Many clients seeking in-depth talking therapy will already have been through Cognitive Behavioural Therapy. CBT is symptom-focussed and uses standardised techniques which make it testable. This makes it the treatment of choice in public health systems*.
The main strand within in-depth talking therapy is psychodynamic psychotherapy which means therapy derived from psychoanalysis. When this is standardised (a process that is at odds with its interpersonal character) to facilitate testing
I offer the following discussion of psychodynamic therapy’ because its necessary to have a label, but the tradition I work in is something to help me. It helps by orienting and deepening my thinking about personality. Hopefully its not important or particularly apparent to the client, because no-one gives the time and resources necessary for therapy because they want a ‘tradition’: you want to feel held and understood, look yourself in the eye, and feel better and more firmly rooted. You must be the complete focus of the work – you provide the material, the focus for each session and the therapy takes place in the language you use, certainly not in the language of my theoretical tradition.
Psychodynamic psychotherapy draws on the theories and practices of contemporary psychoanalysis and Jungian analysis, which have the most extensive base of clinical experience and theoretical foundation of any mode of therapy.
As a therapeutic process, it sets out to help patients understand and resolve their problems by increasing awareness of their inner emotional life and its influence over their relationships.
There is an important first level in the work: the level where what is distressing or preoccupying the client is closely attended to. But, it works at others, including the direct level of experience, because (alongside our genetic inheritance) everyone is formed by experience, and can be changed by experience. Neuroscience has its own concerns, but broadly it confirms the two main premises of psychoanalysis: that emotion is the core of how animals, including human beings, experience life; and that the experience of our early relationships sets-up our emotional responses in later life*.
Since Freud and Breuer made the first steps around a 120 years ago, psychodynamic/psychanalytic psychotherapy has changed a great deal. In particular sex is much less important, but something Freud and Breuer discovered (to their discomfort) in relation to sex has taken over: that the client, however subtly, brings their precise emotional habits to bare on the person of the therapist.
The normal flux in human relationships is full of live emotion (like, like less, love, resent, disagree with, envy, feel smothered by…). Speaking analytically, it is the client’s relationship that is most vividly available to us for seeing what emotions are active. Its the unconscious ones that interest us most. They are unrecognised, perhaps because they haven’t been given enough attention or because they are, for one reason or another, not things we wish to recognise. But they can drive us, and knowing they are driving us offers us the chance to take control of the situation using our intellectual power.
That written, it is important to realise, although intellectual analysis can create insights that are very interesting and allow us to change simple processes, it can’t change a person’s emotional makeup. Just knowing something about your emotions and controlling it puts an emotional cap-stone on it. What changes people is what sets them up in the first place: relationship with other people.
Psychotherapy is a longterm exercise in relationship. Done properly, it is a real (if carefully boundaried) relationship, and we know that both parties can be changed in a real relationship. A lonely person can be comforted, an angry person stilled, a self-obsessed person can learn to love, a depressed person can reconnect with what is good in the world, an envious person can learn simple appreciation… The relationship is by far the most important thing.
The therapist is not under analysis themselves from the client (although Ferenczi experimented with this). This is partly to give us the privacy we need for the work to be possible for us, and partly because not talking about ourselves allow us to focus on you. But we are live and present in the relationship. We cannot heal unless we are. I am describing something very unusual, yet completely human: one very highly skilled person dedicating themselves to feeling and thinking with another.
** see for instance Schore, A. N. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Lawrence Erlbaum Associates, Inc.
Choosing a Psychotherapist
What is the difference between counselling, psychotherapy and analysis?
There are three main sorts of talking therapist: counsellors, psychotherapists and analysts. I am a psychotherapist, which means I am qualified to conduct counselling as well as psychotherapy, but not analysis.
There are two quantifiable factors that distinguish counsellors, psychotherapists and analysts: the therapist’s level of training, including the amount of experience they are likely to have had themselves as a patient in a training analysis, and normally the frequency and duration of treatment.
- Counselling is therapy one or fewer sessions per week for a limited period generally working on a particular symptom or life situation. Counsellors tend to have a shorter and less intensive training and, recently, some of the regulators removed the requirement for counselling trainees to have any therapy themselves which will make the distinction with psychotherapists greater over time.
- Psychotherapists are trained to graduate level and beyond. Like a counsellor, a good psychotherapist will work with you on what is happening in your life at the moment, but they will also be able to help you find connections between whatever is going on now and the underlying patterns, beliefs and expectations in your life which can then, over time, be better understood and resolved. They may notice the significance of something you had never really thought about before, and may be able to help you recognise and process any unspoken distress that is stored inside you. They do this partly because all good trainings require therapists to have had at least as much therapy as the patients they are qualified to see. Psychotherapy is one, or two sessions a week and ends when the client feels enough work has been done.
- Psychoanalysts and Jungian Analysts are therapists who have had their own analysis for at least four years alongside a more extensive clinical and theoretical training than psychotherapists. Treatment involves sessions three, four or five times a week and are used by those requiring an especially high level of attention. Although this very intensive mode of treatment has developed enormously in both theory and practice, in intensity it is the same as that invented by Freud 120 years ago, and he invented it for people with more resources and time than are usual today. It is a huge commitment, but life-changing work can be done, usually strongly focussed these days on the relationship between the patient and the analyst.
There are a lot of counsellors, fewer psychotherapists, and very few analysts.
What should you look for and expect in a psychotherapist?
Psychotherapists hold a position of great responsibility towards their patients, and should be registered with one of the reputable national bodies such as the British Psychoanalytic Council
. This ensures that your psychotherapist has undergone and satisfactorily completed a lengthy clinical training and that they are appropriately monitored, insured and supervised. It also means that they subscribe to a recognised Code of Ethics, ensuring that, if you should at any time have a problem with your therapist, there is a body to whom you can appeal who will take your problem seriously and offer you a way forward.
There are some things you should always expect:
- your therapist to offer regular sessions in a room that is private, comfortable and reliable.
- they must ensure confidentiality is maintained to the highest of standards.
- they must treat you with care and respect, listening carefully and interpreting what you say constructively.
- and, they must keep good boundaries, especially personal boundaries, so the work can continue safely at the depth and intensity that the client requires.
Finally, when you are thinking of starting therapy, I recommend you hold initial consultations
with a couple of psychotherapists. Reputable therapists will generally offer initial consultations as an opportunity for both of you to ask any relevant questions, decide if working together is likely to be fruitful and feels right.