I am writing this entry in preparation for my clinical work in my second year of graduate school in clinical psychology, having completed around seventy hours of work with individual clients and some as yet uncalculated sum of hours of supervision, training, and clinical writing. My program provides a background in the philosophical and theoretical background of psychology, particularly the existential-phenomenological and psychodynamic traditions; qualitative research; and clinical practice. These three pillars more or less relate to one another, and it is, of course, up to the individual to find a golden thread. One of the important connections to make is between how one acts as a therapist and what one believes about the nature of man and the good life. (One is eventually asked to lay this down officially as part of the comprehensive examinations, in the clinical position paper.) This is not the place that I will go deeply into what I believe about what we are or ought to be, nor will I even discuss whether therapy is possible. This paper will simply give a description of what I find myself doing in therapy sessions, and perhaps an attempt at explanation of why I do these things.
I will discuss what I tend to notice and respond to when I am in the position of the psychotherapist, what I recoil from, what I feel during sessions in general, and my evolving “theory of therapy.” I’m not sure whether I fit into a certain school– I am probably closer to the humanistic therapies than anything else, although I feel I regard patients with a psychoanalytic eye. By that, I mean that I see many parts of an individual hidden from that individual, and many motives that are not clear to the person enacting them. There is an unconscious force at work. On the other hand, the unconscious is not hidden at all, expressing itself in every gesture, in the person’s comportment toward every situation. It is hidden on the surface. Anyway, theories of psychology should arise from clinical practice, so here is what I tend to do and to notice:
When I first talk with a new patient, and for our first sessions (sometimes for a while), I find myself listening for ways that the person “makes sense.” For example, I had a patient who felt unconfident in making decisions for herself. She related a few times when she had attempted to make her own decisions and encountered negative consequences from others, primarily the loss of support. Thus, her anxiety surrounding making more decisions makes sense. Her difficulty did not arise from nowhere– it is situated. This is also a way I establish rapport with my patient. She sees that I am attending to her closely and that I don’t think she’s “crazy,” but that what she’s doing somehow “makes sense.”
Related to this, I try to get a sense of my patient’s world. What is her experience like? What are some essential components of her life? I learn this by looking for patterns. I look/ listen not only for patterns in events she relates, explicit or oblique (here is a loose example of what I mean: explicitly, she might date the same “type” of man, more obliquely, she may date men who are in some way like her father), but for patterns in words and phrases she uses, in her body language, or in other styles she uses. I had one patient who often said “I’m done with that/ them,” but then would continue on in the situation/ with the person nonetheless.
Another way I try to get a sense of my patient’s world, at a more advanced level, is to discover ways that the pattens manifest themselves. I try to look at the therapeutic situation, and more the assessment session, as a microcosm. The patient’s world will be recreated in the therapy room. How she deals with some situations will reproduce itself in the assessment. The patient has a particular world, this world is structured in a particular way, and this structure will reproduce itself on micro- and macro- levels.
I also tend to remember a lot. I remember general and particular things my patient tells me, including words and phrases she uses often. I remember events in her life, including former challenges and problems. I sometimes remember exemplary events– “the time the worst thing happened,” or “the time what you were afraid would happen did not happen,” and so on. In this way, I treat therapy sessions as somewhat continuous. What the patient brought up three sessions ago may relate to what she brought up in this session. I often point out connections– “that sounds like the situation from your dream” or “it seems like you experienced disappointment about not getting the job in the same way you experienced it when you didn’t win the game” and so on. Sometimes this forms a narrative or whole that was not present before, and helps with “making sense.” Sometimes it helps the patient feel understood. Sometimes it helps to consider events in light of other events. Overall, doing this ends up helping the person to notice patterns, and perhaps to observe these pattens in action.
I try to point out ways that the structure of the patient’s world is reproduced in the therapeutic situation (I think this may legitimately be called transference). The first time I do this might be in the assessment session. For example, if the patient has an angry outburst when she is unable to put together a WAIS block design, and has come in to therapy concerned about a possible break-up with a partner due to her angry outbursts, this would be an opportune moment to observe and discuss what happens in these moments. Other opportunities may come up in therapy sessions, such as how a patient reacts to the therapy room, contingencies like noises outside or a lack of air conditioning, or for a particularly dramatic example that happened to one of my patients, finding her ex in the waiting room. I also sometimes point out a patient’s reactions to me– how she seems to feel about me, what our relationship is like– but I find this more difficult, both because it’s intimidating, especially when a patient is angry or disappointed with me, and because I don’t want the patient to feel unsafe or invaded. This last move requires a great deal of trust and rapport.