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Key points
- Psychotherapy is a creative process between two people in search of discovery but is driven by structure.
- Many therapeutic modalities work by making what is familiar to us seem increasingly unfamiliar and even alien.
- Defamiliarization complicates our facile understanding of the world, allowing for mindful curiosity.
Like grammar, psychotherapy is equal parts science and art. I can convey meaning with a basic understanding of mechanics, but without creativity, the prose will not emote or inspire—it's like the difference between nutrition and culinary taste. Similarly, I can memorize the structures and theories of psychotherapeutic modalities, but without the humanity behind my delivery (what we refer to as common factors in psychotherapy practice) those discrete, evidence-based techniques will be lost on my client.
Though validated by science and backed by insurance companies, psychotherapy is fundamentally an aesthetic process, with two artists—therapist and patient—in search of emergent meaning. While both art and psychotherapy start from blank slates, meaning cannot be derived in a vacuum. Art can never be wholly original but is rather a process of novel recombination. While the therapeutic space is the same tabula rasa that artists claim, both therapist and patient come to the couch with a lifetime of experience. So begins a recombination of their distinct life experiences—what Thomas Ogden refers to as the “analytic third.” That “third” is the artistic product, born only in that time and place and between that specific dyad. If this sounds too lofty, remember that this third is also the product of structure. Art, after all, needs gears for the wheel to turn. Art animates the dialogue but science advances it.
In literature, good writers write outlines; great writers throw them away. Good writing is the product of vacillating between rigid structures and abstract, amorphous ideas. Too rigid and you close yourself off to discovery. Too abstract and you’re like the Laputans, immobile and wholly impractical. You must be rigid enough to gain traction but open enough to abandon the structure when discovery strikes. That same sense of discovery then becomes communicable to the reader. Art is a quality of attention, an opening up of the self to risk and surprise. Like a solvent, it breaks down what is rigid, formulaic, and overly analytical.
Balancing Structure and Surprise in Psychotherapy
As therapists, we provide our patients with in-the-moment interpretations, write case conceptualizations, and formulate treatment plans—all attempts to give structure to the amorphous. But we are also trained to abandon them, continually revisit and revise them, and try on various modalities like hats in a bazaar. Surely, there is a eureka moment in finding a theory or concept that neatly explains a patient’s life or problem—but also a kind of death. “Habitualization devours work, clothes, furniture, one's wife, and the fear of war,” writes Viktor Shklovsky, the Russian literary theorist. Labels tame the inherent uncertainty of life but can make us too complacent in our knowledge set. When all new information must conform to the label, that neat bowtie of a theory, we risk seeing the person as a theory rather than a person, just like a character’s roundness in a story can be flattened to become a too-obvious device (“I approached the symbol, with its layers of meaning, but when I touched it, it changed into only a beautiful princess,” writes Donald Barthelme in the climax of his short story “The Glass Mountain”). That is again where art comes in—and particularly the idea of defamiliarization.
In describing defamiliarization, Shklovsky writes, “The technique of art is to make objects “unfamiliar,” to make forms difficult, to increase the difficulty and length of perception because the process of perceptions is an aesthetic end in itself and must be prolonged. Art is a way of experiencing the artfulness of an object.” The same is true for therapy.
Much of story structure is a process of familiarizing or defamiliarizing the viewer, bringing them from a state of knowing to not knowing, from certainty to mindful doubt. A sci-fi flick featuring aliens will at first make them seem well… alien, but will then familiarize us to the ways they are surprisingly human. Oppositely, a drama will present the quotidian customs of our culture to then reveal all the strangeness flush below the surface (e.g. the film American Beauty). Plot structures can defamiliarize as can description, like Tolstoy’s account of the opera stage in War and Peace: “The middle of the stage consisted of flat boards; by the sides stood painted pictures representing trees, and at the back a linen cloth was stretched down to the floorboards.” No matter the direction or scale of (de)familiarizing, the result is a kind of aesthetic and perceptive flexibility in the writer and reader. In helping our patients practice perspective-taking, psychotherapy is one big process of (de)familiarization.
Making the Familiar Unfamiliar
Take, for example, Acceptance and Commitment Therapy (ACT), which at its core equates psychological flexibility with mental well-being and psychological rigidity with illness. Try one of its defamiliarizing practices yourself: Identify a negative thought you have about yourself (e.g. “I’m ugly”) and repeat it out loud as fast as you can for thirty seconds. Notice how those once emotionally charged words turn to nonsense sounds (a process called semantic sanitation). Now, find another negative thought and repeat it to yourself to the tune of “Happy Birthday” using the most cloying, ridiculous voice you can muster. These practices help patients see their thoughts rather than seeing through their thoughts. It is the difference between saying “I am having the thought that I am worthless” vs. “I am worthless.” By leveraging this psychological distance between stimuli and response, our patients can better hold multiple perspectives (aliens = scary, to aliens = sort of similar to me actually).
An opposite movement (familiarization) often occurs in the treatment of anxiety. We ask our clients to cozy up to feelings they typically avoid. “Where exactly do you feel that anxiety?” we will ask. “Okay, what does it feel like? What temperature? What sensation?” What was once an alien sensation becomes more knowable and therefore more manageable. In short, we build an interoceptive vocabulary while deconstructing our cognitive language.
Or consider mentalization-based therapy (MBT), which helps patients see “others from the inside and ourselves from the outside." A common technique is to analyze a single scene in the patient’s life, breaking it down into a play-by-play analysis. What were you feeling here? And there? What else might you have been feeling? Okay, and what else? Questions strive to break down automatic emotional reactions. What was once a facile (familiar) account of an interpersonal interaction gives way to a complex, multi-perspective view of emotional experiences. Remember, a goal is “to make forms difficult, to increase the difficulty and length of perception.” We take a morsel of a moment, blow it up, and look at it from every angle. Perception becomes a process to enjoy in itself rather than a means to jump to a definite conclusion. We become writers, not something written.
Prioritizing Perception in Art and Therapy
At its best, therapy does for patients what art does for Shklovsky: “art exists [so] that one may recover the sensation of life; it exists to make one feel things, to make the stone stony. The purpose of art is to impart the sensation of things as they are perceived and not as they are known.” In both domains, we are striving for something like wonder.
In her book Pilgrim at Tinker Creek, Annie Dillard laments the fact that she will never experience “pure sensation unencumbered by reason.” She recounts how newly sighted patients reacted to their immediate surroundings following cataract surgery: The human hand is “something bright and then holes.” Grapes are “dark, blue and shiny… It isn’t smooth, it has bumps and hollows.” A girl stands before a tree in awe; “the tree with lights in it,” she calls it. “I’m told I reached for the moon,” Dillard writes as she wrestles with the fact that she can, now as an adult, never “unpeach the peach.” But she also warns that such raw perception can quickly overwhelm: “Like a blind man at the ball game, I need a radio.” Balancing art and science is a juggling act, shifting perspective where and when it will most help us. But perceptive and aesthetic flexibility is key to that leveling process. In art, and therapy, may we try to unpeach the peach but never lose sight of the ball.
