How does psychotherapy work?

Someone who has never experienced psychotherapy may understandably have questions about what it is like, how it works, and why it works. While psychotherapy sessions are different for every person, tailored to a client’s needs, based on the person’s biography and the issues they present, there is nonetheless a general pattern that a series of sessions follows. This article sets out that pattern, intended as a guide for clients.

The general principles of therapy are set out, and we see what that might look like in practice with a fictitious client, Steve, whose relationship is on shaky ground because he repeatedly has arguments that don’t make any sense to himself or his partner.  

Stereotypes

There are some stereotypes about psychotherapy that people sometimes have in mind from the media. I want to dispel four of these immediately.

First, I won’t have you lie on a couch as in the image on the right, the stereotypical pose of the therapy client in films and cartoons. Instead, I have a comfy sofa and I will offer you tea or coffee.

Second, you are not a patient because you are not ill. Unresolved emotions and unsettling thoughts can be disturbing, but emotions and thoughts are not illnesses. You will be my client.

Third, it follows from the second point that I will not behave as a doctor does: there is not a diagnosis followed by treatment in which you are an entirely passive recipient. In the medical profession, that is appropriate: you cannot be expected to know the medical intricacies of biological organs and why they fail to function correctly, nor know the appropriate drugs to administer, and you certainly cannot carry out your own surgery. In psychotherapy it is different. To use the medical analogy, I am not a surgeon, doing to you while you are passive; I am more a midwife: I know the psychotherapy process and will guide you through it, but you do the work with me. You are the expert on you and know yourself best, but you cannot make choices about what you cannot see. So my job is to ask the right questions to help you know yourself better, suggest models of understanding that may help clarify your predicament, and support you along the way. To help me do this, I am trained in a range of psychotherapeutic perspectives (my professional title is integrative psychotherapist), I regularly read theories and research, and this helps guide me in knowing what to ask and how to explore with you.   

Fourth, I won’t ever ask you the stereotypical counselling question of TV and radio drama: ‘How does that make you feel?’ There is one good reason for this: no event makes us feel anything. There is no necessary connection between an event and a specific response. Take, for example, a response to seeing two men fight over a space in a car park. Do you freeze in terror, or use it as a hilarious story to tell your friends, or immediately start taking care of other onlookers, or restore order by phoning the police? Whichever you would have done, the fight didn’t make you feel what you felt or do what you did. Instead, your response says something significant about you and your cognitive/emotional processes, and it is therefore important information about your biography and your personality. (For more detail on this question, see The childhood blueprint.)

Having addressed four of the stereotypes, before describing the typical psychotherapy process over a series of sessions, we turn to the most fundamental question of all: What is psychotherapy for?

What is psychotherapy for?

Generally in life, people feel relatively stable when they know what to do, even if the situation is uncomfortable. For example:

• I can’t afford a mortgage, so I will work hard and get a better-paying job.
• I want to do well in the exam, so for several weeks before I won’t go out but devote all my time to studying and revision.
• I see a lump on my arm which is bigger than it was last month, so I will make an appointment with a doctor to get it checked.

These are all straightforward examples of a person’s capacity: they see an issue, they understand the solution to the issue, they carry out the solution. In the descriptions of situations above, thoughts and actions are described. There will also, of course, be attitudes and emotions: determination to own a home; nervousness about the exam; worry about the growing lump. 

In each case the person looking to afford a mortgage, to pass an exam, to resolve a medical issue, has capacity: they see a problem and know how to resolve it. Emotions are present, but they do not dominate or destabilise.

When a person feels their incapacity, emotions and emotionally-led thinking dominate or destabilise to the point that the person feels stuck or over-whelmed. In the three cases above, this may present as:

• I can’t afford a mortgage, and I am angry: I’ll never get a better job because everyone is against me.
• I want to do well in the exam, so for several weeks before I will be sleepless and over-wrought with fear because I will never be good enough.
• I see this lump on my arm which is bigger than it was last month, so I should make an appointment to see a doctor, but I can’t go because I feel sad and ashamed: the doctor will think I’m stupid and has more important things to do than see me.

In each case and for each person, the negative thoughts and accompanying emotions will not be a one-off event, but part of a continuing process of self-defeat. It is in just such a situation of emotional and cognitive incapacity that a person senses something is amiss that goes beyond this or that situation, that the problem is part of a bigger personal issue they don’t know how to resolve. It is then that the person would see a psychotherapist.

The therapist will work with the client to understand what those patterns of thoughts and emotions are, to recognise their biographical roots and, with this understanding, work together to consciously change personal processes that were established unconsciously. To put it another way, we work together to move you from personal incapacity to capacity. What you need to establish that change will depend entirely on your own history, experiences, and your resulting outlook and habitual processes.   

The four stages of psychotherapy

The four stages of psychotherapy are typically:

1. Discovery
2. Change
3. Maintenance
4. Self-processing

For some clients, we move in a linear progression from one stage to the next, but this is not always so. Many clients come with issues that have many layers, so we may work through the first stage of discovery, move into change, maintenance and self-processing for one layer, then move to another discovery, change, maintenance and self-processing for the next layer, and so on.

Clients don’t always have sessions because there is a burning issue they need to resolve, but because seeing a therapist is the only chance they have to speak truly openly, in a way that is impossible with friends and family for one key reason: friends and family have a stake in what the client does, thinks and feels, and they often have opinions on what is best for themselves in relation to the client. I, as the therapist, have no such stake, and am unaffected by what the client does, thinks or feels outside the therapy room. This creates openness in which the client can air their feelings and experiences without judgement or consequences, which in itself leads to a sense of personal acceptance and clarity.  

Some clients go through the four stages and continue to have sessions after the presenting issue has been resolved, for the space that therapy sessions provide to be heard and to process thoughts and emotions, as described in the previous paragraph.

The details of the four stages of psychotherapy are as follows.

1. Discovery

The quality of the therapeutic relationship is fundamental. We function better when we are relaxed and not concerned with how we imagine others perceive us. It is therefore critical that from the beginning the client experiences a warm, compassionate and approachable therapist. For this reason, for some people the therapeutic relationship itself is part of the healing process: for some, it is the first time they have ever felt that someone has truly listened and tried to understand them.

In the first session we begin the assessment. There is no standard assessment used by psychotherapists – I devised mine as a structured way of getting to know you very quickly. I will ask you about medical history, your experience of relationships in your family growing up (which tells me how your personality was formed, and how you adapted to others), the issue(s) you want to resolve, how the issue(s) you want to resolve are affecting you and your relationships, questions of personal safety, and how you’ll know when it’s time to finish sessions.

During the assessment I am formulating the nature of the problem through the lens of a range of psychotherapeutic perspectives. In particular, I will want to ascertain your attachment style (see the articles here, here, here and here); your childhood blueprint or life script for behaviour and relationships (see the article here); which emotions you have therefore allowed or disallowed (see here); what is therefore your idea of emotional intimacy and love (see here); how you move between Parent, Adult and Child ego states (see the subheading, The right page: ego states, in the article here); whether you or anyone in your family has taken a position on the Drama Triangle (see here); whether you engage in what psychotherapists call games (pre-determined moves in relationship with another, with a pre-determined outcome, reinforcing the problem – article coming soon); and whether there is emotional trauma (emotionally destabilising hypersensitivity to everyday events, which are perceived as threats – see articles here and here). Of course, none of this is asked of you directly, but ascertained through what emerges during the assessment process. 

The assessment usually takes two to three sessions, and it sets us up for all the sessions that follow. By the time we have finished the assessment, I will have noticed key aspects of your speech patterns, thought patterns and emotional patterns, formulated the therapeutic questions we need to explore, and begun to think about the best approach or therapeutic framework to follow.

2. Change

Raising the client’s self-awareness and self-understanding is fundamental to change. Our own emotional, cognitive and practical habits are often so ingrained and normalised that we are either completely unaware of them, or we see them but are unaware how they are reinforcing the problem we wish to resolve. It takes a psychotherapist to see what is going on and to sensitively ask the key questions or offer a perspective that raises awareness of habitual patterns. In this way change begins. I often find there is a turning point when I offer a client a framework through which to understand their problem. 

The best explanation I have seen of the power of a therapeutic framework is the cartoon above. The client tells her story, describes her distress, pictured as an intertwined muddle of different-coloured lines without any pattern. The client feels and describes what is going on, but cannot make sense of it. While only the client knows her own experience and the emotional impact that has on her, the psychotherapist perceives that the experience and the emotional response forms a pattern. That pattern may indicate avoidant, ambivalent or disorganised attachment, or a position on the Drama Triangle, or repeatedly playing a game, or unresolved emotional trauma (all mentioned above in the formulation stage), or some other process that keeps the client unhappy, locking her into a self-defeating cycle. At a pace and in the detail that the client can tolerate, I will offer the client the framework of understanding that fits the experience, shown in the cartoon as the therapist taking the client’s mess of muddled lines, forming them into three clear and distinct bundles, verbally offered back to the client. 

To reinforce the analogy I used above, I am not a surgeon, doing to you while you are passive, I am more a midwife: I know how the psychotherapy process goes and will guide you through it, and you do the work with me. So the point of the first stage, discovery, is for the therapist to understand the issue the client brings and, since we have no power to change something we cannot see and cannot understand, the point of the second stage, change, is for the client to understand the issue, and thereby to become equipped to make changes in her/his own life. 

This doesn’t happen in one go, but incrementally. In this task, every detail of a client’s presentation is potentially important, an indication of the client’s cognitive and emotional process. For example, a client may habitually express a negative view of what they’re about to say, beginning sentences with phrases such as, ‘You’ll think I’m silly to say this but …’ When the client is ready for it, I will bring the client’s attention to their self-negating sentences (or other counterproductive habit), to heighten self-awareness. We’ll want to know why the client feels the need to do it, what purpose it serves, the origin story of such a self-defeating habit (nearly always in childhood family experiences) and, now that we’re aware, how better habits can be formed that promote self-confidence rather than self-negation.

If a client comes to me at the age of, say, 40, they have had potentially 40 years of ingrained emotional and cognitive habits that perpetuate their self-defeating process. This may be, for example, sad self-blame, the notion that whenever a bad thing happens it is always my fault; or the angry presumption that others will always let me down, which leads to regular relational conflict; or the fear of abandonment, leading the person to form unhealthy and abusive relationships for fear of being alone. Those 40 years of life do not mean that change isn’t possible – change is always possible – but it does mean change won’t happen overnight. So having understood the nature of the issue, and the client having understood what s/he habitually does to perpetuate the distress, and with the client now challenging and changing those habitual patterns, we come to the next important stage: maintenance.

3. Maintenance

The people and stories that follow are fictitious, based on common patterns in psychotherapy.

Having identified the nature of the problem; seen how this presents in cognitive, emotional, practical and relational habits; and identified better habits to reshape life in a more fulfilling direction; the next stage is maintenance. 

In the maintenance stage, I often see progress move in the following way. This is easiest to explain with a fictitious example, recapping the discovery and change stages first.

In the first stage, discovery, Steve revealed that his father was a gambler, always in debt, who not only spent the money meant for the family’s bills, he also gambled away his wife’s money, leaving Steve’s mother struggling to feed him, his sister, and herself.

Steve’s presenting problem is constant arguments in his relationship, always over money. In practical reality, finance is far from being an issue for this couple, Steve and Steph, both of whom have secure and well-paid jobs. During the second stage, change, I explained to Steve that this is transference, an emotionally unresolved issue from the past that imposes itself on the present when there is some element that hooks us back into our unresolved theme. In this case, his girlfriend Steph mentions anything that involves money, such as ‘Would you like to go to the cinema to see this film?’ or ‘We have run out of bread’, and Steve is struck with terror at being in debt, which he presents to Steph as anger.

It is often the case with unresolved developmental (childhood) experiences that the longer it remains unresolved, the more it spreads unseen into more areas of life, and the more exaggerated the emotional response becomes. Thus for Steve, he is very angry at Steph for being so ‘irresponsible’ that she would suggest going to the cinema or telling him that bread needs to be bought. For Steve, whenever Steph mentions anything that implies money, in transference she becomes a version of his debt-ridden gambling father who cared more about frittering money away than he cared about his son, or a version of his mother, who took no action to stand up for herself or him, and it feels powerfully like abandonment. As a result of these arguments, Steve and Steph’s relationship is hanging on by its fingernails.

Having gathered this information in the first stage, discovery, and with Steve having understood the root of the problem in the second stage, change, it was important for Steve to locate his habitual anger where it really belongs: not with Steph, his girlfriend, but with his father for being so irresponsible and neglectful, for never putting his family first, and with his mother for not standing up to his father so that he, their son, would be looked after. As a result of this work in sessions, Steve’s arguments with Steph became less frequent – eventually. Steve is 27, so he has had more than two decades of being preoccupied with money and debt. Progress followed the typical incremental pattern in the change stage, as follows.

• Another argument with Steph about money. Although Steve now knew arguments of this type were transference from his past, he didn’t realise this particular argument was transference until we talked about it in the next session. This happened several times.

• Another argument with Steph about money. He understood that shouting at her for buying an expensive cake when there are cheaper ones was transference, but not until 3 days later, the day before the next session. Upon realising, he was too embarrassed to apologise to Steph. Now we were beginning to see change. Now the new understanding was closer in time to the event, closer to breaking the old pattern.

• Another argument with Steph about money. He understood that shouting at her for bringing up the car insurance was transference … 30 minutes after the argument. He apologised to her. She accepted. Now the new understanding was beginning to break the old emotional and cognitive habit.

• A few weeks went by. Now Steve and Steph were much happier as a couple. Now when he thought about money, he tended to think about what we had discussed in sessions. He remembered the session when he expressed his anger at his parents, putting his sense of abandonment where it really belongs, in his past, with his upbringing, not with Steph. His emotional life was now calmer; he and Steph were happier together. Then he had another argument with Steph about money – almost. He understood that he was about to shout at her during a discussion about changing the mortgage; then he realised what he was about to do, and why he was about to do it. Now cognitive and emotional understanding was deepening, and change was becoming established.

Now, in moving from change to maintenance, we keep reinforcing what we have learned. This reinforcement in the maintenance stage is necessary for three reasons.

i. Contexts or parts of self

Steve had recognised the hook that activates his transference and imposes his childhood past on the present. That hook is anything to do with money, which easily invokes childhood emotions of unbridled anger, fear, and impending abandonment, as if Steph is a version of his father and mother. As is so often the case, the tragedy and irony is that Steve’s reaction is, over time, likely to lead to exactly the same emotional result as in childhood – abandonment – when Steph can take no more of his anger and leaves him. Thankfully, Steve managed to avert this, but there was more work to do. 

A common feature of the maintenance stage is relearning the same lesson in different contexts, or reapplying the same principle to different parts of oneself. In Steve’s case, he had understood that any conversation implying money had a transference hook. He implicitly understood this to mean any conversation with Steph implying money had a transference hook, as that was the main source of his distress. It took Steve more time to recognise that any conversation with anyone implying money had a transference hook, because with friends and at work he was much better at hiding his feelings, even to himself. ‘In retrospect,’ said Steve, ‘this is obvious, because the hook isn’t in the situation, it’s in me, in my memories, my emotional response and thoughts.’ We were then able to progress to the next layer of transference, the more subtle hidden hooks.    

ii. Hidden hooks

Having recognised that the hook is talk of money, the more obvious examples become increasingly easy to recognise. In the maintenance stage, Steve is likely to bring less obvious examples of transference, and wonder why he is so angry or fearful. In Steve’s case, one example was receiving a hand-made birthday card from his sister’s 7 year old daughter. He knows intellectually that it is a lovely gesture: he can see the effort that has been put into it, with the drawing, the cutting out, the sticking on, the gluing together of layers. ‘So why do I feel so angry with a 7 year old girl, for goodness sake?’, he asked in the following session, exasperated. We explored the question. I asked what his birthdays were like when he was her age. Always a disappointment. He never got what he wanted. Instead of the toy he’d asked for, he’d always get a cheap imitation, or something completely unrelated. His father wouldn’t even be there on his birthday, but in the betting shop or the casino, as always. Then, through some further questions, Steve realised. The effort his niece had made in creating such a lovely birthday card, and the fact that she wanted to spend his birthday with him, evoked in him the implicit contrast with his parents. Emotionally, he was angry with his niece for showing him such care, as it reminded him of his parents’ lack of care. He was angry with her for wanting to spend his birthday with him, as it reminded him that his father didn’t. And the fact that his niece had made the card rather than buying one reminded him of the cheap imitations his parents bought for his birthdays. If his anger could speak, it would say, ‘Why couldn’t she spend the money and buy me a proper card?’

‘I feel ashamed,’ said Steve, ‘being angry with her. That’s so unfair after the effort she’s made. It’s such a lovely card. She’s such a lovely girl …’ I reassured Steve that emotions aren’t always fair, that they don’t always follow obviously pathways, and that he was in a far better position now he could see the subtle ways transference hooks can operate. Having understood and faced his more subtle transference, he was now an important step closer to understanding then preventing such responses in future. This was real progress.

iii. Script and script backlash

In childhood we learn the fundamentals of life: how to feed, how to gain attention, how to talk, how to walk, how to manipulate objects with fingers and thumbs and, most critically of all for our emotional life, how to relate to others and have relationships. This forms the foundation of the personality. It is in these early years, in relationship with our immediate family, that we implicitly understand how our life is going to go. In very simple terms, we could put it like this. If we feel loved and supported in the family, we will likely imagine our life will go well, and we are emotionally equipped for a life that will go well. If we feel unloved and unsupported in the family, we will likely imagine our life will be an uphill struggle, and we are emotionally conflicted about what is ahead.

Within each life, the finer details are biographical, reliant upon events the child is subject to and the meaning the child makes of those events. The predictive element of this childhood meaning-making is known as a script or life script in Transactional Analysis (a branch of psychotherapy). A script is a summation of the child’s experience and the meaning s/he makes of it, formulated unconsciously into a path to follow, a fate to be proved true. Since this is decided by a child, a script can always be summed up in a single sentence.

On the social level, Steve behaved to his parents as if he was happy with his birthday presents, as if he didn’t care that his father was never there on his birthday. What else was he to do? He could not change the situation in any way. This is why today Steph and his friends say that much of the time they don’t know what he is feeling, that he is difficult to read.

On the emotional level, Steve’s life script was formed from his disappointments, habitually hidden. From his father’s absence and his mother’s failure to protect him from hunger, regular frustration, and feelings of abandonment, he learned the script: I am unlovable so I can never be happy.

When I put this formulation to Steve, he said that when he and Steph have argued he has a strange sense of satisfaction that he hasn’t been able to explain until now. Through further exploration, we now understood four important things:

(a) In arguing with Steph he was expending the anger at his parents, which felt both horrible and oddly satisfying to do, but that anger belongs with his parents, not with Steph. 

(b) His parents were estranged from each other and from him, so from them he learned the lesson: Don’t be close. Not only did they teach him not to be close, they taught him the means by which to keep his emotional distance: argue about money.

(c) The hours, sometimes days, of not talking following an argument felt awful, but somehow it felt like home, like it was where he belonged emotionally. It felt like home because it was his childhood home, where he learned Don’t be close and formulated his script, I am unlovable so I can never be happy, which he was now reinforcing.

(d) In arguing with Steph so regularly, he was unconsciously reinforcing the implication of his script: that being unlovable meant Steph couldn’t really love him, so if he drove her away completely it would be only what his parents taught him he deserved: Steph leaving him would ‘prove’ he could never be happy and didn’t deserve to be happy.

In understanding the fine mechanics of how the life script operates, we were now entering the deepest part of therapy and the most important part of the maintenance stage. In undoing the script, which was decided unconsciously, we consciously re-decide the way we want our life to go. This requires letting go of the parental injunction, Don’t be close, giving oneself permission to defy the script, giving oneself permission to be happy.

When the script is challenged it can have a habit of reasserting itself. The unconscious reassertion of the script is known as script backlash. This may take the form of ever more subtle versions of the script, so that now the arguments and unhappiness are not about money but something else, to make I am unlovable so I can never be happy still true. The experience of script backlash can be disconcerting and upsetting, but it means we are making progress: the script that has marred life to this point is resisting and fighting for its life.  

4. Self-processing

The ultimate role of a psychotherapist is to help the client understand their own processes in such a way and to such an extent that s/he now feels in charge of her/his own life, able to see her/himself with much greater clarity, to the point that sessions are no longer needed.

The final stage of therapy, then, is self-processing, when the client is not coming to sessions with unresolved conundrums to work through, but instead recounting new events that have the following storyline: This is what happened; this is how it affected me emotionally; this is how I understood my own internal response; and this is the emotionally healthy thing I did with it.

I call this stage self-processing because, as we have seen, in psychotherapy the most important aspect of our personal history and present interactions is not what happened, but what we do with it, or how life script shapes what we expect and experience, or how we process emotions and relationships. We may therefore now characterise the four stages of therapy as:

1. Discovery: How was the client’s personality formed? What is their life script? How therefore does the client process emotions, relationships, events?

2. Change: How might self-defeating processes be remoulded into self-supporting processes?

3. Maintenance: Noticing and challenging the self-defeating processes in greater depth, further modifying and remoulding self-supporting processes.   

4. Self-processing: The client processing in a self-supporting way for her/himself, with the therapist as witness.

This fourth stage is just as vital as the previous three, and should not be rushed. While I have presented the therapeutic process as a linear progression from one stage to the next, in reality it is not always quite so neat. There may, for example, be a bump in the road during the self-processing stage, if the client experiences a difficult patch so that some aspect of the client’s process slips back into self-defeat, at which point we retrace our steps. If this happens, sometimes a client will fear that they have not made so much progress, after all. This is an understandable fear, but it soon becomes clear that none of the previous progress has been lost and is soon regained. The important thing is to learn from the experience, to identify the particular vulnerability, so that next time the client is more equipped.

As with the previous three stages, self-processing takes as long as it takes. For this reason, I never decide when to end sessions, but leave this decision to the client. The client knows much better than I how confident they feel to go solo, and when they feel ready to fly the therapeutic nest. When the client does go, the door is not closed: the occasional top-up session, or a series of new sessions at a particularly challenging time, is always a possibility.      

 

About Ian Pittaway

Ian is a psychotherapist and writer with a private practice in Stourbridge, West Midlands. Ian’s therapy is integrative, chiefly comprising key elements of transactional analysis, object relations, attachment research and person centred therapy. Ian has a special interest in trauma recovery and bereavement.

To contact Ian, call 07504 269 855 or click here.

 

© Ian Pittaway Therapy. Not to be reproduced in any form without permission. All rights reserved.