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Fear

Standard Interpretations in Psychotherapy

Avoiding banalities

Patients come to psychotherapists with the expectation that they will learn something in their encounters that will help them in some way to deal with problems that they have been unable to manage by themselves. Therapists are supposed to be expert not only in the difficulties that certain emotional disorders present; but also, to some extent, the difficulties that the world presents. They are supposed to know something about the world in general.

Psychotherapy may be construed differently by different therapists, but they would all agree that the purpose of psychotherapy is to help the patient manage the various problems of life. An idea underlying psychodynamic therapy is that a better understanding of inner (unconscious) motivations will help the patient to behave differently and in a manner more likely to succeed. Remarks based on these conjectures are called “interpretations.” It is the sort of thing that is super-annoying when it is not done by a therapist. Imagine that you are complaining to your wife that she keeps throwing away your car keys in the trash, and she responds by saying that you are really angry because she interrupted you when you were speaking to the neighbor’s wife at a party last night. Such remarks are inadvisable by family members. When they are right, they are annoying; and when they are wrong, they are more annoying. But therapists are privileged. They do not have an ax to grind, and so what they say deserves more respect.

A really good therapist will know the patient well enough, hopefully, to point out motivations the patient has that are just below the level of his/her awareness. It should reflect an idea that seems new in a way, but at the same time immediately seems right. Or possibly right. It is an explanation of sorts. Presumably, if a patient understands better just what she or he wants, reaching that goal by some more effective means becomes possible. At least, the patient is provoked into considering these possibilities. Obviously such an interpretation grows out of an understanding of a particular patient and is particular to that patient and not the sort of general remark that might apply to everyone.

Psychotherapists, like people in general, have varying skills and are more or less effective depending on training and experience. And an innate common sense. A certain amount of modesty is helpful. No matter how well we understand a particular patient we do not know an awful lot. Interpretations, therefore, should be more in the way of a suggestion than of a statement of fact. It is easy to be wrong. But they should be, at least, carefully thought out. Sometimes, because a therapist cannot think of anything sensible to say, he or she may resort to vacuous and trite interpretations that really do not explain anything. I have listed some of these below:

Maybe you want to fail. The patient has done something which seems obviously self-defeating. Maybe she has been repeatedly late coming to work. Or, maybe she has argued with her boss. Or, maybe she refuses to give work presentations when asked. In some peculiar way, this interpretation might seem to be true; but the same interpretation can be used to “explain” any self-defeating behavior. In one way or another, such behavior is characteristic of all neurosis. This interpretation is not specific to any particular patient. And, fundamentally, I think, it is wrong. Self-destructive behavior is not designed with the purpose of destroying oneself. Failure is an inevitable by-product of what the patient really wants or fears. In the example mentioned above, for instance, the patient, who has a social phobia, may come late because she wants to avoid the unscripted conversation with colleagues she will otherwise have to endure. She may be quarreling with her boss because she thinks that he—and most of the men she knows—are prejudiced against her because she is a woman. She may refuse to give presentations because she thinks she will embarrass herself by falling apart in front of everyone. It may be precisely the fear of failing which motivates her.

Maybe you are afraid of succeeding. More likely, the patient, whoever he or she is, is afraid of something else. I think it is reasonable to start with the assumption that everyone wants to succeed. But many people are afraid of being promoted because greater responsibility comes with the new position. They may think their incompetence will be revealed. Or, they may be afraid of supervising others and causing them to become angry. They are likely to have a specific fear which a therapist can divine over time.

Maybe you really don’t want to lose weight. Someone who has been trying for years unsuccessfully to lose weight will not accept this explanation. Maybe what the therapist really thinks is that the patient is afraid of the sexual encounters that comes with being attractive; but that, then, is what the therapist should say. And even that is not specific enough. The better question is: why is sex threatening? Most of the time, the inability to lose weight is due to other causes, too many to list here. (See my book “The Stuff-Yourself Diet.”)

Maybe you like worrying. Sometimes a patient will go along with this absurd suggestion since he/she may be aware of the sense of searching around for something to worry about. The truth is that certain patients (suffering from, for example, generalized anxiety disorder or obsessive compulsive disorder) are convinced that dangers are always at hand. They are committed to being vigilant, which is another way of saying that they worry. No one likes to worry. Worrying comes when planning is frustrated. We would like to plan our children’s lives so that they can be safe, but we cannot, so we worry about them.

Maybe you like being in pain. One would think no one would make such a remark; but some patients who hesitate to take pain medication have been scolded in just such terms. There may be different reasons to refuse pain medication: ie. The wish to avoid side-effects such as mental clouding or sexual incapacity, the fear of addiction, the wish to maintain a sense of control, etc. A therapist who suggests that his/her patients desire pain will lose credibility with those patients.

These careless interpretations can be offered also to the family members of patients:

Some individuals who are thought to enable a loved one to overeat, or drink alcohol, or use drugs, may be told, Maybe you really want him to stay that way, when the family member is really motivated by the wish to lessen the patient’s distress, or prevent a possible suicide, or avoid an argument. These may not be good reasons, but they cannot be examined without making them explicit.

These facile interpretations are a sign of a therapist who does not understand his/her patient and, worse, does not realize that he/she does not understand. I would worry that such a therapist might be deficient in other, less obvious, ways. © Fredric Neuman Follow Dr. Neuman's blog at fredricneumanmd.com/blog/http://fredricneumanmd.com /blog/ Author of "Caring."

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