Does your therapist have a blind spot? Every therapist has to have a theory that guides his or her work. We can’t function without one. The problem with theories is that they can too often obscure what people need rather than clarify them. Theories that are held too strongly create blind spots.
The reason is simple: Therapists forget that there are always exceptions to their rules. Most generalizations about how therapy is supposed to work, usually derived from theory and learned in training from cherished teachers, can be blind to the infinite differences among people. In order to be effective, therapists have to have an approach that allow for maximum flexibility. They have to have an open-minded intention to tailor technique to people’s special and idiosyncratic needs. And, lastly, they have to subordinate theoretical allegiances to the only goal that matters—therapeutic progress—in every session.
You would be surprised how rare such flexibility is among even the most empathic and committed psychotherapists. Many will insist that they treat every person as unique, but too often their theories about “what therapists are supposed to do” make this impossible. Behind what looks like attentiveness often lay lots of assumptions, proscriptions, rules, and theoretical loyalties that can feel like a one-size-fits-all approach. It’s difficult for a therapist to unlearn what he or she has learned in one’s training, but it’s vital to do so if one is to be truly responsive to the very different things that each person needs.
Adhering too much to one “approach” creates blind spots, places where there are exceptions to the rules. Most therapists have them, but it behooves people seeking help to be alert to them.
Here are some assumptions held by therapists that can blind them to exceptions and that, therefore, impair their effectiveness with some or even many of the people they treat. People seeking help don’t often know enough to spot these and, thus, can’t always accurately assess how truly responsive their therapist is to their very unique needs:
1) Does your therapist think that he or she has to be neutral when working with you? Of course, most of us want our therapists to be objective, non-judgmental, and to refrain from too quickly “taking sides” in helping us with our dilemmas. Not infrequently, however, a therapist’s “objectivity” isn’t experienced as supportive but as indifferent or even disapproving. Even if people misunderstand what their therapists think and feel, such perceptions can be hard to change. Sometimes, for example, people do best when they experience the therapist as explicitly partisan and an outspoken advocate. In such cases, therapists may need to jump right in and take sides in an internal or external conflict.
2) Does your therapist think that the interactions between you and them—what is often called transference—is the most powerful lens though which to understand what ails you and what you need to work on? For some people, unfortunately, such a belief hinders rather than helps. Some people, for example, experience any undue focus on their relationship with the therapist as a repetition of earlier toxic relationships with parents who made family life all about them. Conversations about what’s happening in the moment in the consulting room are tempting because something interesting is always happening in the therapy relationship, but “interesting” isn’t always helpful. I’ve had occasion to treat people raised in families in which the world revolved around a parent who derive therapeutic benefit only if the focus remains on issues outside the relationship with the therapist. In these cases, bringing the focus back onto the therapeutic relationship is unhelpful to say the least.
3) Does your therapist think there is usually special power in helping people locate their feelings and conflicts in their bodies? Well, sometimes. Somatic therapies can be powerful. Usually, those people who seek out somatically-oriented therapists will readily make use of such an approach. But, again, it depends on the person. There are many people, for example, who would experience even the most tactful and gentlest versions of this approach as either irrelevant or intrusive. A theory that privileges work with the body will, therefore, completely miss the boat with a sizeable number of people..
4) Does your therapist think that insight is the key to successful therapy? Again, sometimes—even often—but not always. I have had many experiences in which people changed negative beliefs and behavior because, in the context of their work with me, they have felt safe enough to experiment with new, real, and liberating experiences inside and outside the office. Such experiences may or may not be accompanied by new insights into the cause of their suffering. In these cases, situations that offer a corrective to the negative expectations and beliefs that people often carry around can be more than enough to move people toward health.
5) Does your therapist think that psychological problems usually result from bad childhood experiences and, thus, helping people understand these experiences and their connections to current problems is necessary in any effective therapy? The assumption that the events of childhood affect adult life is undoubtedly true, but it is by no means true that understanding one’s childhood is always the most important path to therapeutic change. It is unfortunate that what’s true gets so often confused with what is helpful. Many people derive a special benefit from simply working with a therapist to untangle current dilemmas, to figure out what’s getting in the way right now and not necessarily from connecting these dilemmas with earlier ones. The past certainly influences the present, but often the present can be improved without going back to the past.
6) Does your therapist believe that irrational thought patterns lie at the core of your suffering and must be systematically corrected? Sometimes, but not always. For example, I’ve treated people who seem to need to feel their painful feelings for a long time before any attempt is made to correct the irrational assumptions underneath their pain. Such people need the experience of a deep and open-ended emotional engagement with their therapists who do little more than empathize and offer support. In these cases, transformation comes from diving into one’s emotions rather than correcting one’s cognition.
7) Does your therapist think that there are tried, true, and well-tested therapeutic approaches to treating people with particular diagnoses—so called “evidence-based” therapies? There are too many exceptions to the rules, too much particularity in each case, for such “evidence—based” generic approaches to be useful. The studies upon which such an assumption is based are scant, poorly controlled, and not convincing. In fact, I have never been able, even one time, to match a technique to a patient on the basis of their diagnosis. Such formulaic approaches miss the forest for the trees.
8) Does your therapist think that long-term traditional psychoanalysis has been debunked as an effective treatment modality. For some people, this generalization is simply not true. Some people especially benefit from coming to an analyst 4x/week, lying on a coach and exploring their unconscious minds. Some people, for example, who come from enmeshed families in which they experienced themselves as the objects of constant and impatient emotional demands from others will sometimes do extremely well with a somewhat more disengaged and neutral therapist. Of course, legitimate questions can be raised about the time and money required for a traditional psychoanalysis, but, for some, it is exactly the right treatment.
9) Does your therapist think that working with someone in the throes of an active addiction is impossible? Difficult? Yes. Impossible? No. In fact, many addicts have been treated successfully, with and without the support of 12-step groups, even if such treatment is begun while the person is in midst of their addiction. The belief that an active addict needs to stop using (that is, fix their problem) before being able to use therapy to get help (that is, treat their problem) is an old saw without empirical foundation and contradicted every day in clinical consulting rooms. It depends on the person. While it’s certainly true that some people use therapy as an excuse to continue their addictive behavior, generalizing from such cases is wrong and potentially excludes too many people from the benefits of therapy.
All of these theoretical precepts about “technique” are sometimes true and other times not. It always depends on the person. When they become central to a therapist’s approach, when they become “received wisdom” or taken for granted, they create blind spots, constrain that therapist’s repertoire, and decrease the possibility of a useful and healthy alignment between therapist and patient.
If a generalization has exceptions, then it’s not a particularly useful generalization. The key for a therapist is to come into the therapeutic relationship without many preconceptions other than a determination to offer therapeutic help and a vigilant commitment to using the person’s responses and progress as the only relevant criteria about whether the therapist is on the right track. All good therapies are entirely person-specific. The more flexible and responsive the therapist, the better. There are few ironclad rules, except those that protect people from sexual or financial exploitation by the therapist. Other than that, anything goes if it is helping the patient move forward in his or her life in a healthy direction that the individual and therapist clarify and agree on together. The therapist shapes his or her technique to what the patient needs to be able to help the latter achieve normal and healthy developmental goals, including a sense of psychological freedom and an increased capacity for happiness.
In my view, the only really useful generalization that can be made about successful therapy; the therapist needs to figure out how to establish the conditions of safety that each person uniquely requires in order to be better able to face the obstacles in their lives and the fears that prevent them from overcoming those obstacles. Each individual presents an idiosyncratic challenge to a therapist seeking to help create those conditions of safety. The route to establishing safety for one person is almost never exactly the same as it is for another, and notions about “what the therapist is supposed to do” make this all the more difficult.
I began this essay with the observation that every therapist has to have a theory of some kind. Mine emphasizes the primary importance of safety and a close attention to whether people are getting better as the only legitimate check and balance on my approach. Whatever a therapist’s background, training and beliefs, his or her style and technique has to be highly specific to the person sitting in the room with them. That often means “throwing out the book,” and making sure that each chapter depends entirely on the person being treated.