us are nowhere on at least one of the others.

This is how it works in practice. Izzy will say “I can feel stuff and I understand why, but I can’t actually do anything different.” Ian will lead a highly active life but say “I have no idea what you mean by emotions.” Ibrahim will say “I feel sad” but when asked where in his body he feels it he’ll draw a blank.

In each of these very typical examples, some parts of their life experiences are unavailable to these people; as such these strands can work against them. It’s like having one of the key members of your support staff going rogue.

Therapy is a place to try to activate and integrate each of those areas; to attempt to make this team work together in the interests of their boss: you.

34. Interpretation

An interpretation is an intervention (see below) a therapist makes which involves suggesting a possible meaning for what the client has just said, rather than reflecting it back or trying to deepen the client’s thought. Inga says “I just feel so angry every time I eat toast which my husband has burnt”: an interpretation might be “Your husband knows you like your toast under-done; when he burns it I wonder if it feels to you like he doesn’t care or he knows better.” Isaac says “Every time I come to these sessions I feel like I’m going to the dentist”; the therapist might say “It sounds like you feel these sessions could be quite painful for you.”

As a rule of thumb, interpretations are best made by the client themselves. But a therapist can usefully help them to do that; indeed, often the most useful moments can be when a therapist makes an interpretation which is wrong or limited. For instance:

Client:              I don’t want to forgive my mum: it may sound horrible but I want to hate her.

Therapist:        You don’t want to let her off the hook.

Client:            It’s more than that. If I forgive her then the only one left to be angry at is me.

35. Intervention

An “intervention” is the therapists’ word for more or less anything the therapist says in a session. It’s the shorthand we use for anything from the “Uh-huh” to the extended paragraph of interpretation or the shared discussion.

It’s useful as a term of art, but I also like it because it implies the therapist is ‘intervening’ in a client’s challenges. That’s as it should be: it’s the client’s life, the client’s process, the client’s capacity to change. The therapist is in support of that, rather than the oracle or saviour.

36. Introjection

There are two main classes of challenging psychological experiences.

First there’s the brick falling on your head and leaving you with constant migraines: that’s trauma.

But there’s another: the breathing-in of subtle (sometimes even imperceptible) quantities of poisonous gas, the effect of which is to make us cough for years later but we have no idea why. That’s introjection.

“See that person over there? He’s such an angry motherfucker” we say, while hurling a chair at a wall and spitting blood. That’s projection: something from within us (like the film in a cinema projector) is projected onto the ‘screen’ of someone else.

Introjection is the opposite. If we introject we are the screen experiencing what someone is giving to us. So our mother and father are constantly arguing; we feel their tension so that by the end of the disagreement the two of them are calm but we are full of rage ourselves.

Melanie Klein, the expert on such matters (see entry 40), explained in her seminal book Envy & Gratitude: “The outer world, its impact, the situations the infant lives through, and the objects he encounters, are not only experienced as external but are taken into the self and become part of the inner life.”

Introjection is often completely unconscious. We can spot it by asking the question “Why would I feel that? I have no reason to” and wondering where we learnt it, where we breathed in that toxic gas.

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J

Joy, Judgement

37. Joy

Time for a huge generalisation: there’s too little joy in the therapy room.

Not unreasonably, clients can often feel that therapy is only a place to talk about The Tough Stuff. If it makes you cry, it’s useful; if it makes you happy, it’s obviously irrelevant to the therapeutic process. I disagree.

What brings us joy can be as informative as what brings us distress. And, moreover, a therapeutic relationship is a relationship; as such it deepens as its range of shared experiences broadens. Congratulating someone for a big step forward or wiping away tears of joy about something fantastic that’s just happened is a wonderful way of sharing together in that person’s unique experience of the world.

It can also be helpful as even joy has different shades: why is it that Jez feels incredible joy about their boss telling them he was proud of them, but shrugs off the exact same experience from their brother?

Joy deserves its time in the therapy room.

38. Judgement

If there was a pill which made a client always express their feelings it might often induce conversations like this:

Client:              …and so on the way here I thought ‘what the hell’ and bought an ice cream.

 Therapist:        Ah.

 Client:              It feels like you’re judging me.

It’s a rare thing for an awareness of judgement (often a fear of it) not to feature in a client’s experience of therapy. Sometimes these are projections: the client feels guilty about something and so imagines the therapist telling them off; often they are re-creations of experiences the client has had before. That’s where it becomes useful.

Typical judgements which clients can be aware of might include:                 

-       My therapist thinks I’m an idiot

-       My therapist thinks this anxiety doesn’t matter

-       My therapist is angry with me

Sometimes clients intuit more positive judgements, which can be just as useful to acknowledge:

-       My therapist likes me better than any of his other clients

-       My therapist thinks I’m doing well

-       My therapist loves me

Fear of judgement, or being a victim of it, is one of the most challenging experiences many of us have in our interactions with others. Sometimes these imagined judgments might apply to others, such as family or partners. If you’re brave enough to raise it, perhaps it can bring about something useful along these lines:

Jada:                When you asked me why my mother said that it felt like you were judging her.

Therapist:        Oh really? And what happened when you felt I was judging her?

Jada:                I wanted to defend her; explain to you that she’s not a bad person.

Therapist:        Why was that important for you?

 Exploring the resonances of these fears is often difficult but usually telling.

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K

Kink, Klein, ‘Knowns’

39. Kink

There’s a cliché about therapists: we’re all obsessed by sex. Not true. Some of us are interested in kink as well.

Kink – an umbrella term for non-traditional sexual practices (perhaps derived from the notion of a bend in the natural order of sexual interests) - is, for many people, even more difficult to talk about in therapy than sex. Maybe it’s embarrassing; maybe it induces shame; maybe they assume it will invite an avalanche of judgment.

When people’s kinks, fantasies or sexual needs come into therapy I tend to wonder one thing above all. And it’s nothing very much to do with the kink.

I wonder to myself what it says about our relationship that the person feels able to share such intimacies with me. Karen has seen me for two years yet only now is mentioning something which she feels is fundamental to her erotic life or her achievement of sexual satisfaction. Why couldn’t she raise it earlier, and what has changed to make her feel safe to do so now? Meanwhile Kenji told me about their kink five minutes into the first session: how come? Does that mean they feel safe to talk about it to anyone, or that they feel they can only tell me before I become too familiar, as then it will feel too risky that I may reject them for it?

A famous rule with kinky lifestyles, fetishes and fantasies is to be Safe, Sane and Consensual. The same applies to therapy. Therapy only works with consent, but works best when an ‘edge’ is being leant on: challenging enough to be helpful but not so much so as to be overwhelming. The same is often true with kink. How the topic is raised – or not – will often have a parallel with the acts themselves.

The second thing I take an interest in when kinks find their way into the therapeutic conversation is “What does this mean for you?” Is it simply something fun with nothing more to be said about it? Is it a safe way of accessing power dynamics in some way? Is it a release of creative energy which sex can’t always fulfil? Is it a metaphoric recreation of some earlier experience? Is it an avoidance of something? Does it change our sense of ourselves, or our perception of our partner’s sense of us? Any of those, and hundreds more examples, can be valuable to access.

There’s more to kink than kink.

40. Klein

To me and many of my colleagues in training, Melanie Klein was the hardest person to get our heads around. Her book Envy and Gratitude may be totemic but it’s also a headfuck, full of anger, aggression, hatred and pain. Once I started seeing clients her work turned out to contain several of the key understandings that inform most of my sessions in most weeks. “Splitting” and the concept of the “good breast” and the “bad breast” suggest the tendency of a child (and, by extension, all of us) to exercise black and white thinking (see entry 100, Zebra Thinking). Mum is a goody, dad is a baddy. It makes life simpler to believe that we can pigeonhole people and experiences into a box marked Good or a box marked Bad. But it’s rarely true.

Excepting Donald Trump, even the worst person has some positive qualities. And, even more discomfortingly, even the best person has some flaws and failures. To understand this is a huge challenge for many people, to accept it is even harder.

41.‘Knowns’, ‘Unknowns’ and ‘Un-Thought Knowns’

Knowing is a cognitive act, right? Well, just hang on a moment.

In the early stages of therapy, for many people there’s a wish to be clear about what they know and what they don’t. It’ll be a rare month of sessions in which a client won’t bashfully apologise for not knowing or remembering something, or caveat something they say with a phrase like “but I’m not sure if that’s true or if I’m mixing it up”. I never mind if it’s literally true or not. We are not journalists trying to get what Watergate reporter Carl Bernstein famously calls “The best obtainable version of the truth”. Rather, we are trying to gain an essence of someone’s experience, and that, often, is not contained in the form of memories.

In therapy a lot of what we ‘know’ is more subtle and less provable. We sense we found an experience frightening but we have no specific recollection of how we reacted at the time. We sense our parents were not able to manage our anxiety, but we have no clear image of either of them saying that in any way. So how do we ‘know’? Our senses are tools of knowledge too, just as the mind is. Often the answer is to look at how we behaved then and, perhaps, still behave now; how we have tended to respond to those senses.

It is both comforting and frightening to believe that, somewhere, we ‘know’ everything about ourselves; we just don’t know that much of it through our minds. So when we say we don’t know something, a more accurate phrase would be “I don’t have access to that at the moment”. It is remarkable, though, that when big moments of revelation or connection happen in therapy they very often feel weirdly inevitable, even familiar; as if the client (and maybe even the therapist) had known it all along and yet somehow not been able to find access to the connective threads to allow it to land with us. These were “un-thought knowns”.

What we ‘know’ is helpful but only part of our story.

What is ‘unknown’ is helpful but neither definitive or unchangeable.

What we ‘know but have never thought about before’ is, I think, the essence of what therapy is for.

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L

Leaving, Listening, Love

42. Leaving

If going to therapy in the first place is the most consequential decision in any therapeutic experience, then deciding to leave is in second place. However long or short the relationship, the ending of it is often a microcosm not only of the relationship but of the client’s experience with much else in their life.

The choice to leave should always be the client’s. It is not up to the therapist to say “You’re ok now. Have a nice life”. It’s up to the client to raise it and, hopefully, allow themselves and the therapist to explore it together.

Laura wants to leave because she feels she’s ok now; she’s achieved all she wanted to achieve. Great. But how does she come to the decision to wind down? Does she just want to send an email saying “All done, thanks” or does she want to wind down over several months to make absolutely certain that she feels ready to leave? Is she seeking her therapist’s approval of her decision or does she not give two shits what he thinks?

Lin wants to leave because it’s not working. They’ve been coming for two or three months but the anxiety remains, nothing has changed, they feel stupid to think it ever would. How does Lin usually approach losses? Is there a tendency to give up if there’s no instant result? What about the therapy is not what they need? Do they feel ok telling the therapist that it’s not working, or will they just ‘run away’ and not turn up?

Leo wants to leave because his work rota has changed and his current slot isn’t practical anymore. But does he mind? Did he ask work whether it was possible to not intrude on his appointment time? Has he asked his therapist if he might be able to swap appointment times? If the work pattern hadn’t changed would he have stayed indefinitely or did it provide a useful context for leaving as he was hoping to do anyway?

None of these are unreasonable responses. But all of them contain meaning. How a client approaches their leaving of therapy will often be a microcosm of the entire experience.

43. Listening

From Minute 1 of Day 1 in any therapy training (I hope) the first skill you learn and are refining for the rest of your career is how to listen. Without intent and active listening there is no therapy.

Being listened to is the fundamental ingredient of therapy: whether because they weren’t listened to as a child, or they can’t hear what they say to themselves, or – as clients often say – they want an “outside perspective”. The therapist’s job, before anything as exciting as “How do you feel about that?”, is to listen: to the story, the words used to tell it, the inflections, the rhythm, the mood and the intention.

That’s why so much of what therapists do involves repeating back what they’ve just heard, summarising what’s been discussed, encouraging a clearer expression of what has been said. It’s not because we’re thick or pedantic (well, not usually): it’s because we want to check that what we’re listening to is what the client is needing to express, and that what we’re hearing is as faithful to the client’s experience as it can be. To do so also allows the client to listen to themselves.

As Susie Orbach says “If you can find a way to listen, people will find a way to talk.”

44. Love

Love is a fundamental part of the therapeutic process. And not just for the obvious reasons: that it can explore the absent or ill-expressed love the person experienced growing up, or the troubled love in a relationship, or the overwhelming love that inspires jealousy or bad behaviour, or the love that makes us grieve for people we’ve lost.

Love also exists in the therapeutic dynamic, whether for its presence, its absence or its implications.

Lorna loves her therapist for his care, his attention, his gentleness, his yearning for her to be happier. Nobody has ever loved her like he has, Lorna feels. Every session feels like being held in a loving embrace: a place of safety which allows her to express who she really is and still feel loved and accepted in return. But she worries: how will she ever be able to leave him?

Levon wants his therapist to love him. Levon feels he’s kind, funny, smart, thoughtful and yet he’s never been able to experience love from somebody else. Not at home, not at work, not even in his marriage. He has gone to therapy, he now realises, to see if he can understand why nobody can love him. But it’s all gone wrong: he doesn’t think his therapist loves him either. And it makes him so angry. So what’s the problem with Levon?

Luc is terrified of loving their therapist or of their therapist loving them. It would make the experience unsafe, humiliation would surely ensue:  that’s what always happens. Their therapist will reject them, or they’ll have to run from their therapist, or, worse still, the love will stop the therapy being therapy. Love (of any kind) can only mean ruin. So what does this fear of love tell them about themselves?

The love we have for our mother is not the same as we have for our lover, which is not the same as the love we have for our best friend, which is not the same as the love we have for chicken curry, which is not the same as the love we have for Ant and Dec.

We may love our therapist; our therapist may love us. But it is not the same as parents, lovers or friends. It is a love that exists only in its particular circumstances. And, like any other kind of love, feeling it can be the most wonderful thing in the world. Or the scariest.

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M

Madness, Masturbation, Meaning-Making, Money

45. Madness

Madness is a horrible word with a history of being used lightly or inaccurately and as a means of diminishing others. Sometimes it’s a synonym for angry or eccentric.

For the purposes of a blog about the therapeutic process ‘madness’ is probably more usefully thought of as a catch-all for “clinical” or “pathological” – people with the kind of presentations which lend themselves better to doctors and psychiatrists than to therapists and counsellors. But even that doesn’t really cover it.

Sometimes, however great or caring the therapist, a client needs more than talk and process to navigate their difficulties; they need pharmaceutical help. With medication that person is able to get to a base level of ‘functionality’ which they cannot access consistently without it, and with that medication they are better able to make use of therapy. Fine.

But, in any case, just because someone is ‘mad’ – in whatever way we mean that – does not mean they cannot be reached by the therapeutic process. R D Laing, the famous psychiatrist whose booked The Divided Self is one of the most influential psychological books of that period, called madness “a sane response to an insane situation”. His approach was to try and not be distracted by the noise and messiness which psychosis and other extreme presentations can provoke and to hear the message beneath.

Sometimes, with all sorts of very challenging presentations, the question I ask myself (and maybe the client) is: ‘If this reaction was a choice, which it isn’t, why would you do it?”

Looked at this way, very often it’s not that mad after all.

46. Masturbation

Yes I thought this one would get your attention. This is not an entry about masturbating during a therapy session which, by and large, would be what therapists might term, in our customarily calm tone, An Incredibly Problematic Idea (see E for Ethics).

Rather, masturbating is one of the few experiences in life which is completely between us and ourselves. It’s for nobody’s benefit but ours; it works because of what we do, feel, think and need. Plus, for some people, it feels like a subject too personal to talk about. Sound familiar?

Most of what we discuss in therapy will feel, at some point, too personal to talk about, or be about what we feel, think or need. The difficulty of discussing it, at least at first, is the point. Masturbation is the whole essence of the challenge of therapy encapsulated in one act.

As with sex, food and many other subjects, our relationship to the subject of masturbating very often contains an essence of us and so contains the least filtered version of how we operate in the world. Not that many clients raise the subject, for understandable reasons, but many more would benefit by doing so.

If your therapist feels the subject is too much for them, then you know what to call them. 

47. Meaning-Making

Therapy isn’t journalism. It’s not a place to try and establish the facts as accurately as possible or as fairly to all sides. It’s a place to see what your experiences and feelings and relationships have meant for you. And only for you.  What did this experience mean for you beyond the facts of it?

Malcolm’s wife has left him. What does this mean for him? Did it mean she was too good for him and of course it was going to end this way? Did it mean he can never trust anyone? Did it mean she was a vile person who was trying to ruin his life? Did it mean everything valuable has a shelf-life? Did it mean he’s a bad judge of character? What has he taken from the experience of being left by his wife?

Mischa always cries every time she passes through Ipswich. What does that mean for her? Does it mean Ipswich has memories for her which elicit tears? Does it mean she’s too much of a mess to be worth exploring this with? Is she happy or sad or relieved, or perhaps they are frustrated tears? Does it mean she’s further away from London than she feels safe being? What does passing through Ipswich mean for her?

Every experience we have – however big or small – will have a meaning which is unique to us. Therapy is where we get a chance to understand what those meanings might be and to see how those meanings have woven together to create our experiences of the world.

And, perhaps, a place to change some of those meanings to something more helpful.

48. Money

I pay for my mortgage, holidays, haircuts and chocolate bars with the proceeds of people’s misery, anxiety and shame. For most therapists (I hope) the fact of that is, at various points, an uncomfortable truth of what we do. Ok, we could say the same thing about doctors re people’s illnesses, undertakers re people’s deaths, or tutors re people’s ignorance. But somehow talking to people in a room about their problems doesn’t seem quite as ‘expert’ as that; surely anyone can just talk?

There’s lots one could say here about the costs of therapy training (generally five years or more with total costs in fees, textbooks, therapy and lost income of anywhere between £40k-£100k). Or about how therapists will generally have done hundreds of hours of therapy while training (and sometimes beyond it) for free, or even paid to conduct therapy. Or the essential fact that you are not paying for the therapist’s time, you’re paying for the years of expertise which got them to that place.

All of that is true but none of it is very important to you when you’re needing help for your problems and a therapist is expensive, particularly if you’re going to be working for an open-ended period as most people do. But maybe this helps:

The money is what makes it work.

It’s the money you’re paying that makes you turn up: if it was a fiver you’d be more likely to skip sessions when you’ve had a bad day at work or you don’t feel like it.

It’s the money that makes you share what you share in the session: it’ll feel like a waste if you turn up and don’t actually say what you need to say.

It’s the money that reminds you that this person who you adore, or hate, or feel suspicious of, or reminds you of your abusive parent, is a professional person with whom you can explore your feelings (including about them): if they can’t handle it, that’s their problem, that’s what you’re paying for.

It’s the money that keeps you safe: this is not a social occasion and the money metaphorically placed on the table between you reminds you (both) that however much like other relationships it may sometimes feel – whether in a good, bad or confusing way – it isn’t; it’s a professional relationship, however intimate or complicated.

And it’s the money that reminds you that you want to have a better life: it’s your investment in yourself. You could have spent it on chocolates, box sets or games consoles but instead you spent it on making yourself happier.

The money is what makes therapy work.

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N

Narcissism, Neuro-diversity, Neuroses, Non-Verbal

49. Narcissism

Narcissism means Donald Trump.

There’s just a touch more to it than that. But if you want to get what the ultimate presentation of clinical narcissism (Narcissistic Personality Disorder) looks like then look at Donald Trump. The key tell-tales are an exaggerated sense of self-importance, a constant need for validation, an inflated expression of achievements, a fantastic sense of prospects, an incapacity for criticism, a disinterest and disconnection with the needs of others, and an overwhelming arrogance.

Most or all of us will have narcissistic traits; if not then we’d have problems of self-worth. Loving ourselves is generally good. Loving ourselves to the detriment of all other people is generally bad.

Narcissism often arises in therapy with people who have themselves been the victims of narcissists: often parents, sometimes siblings or friends. Having suffocated in the airlessness of that person’s self-image, the client now wants to breathe fresher air but is not sure how that will feel. And that’s really important.

I’ve also had clients who worry about being narcissists themselves, perhaps because someone close to them was very narcissistic and they fear repeating the pattern. They needn’t worry. Almost by definition, no true narcissist will go to therapy. After all,  nothing could ever be wrong with them, could it?

50. Neurodiversity

Neurodiversity is a funky word which essentially means ‘different ways of mentally operating’.

Although the term is relatively recent, the presentations which fall under its umbrella are longer-standing and increasingly well understood and treated. Appropriately for a term that originated with a sociologist rather than a psychologist (Judy Singer), the concept suggests that various behavioural, learning or social challenges arise partly out of the wider social context rather than being illnesses.

While some may dread being Othered by this label,  many find it a reassuring collective term to mean “It’s not just me”. Whether you’re autistic, dyslexic, dyspraxic, have ADHD or one of a plethora of others, ‘neurodiversity’ suggests “this is a thing, many people experience it, and it can be treated, stabilised or managed”.

So perhaps it’s not just a funky word after all.

51. Neuroses

Neuroses are the bread and butter of the therapeutic process. Neurosis is the Freud word for anxieties we carry which express themselves in a manner out of proportion to the cause.

Nick gets so worried about people hearing him eating aloud that he never eats in company. Nick has a neurosis.

Nadz gets so worried about being alone that they have to phone someone every hour to feel safe. Nadz has a neurosis.

Nell constantly checks her phone for fear of bad news waiting for her on it, to such an extent that she finds it hard to sleep for fear of missing a crucial text. Nell has a neurosis.

All three people have anxieties which are not just peripheral concerns, they are properly limiting how they function in the world. They are all neurotic. They could all benefit from some therapy. (Probably in the North London area with someone who writes therapy blogs.)

52. Non-Verbal (Communication)

The non-verbal is where a lot of the most useful information about a client’s emotions, relationships and story can be located. The eye contact, the sitting position, the knee that jiggles, the playing with the watch, even where on a sofa they seat themselves (near me or at the far end) can give useful information.

Smiles are particularly telling examples, I find. It’s striking how often people smile while telling me about something incredibly challenging or distressing. Sometimes, when I’ve asked about it, they haven’t even noticed they smiled. It’s an in-built, instinctive, protective strategy designed to take the edge off a difficult experience. It’s as if they’re communicating “This was awful but I’m smiling so it can’t have been too bad”. Sometimes this might be a defence against me probing something too difficult; sometimes it’s a defence against them feeling something overwhelming. That’s why I never give therapy over the phone.

As in acting, it’s not what you say but how you say it.

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O

Object Relations, “Obviously,”, Open Questions

53. Object Relations

Object relations has nothing to do with your connection to your toothbrush.

In “O.R.”, ‘object’ is meant in the Freudian sense of, say, “the object of my affection” or “the object of my ridicule”. Object relations is about how we relate to other human beings. It is a British development of Freudian principles which puts how we relate at the centre of our concerns. It might be called “Relationship with relationship”.

Within this complex and valuable area there is also a sub-term of “part objects” in which we see someone not as a complete person (or a complete object) but as only being partial: we see people who work for us as functionaries rather than whole people, or we see politicians as their views rather than whole people who happen to have some views.

Clients sometimes sees therapists as that: “this is a person who understands stuff” or “this is a person who can help me” and find it hard (and sometimes frightening) to imagine their therapist as a person with a family, traumas, tastes and prejudices just like everyone else.

How we relate is at the essence of the human experience. And at the core of the therapeutic encounter.

54. “Obviously”

For clients, lots of things are “obvious” because it’s their life. For therapists, nothing is obvious because it’s not our experience.

It’s striking how often the word “obviously” creeps into a client’s expressions. Well yes, maybe it was “obvious” to you that you would have talked to your boyfriend about what we discussed last week, say, but people often don’t. If I presumed something and get it wrong that could lead me to act in a way which is completely unhelpful to you.

If a client says something is obvious, oftentimes it wasn’t obvious to me at all – maybe I guessed or presumed, maybe I didn’t. But even if I did and it was, it’s important for the client to say it rather than assume I’ll intuit it. Therapists are not mind readers; if we try to be, we’ll usually get it wrong.

Any therapist who thinks a client’s response is “obvious” hasn’t been paying enough attention. Some responses are familiar or expected or consistent, sure, but few are every obvious.

55. Open Questions

If you’re a journalist interviewing a politician, closed questions can be helpful in keeping things moving. “Did you attend any of the five COBRA meetings about the first pandemic in a century, Prime Minister?” “No.” Such questions are rarely helpful in the therapy room.

Open questions encourage the client to elaborate on their experience and go deeper into their sense of themselves. “Do you like your mother?” would be a closed question. “How do you get on with your mother?” is more open.

When to ask open questions and when to ask closed questions is an important judgment for a therapist. Occasionally a pithy closed question can really sharpen the experience.

Otis:                 My brother has always thought I’m an idiot who’s out to get him and it’s made it really hard to be with him because I don’t do well in an atmosphere of attack as it feels I have to defend myself and I’m not given a chance to think what to say because I’m so busy trying to work out what will stop us getting into a huge fight, and therefore it’s hard when I know he’s always going to come back to “Do I hate him?”

Therapist:         Do you?

On other occasions an open question can help slow down the pace and allow for a more useful development of a thought. It can also be an encouragement for someone who finds it hard to express themselves to elaborate in more detail than they would naturally volunteer.

Oksana            My husband just gets so difficult with me. He blames me for his frustrations at work. He never wants to have sex. He doesn’t even seem to enjoy watching Fawlty Towers with me anymore which we used to do the whole time when we first met. I just don’t know what to do.

Therapist         So when your husband acts in that way to you, what’s that like as an experience?

The playwright Anton Chekov said that the business of drama wasn’t to answer questions but to ask them. There’s a man who understood therapy.

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P (Part 1)

Pace, Paradoxes, Paraphrasing, Pauses

56. Pace

Therapy is not a science, but an art. And, as in music, theatre or any act of storytelling, one of the key arts is pace. Too slow and it can feel under-energised, unmotivating, stuck. Too fast and it can be superficial, distanced, disconnected. As with all arts, there is no right or wrong: there’s what works.

Petra speaks at huge speed: story upon story, detail upon detail. It’s as if her life tumbles from her mouth in every session. This is a bad sign. But Peter speaks at just the same rate: avalanches of detail, masses of subject. But for Peter it’s a good sign.

What’s the difference? Well…

Petra is performative. Talking and talking and talking is what she does at work and it’s her comfort place. In therapy she talks so much that key details, clarifications or feelings have no room to breathe. She’ll say nothing to her therapist that she couldn’t quite easily say to her best friend, and even if she does he or she may miss it because of all the other details smothering it. Petra’s pace needs to change. If she can dare to slow down, pause, think before she speaks, connect with feelings rather than stories, maybe she can access something different. Petra needs to pause.

Peter, on the other hand, is usually a man of few words. He contemplates everything he says; picks his phrases with the delicacy of a poet; never says anything he’s not certain will be accepted, and comes from a background in which control was everything. For months in therapy his silences were louder than his words. But now he’s talking. Words come out of his mouth fluently and fluidly. Sometimes he loses his clarity but his passion and his feelings come in their place. His therapist can feel the release that finally opening up is doing for him. For Peter, at least for now, a fast pace is a huge help.

Petra and Peter’s respective therapists (and yours) need to help find a pace that is the most helpful. That won’t always be your normal pace.

57. Paradoxes

Phil loves his mother but he never wants to see her again. Pamela wants to have sex but is absolutely terrified of it. Ped is excited about their career change but hasn’t slept for three weeks worrying about it. Pablo finds therapy vital but also dreads it.

In these paradoxical situations people sometimes feel that they need to pick one of the two forks in the road they find themselves facing. Unfortunately, both forks lead over a cliff. They are stuck in what Melanie Klein (see ‘K’) called the “paranoid schitzoid” position. What they actually need to do is acknowledge that both forks have their merits and problems: that the new job is scary but also desirable; that sex would be wonderful but may also be frightening; that it is possible to love someone that you can no longer tolerate being with; that therapy is worthwhile but also emotionally taxing.

Therapy is a great place not to ‘decide’, but to tolerate. To allow both sides of the coin to get their say.

As American baseball player Yogi Berra infamously said: “When you come to a fork in the road, take it.”

58. Paraphrasing

Paraphrasing is one of the basic therapeutic skills in which the therapist repeats back in their own words what the client has said to them, perhaps in summary form. So, for instance:

Polly                I think the reason I’m always late for these sessions is that I’m not really sure I want to come. It’s hard sometimes, and I get upset, which is embarrassing, and part of me thinks why the hell am I putting myself through all this?

Therapist         So you’re ambivalent about coming to therapy each week.

Therapists deploy this tool for two main reasons: to allow the client to hear their own thoughts from the outside and perhaps hear them afresh. But, also, to check if we’ve understood it right. We may have picked up the wrong emphasis, or the client might have not been as clear as they need to be.

So the conversation might lead to this:

Polly                I think the reason I’m always late for these sessions is that I’m not really sure I want to come. It’s hard sometimes, and I get upset which is embarrassing, and part of me thinks why the hell am I putting myself through all this?

Therapist         So you’re ambivalent about coming to therapy each week.

Polly                I’m not ambivalent, no. I know that I want to do it, I accept that it’s hard. To be honest I think it’s not the therapy per se, it’s you. I feel really uncomfortable you knowing all this stuff about me.

Therapist         Ah ok. There’s something about how you experience me which feels very uncomfortable, perhaps more than the material itself.

There’s now more clarity, and maybe the conversation can go down a more useful line.

59. Pauses

Any list of therapeutic clichés includes the client finishing their thought and the therapist sitting quietly, staring at them, saying nothing. Why the fuck do we do that?

I promise you we’re not trying to annoy you.

Sometimes we don’t respond immediately because we feel you may have more to say and we’re giving you the space to elaborate further, perhaps noticing something in what you just said which needs more space. Sometimes we want to make sure the session is run by what you need to explore and not by what we may think is important; if we talk too soon we may take the conversation into an area which is not what you need that day. Sometimes we just don’t have anything to say and we want you to be the person who indicates where the conversation should go next. Sometimes we just want to keep the pace gentle, to avoid it feeling too much like a Q&A.

Whatever our motivations, it’s helpful to notice what the inevitable therapeutic silences bring up for you.

Awkwardness maybe (“I don’t know what to say now.”)

Embarrassment. (“I’ve run out of things to say now. He must think I’m an idiot.”)

Anger. (“What the fuck am I doing spending all this money if I have nothing to say?”)

Relief. (“Thank God. It goes at my pace, I don’t need to race to get a word in like I do at home.”)

There will be dozens of other examples.

All are useful. All are worth mentioning. 

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P (Part 2)

Projection, PTSD, Punishment.

60. Projection

Nobody can mind-read. Even Derren Brown, by his own repeated admission, can’t mind-read. When we feel we can we’re sometimes describing empathy, or familiarity, or instinct. But often we’re projecting.

In olden times, a roll of film would be loaded into a projector. The projector was pointed at a cinema screen or a wall. The projector would be turned on, and the images on the roll of film would be projected large onto the wall. Therein lies the essence of how we project.

Here’s how that works.

Phillipa is full of anger: about life, about work, about money, about everything. But she hates feeling angry, because she fears that anger is the same thing as violence which is how her mother was when she was growing up. So as far as she’s concerned she never gets angry; perhaps even the people around her think “Wow Phil is never angry. How does she manage that?”

If they looked more closely they might notice how often she sees anger in others. “You see that waiter serving that table over there? He’s so angry.” Or she’ll comment on the students she teaches. “Wow there was a lot of tension in the room today.” Philippa is projecting.

Unconsciously the unendurable anger Phillipa has good reason to feel is being projected out and hitting the ‘screen’ of other people.

As Jung said “We’re only affected by ourselves.”

Projection is the lifeblood of much therapy. A client feels stuck so thinks the therapist is stuck. The client feels angry with herself but thinks the therapist is angry with her. A client is used to people telling him what to do, so imagines the therapist telling him what he should do.

When projection can be moved from being unconscious to conscious – essentially ‘I’m feeling this but I’m wondering if that’s me projecting” – then it can be a magnificent spur to clearing our mind and engaging with our own needs rather than our imaginings of others’.

But don’t get too excited yet; it’s not easy.

61. PTSD (Post-Traumatic Stress Disorder)

PTSD began in 1980.

Balls. Of course it didn’t. PTSD has existed forever. But we only started calling it PTSD in 1980 when the DSM III (the handbook of mental illness for psychiatrists and therapists alike) called it that. Prior to that it was “shell-shock” and ascribed to army veterans returning from the second world war. But PTSD pre-dated even that; Charles Darwin wrote about it in The Expression of Emotion in Man and Animals in 1872, a less famous book than his Origin of Species (which pre-dated it) but just as fundamental a contribution to our collective understanding of how emotions live and breed in our bodies.

Not everyone who experiences a trauma (an accident, an assault, an abuse) will suffer from PTSD. Indeed 60% of people won’t. They can experience it, find it horrible, cry or get angry about it for days or weeks and then move on with their life. They don’t ‘forget’ the trauma but they can carry it fine. But for 40% of people, the trauma gets stuck. Like food which the body can’t process gets stuck in our stomachs and gives us indigestion, our emotional experiences can become held and remain as a bruise on our lives.

Phil was chased by a blood-loving Rottweiler in a public park late at night. There was nobody there to help him and it was late: had he been savaged then nobody would have found him for many hours. He ran and ran and ran and, by some combination of huge strength and enormous luck he escaped unscathed by the rabid dog. He had to get away; had he not done so he would have died. Phil experienced a trauma. But, strangely, a day or two later he can scarcely remember it. He can tell the headline “I saw this dog coming towards me” and he can remember the ending “I was panting away on the other side of this wall and I could hear the dog but I knew he couldn’t get to me”. But he couldn’t remember the chase. Phil has PTSD.

When we are in panic mode part of our brain (the pre-frontal cortex, where our narratives get stored) is knocked out, and the “fight/flight” part (the amygdala, the fire alarm part) takes charge. Our brain puts all its resources into survival and ditches those parts which are into anecdote. That’s all great. After all, we don’t need to remember whether it was left or right we turned to get away from the dog, we need to be able to focus on doing what our body tells us in that moment.

The problem comes later. Our minds thrive on stories. Yet, here, Phil’s story has bits missing. It’s as if we have vital papers missing from a box file and we have no idea where they are in our office but they must be here somewhere. That’s why we get flashbacks or intrusive thoughts: it’s our brain picking up a piece of paper from another file and saying “Is this it?” Our trauma does not yet have a beginning, middle and end. And until it does we can’t relax because we’re not sure the story is over yet. That’s PTSD.

PTSD makes a past experience (often not remembered, or not fully remembered) play out in the present moment. We walk down a road, we hear a tiny dog woofing inside a house and we panic as if a Rottweiler is heading for our heels. We haven’t yet processed that “that was then, this is now”.

Therapy can be a place to try and do that processing. Sometimes a therapist can help you find those missing pieces of paper and gradually put together the distant memory in the safety of the therapeutic space. Sometimes it can be approached the other way: we don’t look at the rock that fell in the pond, we examine the ripples as you experience them in your life (trauma responses) and work our way through managing those better. Often some combination of this “top down” and “bottom up” approach can be helpful.

The final letter of PTSD (the D for disorder) is the crucial one: it’s literally a dis-ordering of your mind and experience. Therapy can be a great place to try and make some order of it.

62. Punishment

In the 1950s Mary Main developed the Adult Attachment Interview: twenty questions (and various sub-questions) which allowed a therapist to understand how a client experienced their childhood and how those patterns carried on into adulthood. Many of these questions are fundamental to how most therapists approach a new client. Number 8 can be neglected: how the client’s parents disciplined them.

Whether one had strict or laissez-faire parents, and no matter whether they were practical, psychological or physical in their punishments, the evolving child will inevitably draw a sense of core beliefs from the experiences they had. These can often be more complicated than first thought.

Pasha and Peled are two brothers whose parents treated them much the same. If either of them misbehaved they would be sent to their room for hours on end. Pasha had no problem with this: he liked his own company, he didn’t feel he lost anything by being in his room. For Peled, on the other hand, he found grounding highly anxiety provoking. He interpreted this as “We can’t deal with you, we want you to become invisible for a few hours”: a temporary expunging of himself from the family. As adults Pasha has internalised his childhood punishment: if he gets into difficult situations at work he finds the best plan is to withdraw and work out what he needs to do without the pressure of outside eyes. But Peled fears anything he does ‘wrong’ with his wife, boss or friends will result in them giving up on him. If he doesn’t get an expected phone-call from his wife he feels the kinds of lonely anxiety he felt as a child. For these two brothers the same punishments had different legacies.

Phia and Pippa are best friends whose parents treated them much the same. Their parents were anti-disciplinarians: they never punished their kids, never told them off, were big fans of allowing their daughters to understand the world in their own way. Phia felt she was the luckiest girl in the world, never fearing her parents, never unable to go to a party, always feeling trusted to live on her own resources. But Pippa was constantly anxious: for her, the absence of boundaries meant a presence of risk. “I could get into all sorts of trouble and my parents wouldn’t react.” Sometimes she’d even think “Maybe they just don’t care if I get hurt”. She had a rebellious teenage period – drink, drugs, smoking, late nights, anything to try and see if she could get her parents to take her confusions seriously.

Paddy and Penny were boyfriend and girlfriend and were treated much the same. Both their parents believed in corporal punishment and so if either of them misbehaved between the ages of six and ten they could expect a slapped hand or a smacked bottom. For Paddy, he accepted it as a clear marker of the moment he strayed over a line. It made him feel safe. But for Penny it was traumatising. Even though she was smacked only three times in her life she became frightened of what mistakes or misbehaviour could lead to; she instinctively felt “if they could hit me then, why wouldn’t you hit me now?” The closer the relationship, the more she instinctively braced herself for fear. In times of argument her body would seem to freeze. Somehow, somewhere, fear of punishment had burned itself into her personality.

Punishment can be an important therapeutic thread. Partly this is because it helps get a sense of the person and their upbringing (as per the Adult Attachment Interview). But it can also open up a sense of how the person might expect the therapist to ‘punish’ them (for instance for being late for a session, not knowing the answer to something, or being ‘difficult’). Maybe the client is fearful the therapist will not care enough to do anything (like Phia) and so will make attempts to make him care. Or maybe the client will be fearful of being humiliated (like Penny) and be in a state of readiness for whatever penalty might come her way.

Punishment can be tough to talk about in therapy – it takes us back to more vulnerable time – but it can be deeply valuable.

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Q

Qualifications, ‘Queer’, Questions, Quiet

63. Qualifications

There’s only really one thing that matters about a therapist’s qualifications: make sure they have some.

The entry level for qualified counsellors is membership of the BACP. For psychotherapists – which means we have a Masters and therefore have received a further couple of years of training – the person may be UKCP-accredited instead of BACP (a relatively small number of us stay with both). If in doubt, you can look up the counsellor on the website of the governing body they are accredited with and get a sense of what’s what. Child Psychotherapists and those with particular specialism are sometimes registered with other bodies.

Qualifications give no guarantees about how helpful a therapist may be for you – that’s something only you can judge. But it guarantees a certain level of training, an ethical code which the therapist has agreed to abide by (confidentiality etc), and also a place to which you can turn in the (hopefully very rare) event that you feel you’ve been mistreated and wish to lodge a complaint.

Qualifications offer some safety and reassurance. Make sure you see someone who has them.

 64. ‘Queer’

While observers might have noticed the many ways in which people in leadership roles have encouraged a regressive attitude to social evolution in recent years on both sides of the Atlantic, one realm of progress has been the ability for those with different sexual identities, tastes and awarenesses to discuss these topics which, once, were inexpressible or illegal.

What was once a slur and then a reclaimed slang, “queer” is now generally taken to encompass a broader scope: an umbrella for those who are not heterosexual and/or are not cisgender (those whose gender identity corresponds to the sex assigned at birth). It remains controversial: for some, so broad as to be meaningless; for others, so associated with generations of oppression and prejudice as to make the word invalidating. 

The availability of such topics to be raised, explored or debated, however, in no way makes them easy or makes the problems that come with them evaporate. I have learnt – occasionally the hard way – that making any assumption about the sexual or gender identity of my clients can accidentally foreclose a topic which is looking for an opportunity to present itself to our interest.

In the therapy room, what counts the most is the client’s definitions and language. But, crucially, those definitions and associations are going to bear the imprint of the wider culture. Sometimes this is problematic. Maybe the therapist behaves in a way which embodies some of those wider trends. Maybe their gender or sexual identity is fundamentally important for a client to feel understood; maybe it’s crucial for the client not to know.

All of those responses, and the many others which issues of sexual and gender identity can provoke, are valuable subjects to explore.

65. Questions

The right question from a therapist can really open up a new layer of understanding. The wrong one can take us away from what really matters.

If there was a list of rules about asking therapeutic questions, my vote for the number one spot would be “Does this question get the client closer to their own experience?”

For instance, if a client talks about having a row with their fiancée over a burnt pizza “How did you end up burning the pizza?” may be interesting if you were talking in a pub but is probably of limited value in therapy. Asking “What was going on for you when you saw he’d burnt the pizza?” may get closer to why something so seemingly mundane should elicit such a strong reaction.

Here are some more examples:

Client:                      I hate my boss; he’s always having a pop at me. I don’t know  why I keep working there.

Bad Q:             What’s he got against you?

Good Q:           What’s it like when he’s having a go at you?

Client:                     I find these sessions really frustrating at the start. I don’t know how to get going.

Bad Q:             Why don’t you make a plan beforehand?

Good Q:           What is it about the start that’s frustrating for you?

66. Quiet

As a rule of thumb, the cliché of the therapist sitting quietly, leaving pauses and when they speak they speak relatively quietly is probably not that far off the mark. Sometimes, at least.

We leave space for the client to sit with a feeling or develop a thought, or to reflect on our response rather than being unhelpfully spontaneous. We speak calmly because often the client will have avalanches of thoughts and feelings all the time and we want to provide a gentler, less impatient kind of space.

But sometimes the reverse is true. Sometimes a client’s depression or despondency can lead them to communicate in low tones, low energy, slow pace. In that case, sometimes, it may be more helpful for the therapist to try and encourage a more energised, less placcid dynamic in the room; to help the person reconnect with their enthusiasm and hope.

But yeah, in the main, therapists are a pretty quiet breed. But we’re not all dullards.

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R (Part 1)

Regression, Rehearsal, Relationship, Reparative Experience

67. Regression

If therapy was a film, regression would be a moment where the image goes blurry and then we see our central character back in the train station at which they met their lover twenty years before. We hear his voiceover as he describes what happens, all the while we watch what he’s describing as if we are in his head.

If only regression was like a film, though.

Regression means returning to an earlier (younger) developmental stage. When clients ‘regress’ it is usually subtle: maybe a feeling from long ago, maybe a voice, a fear or an interaction with the therapist emerges which feels palpably younger than the client usually presents. I’ve experienced it when clients talk about their childhoods and the native accent they had back then, which has long since vanished from their voice, creeps back in. I’ve seen clients almost literally become younger before my eyes – their body posture, their voice – and for a few moments I get the sense of what it would have been like to sit with that person at a much earlier time of their life.

Regression is a process to be cautious about. For people who have experienced trauma, for instance, it can be their worst fear: a sense that they could be taken back almost as if in a time-machine and re-live what happened to them all over again. Nobody wants that, including me, not least as it makes the process of healing even harder. But when, as Harry Guntrip (1968,p71) expressed it, we can “convert regression into rebirth and regrowth” it can be an incredibly valuable and reparative experience.

68. Rehearsal

Before training as a psychotherapist I worked for many years in the theatre. I loved rehearsals. If I could define them it would be something like "place where we say 'let’s try this and see if it works and if not we’ll do something else’”. In therapy, sometimes, I encourage a similar process: “Let’s imagine I’m your dad that day when he said that. What would you want to say to him?” And I have the client talk to me as if I am him. They’ll say “You hurt me” rather than “I’d tell him he hurt me”. We make it as real “as if”.

Often I don’t say anything at all; it’s enough for the person just to be talking to a live human being. Occasionally I will respond, or maybe say the thing which caused the issue we’re discussing so that the client can get a context for their remarks. It is very striking how often I, who looks and sounds and acts nothing like the person in question, can provoke a reaction which gives us a semblance – say 20 or 30% - of the feeling the person felt at the time. But the script is theirs; I am not a director. I am an actor reading-in.

Therapeutic rehearsals can also be useful in preparing for a hard conversation: ‘trying out’ what the person might say to their husband in order to explore what feels important to say. Sometimes the reverse is true: we explore what they would love to say but know would not actually be constructive in the real situation.

Whatever the purpose, rehearsal can be a useful technique for some people to have the experience of saying something out loud which they have never expressed and seeing how it feels.

69. Relationship

All therapy, all life, is about relationship.

Almost whatever people come to therapy about, relationship – how they relate to others – is likely to be central to their concerns. And a great way to gain access to that is via the relationship that exists live in the moment: the relationship with the therapist; what Martin Buber called “the sphere of the in-between”.

Renata feels intimately and permanently bound to her therapist within ten minutes of sitting down. She can’t imagine ever leaving him. And yet she knows nothing about him. What does this say about how she relates to people?

Rennie is adamant his therapist means nothing to him: it’s a business arrangement and that’s all there is to it. If his therapist left the country tomorrow he’d just find another therapist. What might this say about how he relates to people?

Reece is afraid of his therapist but also deeply attracted. He wants to have sex with the therapist but also fears her wrath, is terrified of being abandoned, anticipates rejection at some stage and braces for it. What might this say about how he relates to people?

None of the above examples are uncommon. But all have different reasons, and all are central to how those people relate. Relationship is, after all, about recognition. As Jessica Benjamin writes: “In the very moment of realising our own independent will we are dependent on another to recognise it.”

 70. Reparative Experience

The thing I love most about therapy is its capacity to be a reparative experience: a place to correct, re-experience, neutralise or manage bad experiences, bad learnings or rough relationships differently. This is, in many ways, the essence of what a therapist should provide.

You can be angry and not risk retaliation.

You can be messy and not be punished.

You can cry and not be shut down.

You can be confused and not be taken over.

You can be heard and not told.

Very often the essence of therapy is “I said this thing out loud and survived”. What could be more powerful than that?

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R (Part 2)

Repression, Resilience, Rupture/Repair

71. Repression

When we repress something, we unconsciously ‘forget’ it in order to protect ourselves. But while it may appear forgotten from our minds, it’s not forgotten by our bodies or instincts and so it will likely express itself in other ways: humour, passive-aggression, unexplained attitudes and discomforts, somatic illnesses and much else.

As Freud pointed out in his essay on the subject in 1915 “some sort of process… changes the pleasure of satisfaction into pain”. In so-doing, an impulse we have is resisted and sent underground. We repress it.

In therapy, curiosity about what we have repressed and why is often a key ingredient. With the right relationship, safety and pace, repressed feelings can be encouraged to present themselves undisguised and, maybe, the emotional pain that the repression has caused can begin to be cured.

72. Resilience

Most clients most of the time have a proven track record of resilience. Whatever’s brought them into the room, they survived it. The price of so-doing may have been steep or long-lasting but they did it. And not only have they survived it but they’re now able to take themselves to therapy once a week to process it and ultimately make it less of a shadow over their life. That’s resilience.

Resilience is what people often feel they don’t have but manifestly do. Times are tough but they can get themselves out of bed to get to work, or they can come to therapy, or they can pay their bills. Often what they’re discussing is early stuff: if they could survive it aged 7 or 12, then they can survive talking about it at 25 or 38.

Resilience contains the hope which facilitates the change.

73. Rupture & Repair

As with any intimate relationship, the therapeutic dyad is ripe for instances of rupture: moments in which tension, anger, dispute, discomfort or let-down enter the experience. How could they not?

Arielle Schwartz, the deeply-brilliant clinical psychologist and author, suggests that there are three stages of repair: first recognising the rupture is happening, then the client and therapist re-attuning to each other; and finally staying engaged until that reconnection is achieved. This may take a couple of moments, or may sometimes take several weeks or months.

Ruptures can occur when a therapist misunderstands something the client has said and the client feels unheard or disrespected. Or when a client is three minutes late and feels braced for the therapist telling them off so can’t engage in the session. Or when a therapist has said something which has triggered an all-too-familiar but deeply unwelcome emotional response in the client. Or when a topic has been explored which the client finds intimidating or shaming, and they can’t look their therapist in the eye the next week.

I love ruptures. They’re often confusing or horrible or awkward or challenging but, later, they’re almost always incredibly valuable. That’s the bit I love. When me and the client can work out what just happened, and what it felt like, and why it affected us so much, and what we can do to make our interactions safe again, we always discover something deep about how they interact with the world which would not have otherwise been available.

Some therapists will deliberately provoke a client (try and make them angry, say) in order to gain access to this material via a rupture. I wouldn’t do that; it feels manipulative. But nor do I avoid things which have the potential to cause difficulty: to me that would be equally unhelpful.

Don’t be afraid of telling your therapist when you’re upset by them. They can take it (or certainly should). And it may help.

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S

Safety. Secure Base, Self-Harm, Sex

74. Safety

“Being able to feel safe with other people is probably the single most important aspect of mental health: safe connections are fundamental to meaning and satisfying lives.”

Bessel Van Der Kolk (The Body Keeps the Score, p92) is right.

If ‘Feeling Safe’ is not the first priority of therapy then it doesn’t much matter what number two is. But safety is subjective.

For some people ‘safety’ in therapy means a feeling that they can say anything without being dismissed or rejected. For others safety means the absence of an obligation to protect the therapist from their feelings. For some, safety is purely physical: they can sit in a room with someone without fearing attack or abuse.

In practice, though, safety is a fluid thing. Some subjects feel safe, some don’t. Some days feel safe, some less so. And if therapy feels too safe it can discourage the pursuit of the tougher terrain. A mixture is necessary: you feel safe enough to explore what you need, but not so safe as to feel the kind of comfort you might feel with your best friend, for instance.

As a tutor in my training would often say, we want “one foot in the river, the other on the shore”.

75. Secure Base

One sunny day, on a lawn surrounded by woodlands, two families are having picnics some distance away from each other. Sammie, 5, has finished his snacks and wants to explore. By complete coincidence, Sadie, sitting with her family some way away, has the same idea.

Sammie goes wandering in the woods, playing hide and seek with himself, even on one occasion going and chatting to other families on the lawn. Sadie, though, contents herself with only the immediate lawn to entertain herself.

This is the essence of John Bowlby’s famous conception of The Secure Base (1988). Sammie has a secure base. Sadie doesn’t.

A secure base means an island of return which we know is consistent, predictable and safe whenever we need it. If we have it, we can explore the world in the knowledge we can always return to base. If this island is not secure, though – if we feel it has a chance of floating away or vanishing altogether – then it needs us to keep our eye on it so that if we see it beginning to float we can run straight back to it.

Sammie knows his parents won’t leave the picnic blanket until he comes back. Even if one of them comes out to play with him, one will remain behind. So he can explore all he likes, because he knows he can find his way back. Sadie doesn’t have that experience: she fears her parents may decide to move into the shade while she’s gone, which might panic her as she may think they’ve left the park without her. So she needs to keep an eye on them.

A therapist needs to provide a secure base: one that says “wherever you go with this exploration, or however you react, I’ll still be here”. That’s why having a consistent time each week rather than improvising or chopping and changing is generally preferable, particularly for clients like Sadie.

But sometimes therapists, like parents, have spasms of unreliability. They’re late for a session, say, or maybe forget altogether, or they become ill and need some time off at no notice. How the client responds to these rare but inevitable human frailties is very instructive.

76. Self-Harm

Self-harm usually means cutting. Alcoholism, substance abuse and eating disorders would also count as self-harm to many people but in therapy contexts self-harm most often mean cutting. For many, self-harm feels like the worst life can be for someone; training therapists fear the moment when their first client tells them they are doing it.

But it depends. As with many of the subjects in this glossary, the key two questions are: what’s the meaning, and what does it emotionally feel like to do it?

Self-harm can be about punishment: “I feel so useless I deserve pain to make me think better and work harder”.

Self-harm can be about release: “I feel so much pain inside me but thank God I can now feel it physically and be able to point to it and say ‘there it is’”.

Self-harm can feel life-saving: “I sometimes feel I want to die so when I’m harming myself I know I can carry on living.”

Self-harm can be about communicating: “I am frightened all the time but I can’t tell anyone; if they glimpse the marks someone might see and try to help me”.

Self-harm is not something for a therapist to be frightened of, however disturbing it can sometimes be to listen to. It is something to be respected, understood and worked through.

77. Sex

Oscar Wilde said that everything is about sex apart from sex which is about power.

Sex or, more specifically, our relationship with sex is one of the core topics which can reveal fundamental truths about who we are and what we feel. This applies whether we have lots of sex or none, whether we’re vanilla or kinky, married or single, exploratory or cautious. More often than not, if one considers ones attitude to sex (we always find it doesn’t match the expectation, let’s say) we’ll notice a parallel attitude when it comes to food, or money, or some other important element of our lives.

The capacity to talk about sex with ones therapist frequently parallels ones relationship to the topic itself: it feels like an act of intimacy that can only be broached after a long and gentle period of trust, or something to get to immediately but then burns out almost as soon.

So when you talk about sex to your therapist, notice how you went about it and how it felt. That may tell you as much as the content itself. Like sex, therapy is often a bit about the act, but a lot more about the relationship from which it springs.

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S (Part 2)

Splitting, Suicidality & Suicidal Ideation, Swearing

78. Splitting

Splitting is a concept that comes from Melanie Klein’s book Envy and Gratitude. In essence, she argues that as children and later as adults we see the world in blacks and whites: my mum was a hero, my dad was a villain. “There is no neutral zone, only good and bad” she wrote. She called this the “paranoid-schitzoid position” and said it was an early response to a child managing the enormous overwhelm of birth and early life.

The challenge, she argued, is to move to a more true but more challenging emotional position: my mum was great but in several respects she was flawed; my dad was a bastard but he did have this going for him. It’s much more honest, but much harder. She called this the “depressive position”.

Many of us enter therapy with this ‘split’ view in several areas of our life – whether about parents, politics, entertainment or ourselves. Finding our way to the greys of life – the truth of how the world really is – is often a key challenge. We’re in a particularly binary time in the world, which doesn’t do much to help our pursuit of nuance.

It’s worth trying it to see how easy or hard you find it.

“I hate musicals but I cried at Les Miz.” “I adore Mick Jagger but I don’t approve of him not paying his taxes here.” “Boris Johnson is a liar and a fraud but….” Well ok it doesn’t always work.

79. Suicidality vs Suicidal Ideation

These two terms may sound like matters of degree but there’s all the difference in the world.

Suicidality means that someone is actively considering taking their own life. They are thinking about how to do it, and when, and summoning up their resources to do so.

Suicidal Ideation is much more common. It means someone is thinking about what it would be like to die; perhaps wondering if ending their life is the only way to kill the pain they feel inside them. They wish the misery they feel would go away. They feel hopeless. Ideation needs to be taken seriously, but it’s the idea of death which contains the value for exploration and respect.

Every therapist’s worst nightmare – from the first day of training through to retirement – is a client killing themselves while being treated by us. Some of us will experience that in our careers. Most of us will have been confronted with it at some stage; wondered if our client will be coming back the next week.

Understanding from the client whether they are suicidal or are experiencing ideation is one of the key steps to working out how easily we can sleep at night.

80. Swearing

Sometimes only a “fucking cunt” will do.

If therapy is helpful it is because it allows you to express whatever you want to express in whatever way best releases the feeling. Sometimes that’s tears, sometimes understanding. But words count, and sometimes powerful invective is what the moment requires.

I sometimes spot a client pausing for a nano-second before saying that some experience “wasn’t very good”. “Is that what you wanted to say?” I might say. A pause will follow. “No. It was really fucking shit actually” they might say. That’s much closer to it.

Swearing isn’t obligatory. For some people it would feel performative and untrue to the way they talk. But if a swear word is needed, or even an avalanche of them, there’s no number of fucks, shits, cunts or arseholes I’m not up for hearing.

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T

Therapists in therapy; Training; Transference; Trauma; Truth

81. Therapists in therapy

Any therapists worth seeing have had (or are still having) loads of therapy. Why? Well obviously because we’re famously all a bit fucked up. (Some clichés are true.)

Another reason is that all reputable trainings require therapists to be in weekly therapy throughout their three to five-or-more training years. That’s a lot of therapy.

But there’s a more profound reason. Therapists need somewhere to process our difficulties too. We need help working out what we’re feeling, how we’re behaving, what we need and how to get it. And having therapy is a great and constant reminder of how fallible we all are and how valuable the experience can be. If we can overcome our challenges, or keep trying to, maybe we can help others do the same with theirs.

A therapist who thinks they’re all sorted is a really bad therapist.

82. Training

Psychotherapists generally go through up to five years of training. Training involves three core ingredients: theoretical knowledge (from Freud to the present day); therapeutic skills (variously in groups or “goldfish bowls” – giving therapy to another colleague while other students watch and review) and personal development. The latter, perhaps the most important ingredient of the three, happens during the training but also outside it: for instance, most trainings require students to be in therapy throughout (see above).

Different trainings focus on different modalities (approaches) but all trainings will focus on those three ingredients in their own way.

So when you meet your therapist you should be able to assume that, at minimum, they have a well-developed sense of themselves, their skills and the theory which underpins everything they do.

83. Transference

Transference is one of the key ingredients which most therapists, particularly those who work at the more psychodynamic end of the scale, have in mind throughout their work. It means who we become for the client.

Almost inevitably, as the therapeutic relationship develops the client will start to project onto the therapist aspects of their own relational patterns. The client experiences the therapist as uninterested, or punishing, or lustful, or shaming, or judgmental. With help, they can come to see that those feelings are based on their previous experiences with others. Gaining access to this crucial dimension of relationship is often a key component to undoing its power.

84. Trauma

Trauma is an individual response to a traumatic event, generally one which the person experienced as a threat to their life or bodily integrity. Trauma is the mainstay of what most therapists do for a living.

Some events – a serious injury, say, or a sexual assault – are very likely to induce some form of trauma response. But many trauma responses have roots which are more opaque, or even completely unknown. As with most material that is explored in therapy, though, it is the client’s response to the event more than the event which is crucial to release for the person to find their way back to equilibrium.

Of many enormous challenges which trauma can induce is the absence of a narrative timeline. When we experience a trauma, often the part of our brain that stores memories is knocked offline, over-run by our ‘felt responses’ to it. When the trauma is over, our body retains the feelings but our mind confusingly does not retain the memory. That’s why some people experience flashbacks: their mind is trying to slot what little it has retained into a sequence. That’s why, when working with trauma, very often the key technique is to tune in to the feelings it evokes (even in the abstract) rather than the memories it induces (in fragment).

As Babette Rothschild – an expert on the subject – writes in her accessible and detailed book Trauma Essentials – the keys to managing trauma lie in four stages: developing an environment of safety and support with the client; cultivating a strong therapeutic bond; pacing the work at a manageable level including “applying the brakes before the accelerator”; and identifying and utilising the client’s internal and external resources.

Simple as those may sound when summarised, for some clients even the first of those stages can take months or years. How to treat trauma in therapy, like trauma itself, is a completely personal experience, not a generalisable event.

85. Truth

Carl Bernstein, the legendary American journalist, is fond of saying that the job of the journalist is to find “the best obtainable version of the truth”.

Therapy is not journalism.

Frequently clients will worry that in their telling of a story or their reporting of an experience they may be missing a detail or inaccurately expressing what someone said or did. That maybe their memory is partial. Of course it is. That’s the point.

It is almost never important (or even particularly valuable) to hear in therapy a 100% “accurate” reporting of a memory. Such a thing isn’t possible; I’m not going to interview the other people who were there. The only purpose of a story is to access what the client took from it: what their truth is.

The only truth that matters is the client’s. Anything else: call for Woodward and Bernstein.

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U

“Unconditional Positive Regard”; Understanding; Uses of Therapy.

86. “Unconditional Positive Regard”

Carl Rogers, regarded by some as “the most influential psychologist in American history”, coined this term as one of his “core conditions” in his essay The Necessary and Sufficient Conditions of Therapeutic Personality Change (1957). Unconditional Positive Regard (or UPR) suggests that the therapist should aspire to love their clients unconditionally in a way that, often, they have not experienced in other relationships, where love, praise or validation were offered with the price tags of being well-behaved, agreeable or high achieving.

Initially this seems an impossible reach: surely we can’t think well of everybody! (Rogers agreed it was an aim rather than an absolute.) But actually, I’ve found over time, it’s easier than one would think. Everyone has positive attributes (the only exception to this, in fairness, was never my client because he was being the Prime Minister during a pandemic). And negative or challenging attributes are all there for a reason and are for me to try and understand and support rather than reject.

87. Understanding

As suggested in Truth (see T, last week), therapy is not about understanding ‘the facts’ of a situation but about getting closer to what the client made of an experience, or means by a word, or responds to a stimulus. The essential question – sometimes explicit, often implied – is “What does that mean for you?”

Ullah and Ulrika both lost teddy bears on bus trips with their parents when they were six. Same story, same context, same age, same stage in life, surely the same meaning: right? Wrong. The meaning Ullah made of it was “accidents happen, we can always repair” and he scarcely remembers it beyond his parents teasing him years later about how upset he was at the time. But for Ulrika the meaning she took from it was “Everything is lost in the end”: all relationships, whether with people or inanimate objects, end in loss.

Neither are wrong. They are understanding their experience.

The next stage of understanding, sometimes, is to say “Ok, so why would you have felt that way?” Not to criticise or minimise it, but, again, to understand. On some level it was vital for that child to take those inferences from that experience and probably inevitable. But why? How had their experience of life taught them that this response was the best?

Judging a client’s response to things that have happened to them is never valuable. Understanding it always is.

88. Uses of Therapy

The most obvious question to ask a client in a first session is “What do you want from therapy?” In practice it is almost always a guideline question at best, with an answer which is likely to be very general and change many times. The most accurate answer a client can give, usually, would probably be “Well, I think I need this but I don’t really know yet”.

Not knowing is fine. Indeed, not knowing, and the fear which that engenders, is often at the centre of the problem anyway. Most people I encounter in therapy are pretty bright, self-aware, articulate and successful in various spheres of their lives. If understanding stuff was the issue, they wouldn’t need me.

Therapy is different for everyone, and so is the uses they make of it. These might include a place to: process trauma and tragedy; understand their thoughts and feelings; talk without being judged; feel without being overwhelmed; express anger without punishment; allow sadness without pity; reconnect with the childhood they never finished; prepare themselves for the adulthood they haven’t started; practice relationship; survive risk; tolerate vulnerability; find comfort; survive embarrassment; say the unsayable; re-tell their story; be themselves.

Trust me. That’s a pretty short list.

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V

Validation, Value, Variation

89. Validation

Valerie comes to therapy for someone to listen to her without telling her what to do. Van comes to therapy to release a long-standing experience which he has hitherto never spoken of. Vic comes to therapy without knowing why, but they want help understanding why they have such enormous anxiety all the time despite leading a seemingly low-stress life.

Valerie, Van and Vic have different needs, stories and motivations but they all need validation. Val needs to hear someone say “What do you want to do? What do you think is going on here?” Van needs to sit with someone who’ll indicate in their reactions to his trauma: “That’s ok. I’m here with you. I can hear how hard that experience was, and I can manage it. Let me see if I can help you manage it too.” And Vic needs someone who will show her that however comfortable her life is on the surface “I can really see how hard you find it on some level. We just don’t know why yet. Let’s try and find out how to help you, together.”

Tears are, of course, a common experience in therapy but sadness is not necessarily the main cause. Being seen, being heard, being listened to, being understood… all are about being validated and with the tears of relief can sometimes come the tears of grief for not having had that experience enough before.

90. Value

What value anyone finds in therapy is, of course, up to them. Sometimes the value is in understanding themselves. Often value can be found in their experiencing a different kind of relationship with the therapist than they have achieved elsewhere. Sometimes the value is in processing trauma and challenge, sometimes in crying without judgment or dismissal.

My own opinion is that the value of therapy lies in visible change. At the end of a period of therapy, whether six weeks or ten years, I would like a client to be able to point as aspects of their life or experience and say “This is new; that feels possible; I am now comfortable with this” in a way that they weren’t when they started.

91. Variation

Like any relationship, therapy benefits from variation: variation in tone, variation of subject, variation of approach. There is more than one way to gain access to difficult material, or to explore how best to help a client make changes. To my mind (and this is not necessarily a widely-held view) if we have too many sessions which look and sound the same as each other there’s a danger we might get settled into a familiar pattern, whereas I think therapy should always be leaning forward towards the better life we’re trying to find for the person concerned.

Sometimes a “how are we doing?” check-in can help provide the variation; a periodic review of what we’re doing and where we’re going. Sometimes an injection of creativity can help. Occasionally something more practical: swapping seats for instance.

Life is variable. I think therapy needs to reflect that where it can.

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W

“What does that mean for you?”; “Why?”; Window of Tolerance; Witnessing

92. “What does that mean for you?”

As described elsewhere (see T for ‘Truth’), there are no journalistic ‘facts’ I am seeking when I work with someone; I want to hear what their experience is. If everybody else involved would agree, or nobody would, is rarely important: what matters is the client’s experience of a situation.

A way in which I sometimes try to access this is with some variant on the question “What does that mean for you?”

Wilson feels hurt when his friend replies to a story about his lover jilting him by saying “I’m sure it’ll work out ok in the end”. From the outside this might sound like a way of being supportive, or perhaps just an empty platitude. But Wilson is raging. I might ask “So when he said that, what did you hear?” And Wilson might reply “It was like he was saying ‘Who cares? Change the subject.” Exploring why he responded that way – perhaps something about his prior relationship with his friend, or his sense of how people support him in difficult moments – will often yield meaningful results.

93. “Why?”

In training I remember a general view being that to ask a client “Why?” was a pretty bad question. The client doesn’t know, and anyway the more important question is “How?”, which is a question that will get closer to the lived experience than the “why” which goes to the brain. “How” is indeed a better question.

But I think “Why?” is really important. Because I think that people often know. They just haven’t had reason to think about it.

To show interest in why someone reacts a particular way, or why they love or hate someone, or why they get so scared if someone asks them out, feels to me fundamentally important. I never care if they don’t know the answer, but I do want them to know that I am interested and that I think our curiosity might lead us there in the end.

94. Window of Tolerance

A popular term of art for psychotherapists, the “window of tolerance” – coined by Dan Siegel – refers to the realm in which a client can function (in therapy or in life) without their defences kicking in or their capacity shutting down.

If they rise ‘above’ their window they are hyper-aroused, which might include being flooded with memories, experiencing panic attacks or heart palpitations, or experiencing an overwhelm which brings up a fog of challenge which makes engaging difficult.

If the client goes ‘below’ their window of tolerance they become hypo-aroused, which is when they experience inertia, tiredness, depression or an energy slump which makes functioning impossible from the other direction.

The window of tolerance is what exists between those two dysfunctional responses.

In therapy, the therapist and client will often aim to monitor, together, when the client is rising towards the top of the window (talking faster, perhaps, feeling anxious but still able to respond and connect) or falling to the lower reaches of the window (yawning during powerful exchanges, getting quieter or less articulate), as this can be a crucial means of noting how the discussed material is being received by the person’s body and reactions.

95. Witnessing

For a therapist a key part of the role is bearing witness. Showing a client that we can hear, see, witness and tolerate their experiences.

For a client, a lot of the value of therapy is in being witnessed: a private challenge being heard, a vulnerability being shared, a trauma being witnessed.

Often therapy isn’t about what the therapist says; it’s about being there. One of the reasons I love being a therapist is that I like being the person who’s there.

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X

X-Rated Subjects, X-Ray Vision

96. X-Rated Subjects

There are some subjects which are particularly challenging for many people to raise in therapy, and which can be enormously useful when they do. In my experience, they probably include the following (in alphabetical order):

Dreams – Whether because they’re sexual, violent, or both, people fear that dreams are too revealing of their desires and instincts rather than pointers to feelings and processes.

Embarrassments – There can be a fear that the therapist won’t be able to deal with embarrassing material from the past or present. If we’re any good, we’ll be fine, no least because embarrassment is very subjective.

Feelings for Therapist – If you love us, you fear we’ll reject you. If you hate us, you fear we’ll reject you. If you lust after us, you think we’ll reject you. If you imagine we’re awful people you may want to reject us. If you imagine we’re the best person who ever lived then you’ll feel unworthy of us… There’s no end of reasons for avoiding expressing our feelings towards our therapists, and most of them come down to fears of rejection.

Kink – All of us have aspects of our sexuality or emotional make-up which we feel are unusual or illicit or shameful, and many of these are useful routes into understanding ourselves more generally. But that’s not how it feels when the subject of our personal tastes comes up.

Masturbation – With the possible exception of dreams, there is nothing which is more private, more about our relationship with ourselves, and more shrouded in mystery. As such it often feels incredibly difficult to talk about. When people do, it is often more illuminating than humiliating.

Self-Harm – Whether because it’s so distressing, so normalised, too shameful or too risky to share, self-harm is frequently a hard topic for clients to talk about in any detail, even if the role of it in their lives is often part of the reason they have come to therapy in the first place. But like all subjects, it is not something to be afraid of but to be interested in.

Sex – Therapy, like sex, is an intimate act. How someone feels about talking about it to their therapist often mirrors how they feel about the act itself: ‘a subject like any other’, ‘tricky but fine once it gets going’, or ‘terrifying at every stage’.

Shame – A possible umbrella term for everything on this list, shame thrives in the dark. If it’s hard to talk about it’s usually about shame. If it’s shameful it’s probably been hidden from view and unspoken for a very long time. There are few subjects more appropriate for therapeutic enquiry.

Toileting – All of us have a relationship with the lavatory and its related bodily functions. (For instance we use phrases like “bodily functions” because saying “peeing and pooing” feels too embarrassing.) For some people how our bowels function, or don’t, offers amazing parallels with our emotional stability at the time. To notice one is to get in touch with the other.

Violence – Whether it’s violence experienced (domestic abuse, sexual assault, corporal punishment, bullying, inappropriate touching) or violence fantasised (intense anger, fantasies of hurting or harming someone else) violence is a tough topic for many people to acknowledge, and in my experience is more often hinted at than outright-expressed.

97. X-Ray Vision

A few weeks after I began therapy, many years ago, I said to my therapist: “This is great. I say stuff and you read my mind.” She smiled. She’d surely heard it many times before.

Therapists do not have X-ray vision, but sometimes it feels as if they do.

For Xander, early interactions sometimes feel like this.

Xander             So my wife said this thing to me last week and I don’t really know what she meant or what she said but it made me feel weird, kinda tight; I just… I can’t understand why she would accuse me of something like that. It made me feel, kinda, well, you know, (pulls a face) a bit.

Therapist         It sounds like you were quite angry with her.

Xander             Jesus, how the hell did you know that?

Whereas for a therapist the same conversation can feel more like this.

Xander:            So my wife said this offensive thing to me, about which most people would reasonably feel angry, and I’m not very comfortable with expressing anger but I feel tension in my body. I didn’t know why she’d say this angry-making feeling to me, but it made me feel kinda (angry face)fuck you, that’s made me fucking angry.

Therapist         It sounds like you were quite angry with her.

Xander             Jesus how the hell did you know that?

Xander is not an idiot: what’s obvious to the therapist is not in the awareness of the client. He can express himself in code and in facial expressions and even in body experiences but he can’t locate the word ‘anger’ yet.

The therapist is not a mind-reader. Contrary to the impression some people form of therapists (loads of people say to me at parties “Ah I must watch what I say!” as if I’m going to Derren Brown them) we are not mind-readers. We are just very experienced at paying close attention to what you say and how you say it, and trying to get to the essence of what is being communicated.

When a therapist appears to have X-ray vision and is able to speak as if directly from your deepest psyche, it’s probably because you’ve just said something very clear to them; it’s just you didn’t quite hear yourself say it.

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Y

Yes, You

98. “Yes”

With defences, habits, instincts and anxieties so often so prominent in our thinking, we can often find ourselves slaves to the word ‘No’.

No I won’t say what I need because I’m afraid I won’t get it.

No I won’t cry because I’m afraid I’ll be humiliated.

No I won’t get angry because the other person won’t be able to deal with it.

No I won’t change because change must be worse.

One of the benefits of therapy is working on these sorts of assumptions, presumptions and fears. This often entails a therapist helping someone to realise that by saying “No” they are precipitating the exact responses that they most fear. So it becomes….

I don’t say what I need and therefore I definitely won’t get it.

I don’t cry and therefore I feel humiliation within myself for feeling so vulnerable.

I don’t get angry and so the other person won’t have a chance to deal with it if one day I lose control.

I don’t change and therefore improvements become harder to imagine.

In therapy, preferably with a therapist with whom you can gently and maybe playfully practice different approaches, those toxic ‘Nos’ can sometimes become relieving ‘Yeses’.

Yes I can say what I need, which makes it more likely that I’ll get it.

Yes I can cry, which will show how I feel, release my feelings and allow myself to be supported.

Yes I can get angry, as if the other person really matters they’ll be able to deal with it.

Yes I can change, but first I have to want to.

There are few more empowering words in the language than Yes. Use it.

99. You

A therapy room can get incredibly crowded.

There’s your family, your partner, your friends and your colleagues of course. But sometimes your past therapists make an appearance, or your exes, or the younger versions of you. They can all be helpful. At times.

But then there are the impulses which demand our attention too: your protection of your parents from my judgments, even though I will never meet them and I’m not judging them anyway. Or your devotion to being as accurate as possible to what the other people intended (which we don’t know) rather than your own experience. There may sometimes be your concern about embarrassing, shocking or upsetting me (to whom you’re paying money to be able to deal with it).

All of those people, anxieties and approaches have something to contribute. But they are supporting players. The star of the show is you. The only person whose perspective matters is you. The only feelings, judgments, intentions or confusions that will help us are yours.

Therapy is for you and only you. Every minute you spend which is not focussed on you is a minute in which we’re not helping you.

The only one who matters is you. Use that.

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Z

Zebra-Thinking, Zoom

100. Zebra Thinking

What Melanie Klein called “Splitting” (see S) and others might call “All or Nothing” I call zebra thinking: the tendency to see possible interactions with the world in black and white terms.

Zizzi fears expressing her feelings to her boyfriend because to say “I don’t like this very much” would feel, to her, as dangerous as saying “Fuck off you arsehole, I hate you!” Zubin, similarly, fears expressing affection to the girl he’s been dating because “I really like you” might sound like “I love you and want to marry you and be with you forever” which may frighten the girl away.

People will often have had experiences which provoke them to see life on a scale of only 1 (“say nothing”) or 10 (“say everything”). It’s hard for them to imagine expressing anything in the mid-range - a 3 or a 5 or a 7 - which would be saying “I don’t like this but I still love you and we’re all good” or “I really like you and I don’t know where this is going but I’m really enjoying it at the moment”.

Zebra-thinking can often enter the therapy relationship. The client feels that if they don’t do their ‘homework’ the therapist will punish them. Or if they reveal something embarrassing about their sexual life or their vindictiveness or their confusion the therapist will respond with harsh judgment rather than open-minded concern. In such cases, the ‘transference’ (see T) in which the therapist essentially ‘becomes’ someone else from the client’s past becomes a key tool. And this then opens the option to try and do something else, to see if the dial – previously stuck perpetually on a 1 or a 10 – can be gently moved to a 2 or a 9, or maybe even  a 3 or an 8.

Thinking in black and white terms provides clarity, but not the value of the shades in between.

101. Zoom

Covid changed the world. It gave us Zoom.

Hitherto the presumption amongst most therapists was that therapy was an “in the room” experience. For clients a key criterion for picking somebody would be location: not too far from work or home. For therapists remote sessions would largely be a back-up to call on in  exceptional circumstances. After all, how can we feel what our client is going through when we can only see them from the neck up?

Covid taught us all to get over that.

In 2020 three quarters of all my sessions were online. In 2021 it was maybe 30%, mostly for reasons of Covid, whether directly (lockdowns and caution) or indirectly (the client had moved away during the crisis and decided to stay there). In 2022 it’s about a quarter, all for reasons of location: the client wanted to see me but lives, works or studies outside of London or abroad. Pre-2020 I presume they would have found someone more accessible. But now, why should they? They can have the therapist they get the best sense of online, and I can be a therapist to more or less anyone in the world.

I had never heard of Zoom before March 2020. By April 2020 Zoom was what allowed me to continue seeing people, put me in the fortunate position of not losing a single client due to the pandemic and everybody being able to get the support they needed and not have to wait for the crisis to be over, which at the time felt like it might be years away.

For some clients Zoom is very sub-optimal indeed: a only-if-needed back-up, never a first resort. But for many it has distinct therapeutic advantages as well as its practical benefits. Clients with trauma can find it safer, as they’re in their own environment rather than in the sometimes intimidating terrain of the therapy room. Clients burdened by shame can find embarrassing material easier to share to a face online than to someone whose aftershave they can smell a few metres away. I have some clients that I work with regularly in both ‘formats’ and each has their particular advantages or shortcomings which are very useful to note in themselves.

Covid taught us many things: the fragility of our health, the adaptability of most industries when challenges arrive, the danger of putting a malignant narcissist in charge of a once-a-century crisis. But it also showed us that contact, support, love and intimacy can sometimes be achieved via different means.

The world of therapy changed as a result. And Zoom deserves some of the credit for that.