Docsplainin' -- it's what I do

Docsplainin'--it's what I do.
After all, I'm a doc, aren't I?

Friday, September 19, 2008

How do psychologists work?

My Dad e-mailed me recently to say that
"it has always been my understanding that real world, the psychiatrist gets the patient to talk talk talk talk until he reveals his own feelings and finds himself. ...

So the question: How do shrinks in the real world get the patient to see why they work the way they do?"

That ought to be a relatively easy question to answer after nearly 30 years in the profession, so the difficulty of forming an adequate response surprised me.

Part of the problem is that "how" means more than one thing. If by "how" my Dad means "what are the actual motions we go through" then that's not so difficult. If his "how" is more at "why", as in, "what is the actual process by which change occurs?" then we are getting into the harder stuff.

One answer to the why-does-it-work? part of the question, and the part which I gave Dad, is "I'll be damned if I know. It just does." And that really is true. Why should talking to someone about your problems help? I have no idea. But I know that it does. I have experienced over the last three decades innumerable sessions in which I felt like I didn't do anything and yet the patient leaves feeling so much better. It never ceases to amaze me.

Then, when I thought about it, I got back to the old core of William James's interpersonal theory, which is, in modern lingo, that we are hardwired to live and to experience life in groups: mating pairs, family groups, tribes, and so on. In particular, the human species has the longest period of dependency on parents of any species on earth, and this period of dependency lasts long past sexual maturity--which is true of no other species on earth. So any way you look at it, we are definitely relational down to our very bones.

Looked at that way, it makes sense that what gets injured, or never developed properly, in a relational context might then heal, or grow, in a relational context. Add to that the importance of language in our cognitive and emotional lives, and it only makes sense that talk is the solution to any problem that is not strictly biological.

As to the mechanics of how it works, again, as I told Dad, there are reams and reams of writing on that subject. Not something one boils down into an e-mail or blog entry with any degree of ease. The core, however, I think is the ability of the therapist to create a safe space. I have had clients tell me that the only space that they do not feel alone in, or the only space that they do feel safe in (and sometimes both) is my office. This sense of safe, secure connectedness is the sine qua non of therapy. And everyone who comes to me for help, without exception, either has never had that secure attachment (e.g., with a parent) or has lost it in some way.

Talking it through of course involves much more than just talk. Talk, per se, accomplishes little. Sometimes the issue is that there are feelings that could not be expressed at the time (read Charlie Mike for the perfect explanation why)and so an important part of therapy is that the patient gets a chance to experience those emotions in a supportive environment. We call this a "corrective emotional experience." Especially in the case of childhood issues, a vital part of therapy is the cognitive restructuring that, ideally, follows the re-experiencing. Kids have limited ways to understand what's happening to them, and what gets tucked away in the brain in kidspeak has a tendency to remain conceptualized in child-like ways of thinking. Consequently, in adolescence and adulthood, there are vast pockets of experiencing of the self and of self-in-the-world that get thought about, felt, and acted out behaviorally in immature ways. So we have to re-understand ourselves from the vantage point of adult experience and ways of thinking. As a small example, a person may need to see that she wasn't sexually abused because she was "so sexy"* at age 5 or 6, but because her father was a sexual deviate. This will totally change her outlook on herself and on life, not just on men or sex.

So. To recap, this is how psychologists work:
  1. We establish a safe space.
  2. We encourage the patient to talk.
  3. We listen.
  4. We help reframe--if not the experience itself, then the patient's experience of it

How it works is:
  1. The patient gets to bring up issues in a safe space that they may never have had the chance to talk, think, or feel about before
  2. The therapist helps him reframe his experience, or at least his experience of his experience, in a more functional way
  3. As a result, the experience loses its power to interfere with his day-to-day lived experience

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