How Do We Change in Psychotherapy?

Autumn Leaf on Snow

The first session I ever had with a psychiatrist proved to me that I could achieve a real change through psychotherapy. While in college, I had been immobilized by panic attacks and was desperate to get help. I spent three hours with a psychiatrist deeply engaged in the confusing mass of experience I needed to unravel.

After listening for a while with great empathy and attentiveness, he interrupted and suggested a connection between two parts of my life I had kept completely separate. I felt instantly, profoundly, that he had hit it just right. Something shifted and opened up inside, and I knew exactly what had stirred the panic attacks. I felt deeply relieved and was soon able to resume my life.

Breakthrough moments like that have been rare in my experience with psychotherapy, but I’ve had many less intense sessions when important changes took place. The quality of the experience is unmistakable because I always feel a shift in feeling and understanding on a deep level, even when I can’t quite put it into words. But all too often a session leaves me clinging to a verbal formulation or a theory rather than a deeper realization.

The Experience of Change

The problem is that I often lose the immediacy of the experience. If the therapist and I try to summarize what it’s about, we usually come up with a description of a pattern of behavior, or emotional triggers or a tendency in the way I think about things. These all capture a part of what I’ve learned, but they are explanations that fail to evoke the actual experience when I try to return to it.

If the experience has been a major breakthrough, as it was that first time, the shift is profound enough that my life is simply different. I don’t need to summon up the experience as it had first occurred to me because it has done its work. I’ve learned about that aspect of my life and then can deal with other problems.

Most changes I’ve experienced in psychotherapy are more incremental. I have to build on each new insight and so try to return to what I learned in one session to make further progress in the next. That’s when I find that the descriptions and explanations about patterns or causes don’t begin to capture the inner process of change.

The words give names to feelings, thoughts, types of behavior or a structure of action, as if these were things that could be isolated and examined. In reality, they don’t seem to be separate entities that interact with each other but different sides of one unfolding experience.

Change vs Coping

I think the power of descriptions and explanations, whether or not they get at the fullness of the inner experience of change, is that they can give me important tools to manage problems.

Cognitive therapy, for example, has given me many effective tools for keeping myself from being overrun by obsessive negative thinking.

Mindfulness in many forms has helped me gain distance and perspective from the flood of feelings and thoughts that depression can trigger.

Learning to accept rather than avoid difficult feelings has helped me expand the range of experience I can handle in everyday life.

Opening up through writing about depression has kept my recovery on track and helped me explore my life from many new perspectives.

These and a dozen other methods I could name help me cope with depression whenever it threatens to take control. They are tools that I have learned to use. I have usually gotten initial guidance in understanding what they are and how they can work from a therapist, and a great many therapy sessions are valuable because they give me such tools.

There are other types of therapy sessions in which deeper change occurs, and these seem to require the presence of a therapist for much more than teaching new skills. It’s in those sessions that the words and theories about thinking, avoidance, feelings and patterns fall a little short.

Sometimes It Takes a Therapist

Back in the 1960s, Eugene Gendlin, who developed the method of focusing, tried to capture what goes on in a person when change occurs in psychotherapy. For him, the explanations that psychotherapists come up with for their clients are not the reason they might get better. Instead, it is something that happens when a receptive client talks about problems with a receptive therapist.

Through the relationship, they are able to provoke a change in the felt process of inner experience – the changing bodily sensing or feeling that can’t quite be captured by the static meanings of words and explanations. They are able to respond in the present moment to the unfolding experience in its basic form of a flow of sensed feeling.

Therapists have to be fully responsive, free of defensiveness or preoccupations of their own personalities, and capable of empathy while also detached enough to bring into play the full range of methods appropriate to the client’s needs. The client needs to learn to pay attention to the inner flow of experience and stay with it. That’s what the practice of focusing is all about.

The reason the relationship with the therapist is so important is that when left alone, as I well know from my own efforts, a person with a condition like depression tends to go round in circles. I’ve been great at that.

Frozen Explanations

I can identify a self-defeating pattern in my behavior. I can recognize an event that triggers anxiety and know the links in my history that give rise to that. I can spot the self-bashing inner critic in action and shut him down. I know shame when I start feeling it in response to trivial mistakes.

But somehow the ideas about patterns, triggers, negative thinking and toxic emotions don’t get me that far beyond recognizing problems and reacting to them with tools to keep them in check.

Each idea is an explanation that tries to freeze the inner flow of experience or capture one part of it. In fact, my inner life is a mixture of feelings, thoughts, impulses and connections that I’m aware of throughout my body all the time. To try to stop it and say: Shame is causing this, or there goes my all-or-nothing thought pattern again, or here is my panic at going to a meeting, keeps me locked into these fixed structures of explanation.

By focusing on them instead of the inner felt sense, I remain stuck in these isolated ideas or fragments of the experience and make no progress.

Responding to the Felt Sense

According to Gendlin, the therapist can respond in the moment even as you are thinking in terms of a stale structure of explanation. Suddenly, you are interrupted by a person responding in the moment to what you are actually doing. A process of immediate interacting has begun. You’re no longer in the explanation but in the felt experiencing.

Instead of relying on ideas to explain what you feel, you are testing the accuracy of words against the immediate bodily sensing of what you are experiencing.

Even a small shift in what you feel is important because it not only feels like you’re on the right track, but it starts to resonate with memories. You sense a much wider relevance of this shift to other parts of your life. I think that’s more evidence of the fact that all your experience is tied so closely together.

For me, that shift is a learning experience, an exciting grasp of something about myself I hadn’t known before. The breakthrough has only been possible in the presence of a therapist. I’ve been over the same material before on my own, but it hasn’t led to the same opening. I needed presence and responsiveness in the room to open in this way to something I had never grasped before with such immediacy.

The importance of a good therapist doesn’t mean perpetual dependence on the relationship or that progress can only be made through in-person psychotherapy. Focusing on the felt sense of experience is itself a skill that can be learned and practiced throughout life.

It takes a lot longer, at least in my experience, to internalize this approach, compared, say, to the techniques of cognitive therapy. That’s because the mind has so many ways of deflecting your attention from what life really feels like and luring you toward causes, theories and explanations of depression.

As with any aspect of depression treatment, each person has to work out their own combination of methods. How important has psychotherapy been in your experience?

9 Responses to “How Do We Change in Psychotherapy?”

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  1. John, I have come across many articles about psychotherapy, but this article is written from a great point-of-view. Even more importantly it comes from a client. As you know, many people are quite apprehensive about participating in therapy. This is understandable, and I think that such an account of experiences such as the ones you’ve discussed in this blog can help someone in making such a decision. As a therapist, I find your article to be a great resource. Thank you.

    • John Folk-Williams says:

      Hi, Michael –

      Thank you – I do hope the post can be helpful to others who might be considering psychotherapy. Your comment means a great deal to me. Thanks for taking the time to offer your thoughts.

      John

  2. Donna-1 says:

    There seems to be a “cascading” effect for me when therapy is really going well. Sometimes I am able to tap into this experience on my own, but it usually helps to have someone to interact with while it’s happening. But I will make that connection with truth and seem to suddenly enter a different mindset where ideas are fast following one after the other, and usually with it comes a flood of memories connected with the topic. Constant interaction is such a vital part of therapy, yet I have had 2 therapists who talked a lot about their own experiences but never really tapped into mine. Not that I blame them — it is human nature to teach by example — but a therapist of all people should be able to transcend that tendency and move into the realm of discourse and real communication and conversation. You are right about it being difficult to recapture the immediacy of the moment when what I call “cascading” occurs because it almost takes you out of yourself and into another state of being.

    • John Folk-Williams says:

      Hi, Donna –

      Hopefully, a therapist can stay present as you follow all the memories and associations rather than shift the focus to herself. But how many therapists are that well-trained or inwardly balanced and mindful? The urge to offer explanations is the vice of that profession. I understand that it’s much easier to do that than stay fully attuned to one client after another day after day, but training is supposed to prepare you to do that.

      John

  3. Evan says:

    Hi John, the cognitive bias in our culture is so strong. And it is so easy to ‘talk about’ our experience rather than being with it, expressing it, taking action and so on.

    I wish Gendlin was more widely known – her certainly deserves to be.

    • John Folk-Williams says:

      Hi, Evan –

      It’s so true about a cognitive bias in this culture. What I find so strange is that even though the mind’s explanations are favored, they are anything but rational.

      John

  4. Judy says:

    I’d have to say that psychotherapy has been more important to me in my healing than medication. I have learned so much about not only how my beliefs about myself were ruining my life, but also about having the experience of learning to trust somebody to be on “my side” – no matter what! At least for me, so much of my depression is about shame and feeling unworthy of anyone’s care that I don’t think I could have ever dared to believe in myself without this relationship. I feel very fortunate to have found the perfect therapist for me. Previous experiences were not so great and left me feeling even worse, so I know what it’s like when there’s not a good connection. Really, healing from depression is all about reconnecting with oneself and the rest of the world.

    • John Folk-Williams says:

      Hi, Judy –

      It’s true for me as well that psychotherapy has been much more important than medication. Even though therapy hasn’t had the overall effect of ending depression, it has helped in basic ways to open my awareness to how I live and think of myself and the ability I have to change my approach to life. You’re very fortunate to have a relationship with a therapist that has given you so much. It’s only recently that I’ve come to understand the power of the relationship itself. In my first years with psychiatrists, back when they were the primary therapists, I only focused on the content of what they said or helped me to understand, rather than the process which now receives so much more emphasis.

      John

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