Inside the Patient in Therapy: What’s Going On?

We think of therapy as a conversation between two people.

Dig a bit to find the unspoken thoughts and feelings stirring inside the client. What are they? In what order do they arrive? And why can’t some patients recall the discussion even a few minutes later?

Let’s imagine observing a middle point in a hypothetical session.

The client’s inner world, from a photographer’s perspective, might look this way:

Emotions are brewing. Think of beer or a broth. Visualize the internal concoction as a liquid of at least mild temperature and motion. Active ingredients could include anger, embarrassment, calm, feelings about the therapist, confusion, shame, and sexual arousal.

Don’t forget thoughts.

Where do the stew’s components originate?

  • the client’s life history and memories
  • sensitivity to pain or judgment
  • openness
  • the world in which he lives
  • his brain’s capacity to deal with and analyze complex material
  • the genetic makeup with which he was born

The therapist’s tone of voice, confidence, understanding, and guidance of the process play into the other person’s state. The security associated with the office shouldn’t be discounted as a factor, either.

The specialist’s next comment spins from his lips into the air. Perhaps it is a statement, a question, or an interpretation of what came before.

The client’s ears hear the voice, clearly or not, and understand the words as the counselor intended or not. The language now launched lands in the mixture already present.

The woman or man’s experience is a combination of what he perceives outside of himself and its meeting with what is inside.

More is possible. Patients, if they place a high value on the relationship, sometimes ponder how to respond. They wish to say the “right” thing — to be “good.” Self-consciousness in this setting isn’t unusual.

Consider the chance the listener is not listening and has lost focus. Maybe the language and inflection increase or calm any emotional turmoil.

The unconscious plays an undefined role too. Past events may be evoked.

The patient might not be as attentive and emotionally “present” as he was a few seconds before. Confusion sometimes scrambles his consciousness — bodily sensations, as well.

Therapists must be careful not to overwhelm this soul, amplifying his struggle to process the unstable encounter between external and internal events.

In some cases, the individual cannot “stay” with the flow of ideas, memories, visceral changes, and feelings. In this situation, the client often takes a kind of unseen flight from his fraught condition. His action is like putting a part of himself in another room, away from whatever is troublesome: dissociating portions of the momentary experience and “going away” from it.

He remains in the chair or on the couch, but a segment of his awareness, including access to his complete range of emotion and sensation, is elsewhere.

Treatment would fail if this were to occur in each session.

I’ve created an example of one kind of encounter, not typical of everyone’s experience. Many, if not most meetings, are calmer, less stirring, more laid back.

Assuming this did happen, however, the end of the visit might produce amnesia of some of the material discussed during it.

How do counselors prevent this?

  • They take in whatever is in front of them: tone of voice, postural alterations, physical evidence of anxiety. Eye movements, changes in the rate and intensity of speech, facial expressions, perspiration, and tears need to be noticed, as well. These and the patient’s comments concerning comfort or discomfort should enable the doctor to know whether to intervene: reduce the client’s tendency to become overwhelmed or dissociate.
  • Both parties need to converse about how much intense material can be tolerated and how to communicate distress as it occurs.
  • The health care professional can suggest the patient write a summary of the session’s end, perhaps when he returns to the waiting room. Like dreams, the experience or portions of it are not always recalled otherwise.
  • Zoom and comparable virtual treatment platforms include recording options. This permits the client to review a video of the session alone or with the counselor during the next appointment.

A sensitive and competent therapist will inquire about what the patient wishes to talk about and recognize what he might not recall from recent sessions.

His job is not to interrogate. Rather, he desires to be attuned to the person who has entrusted him with the responsibility of his care. He hopes the client will join him in a shared enterprise designed to achieve progress on the treatment path.

Obstacles like suppression or dissociation can prevent mastery over the life challenges that brought the individual to psychotherapy.

Psychotherapists aren’t magicians. We have only words, compassion, and understanding of what is required and when. Words in the right order spoken in the right way are often enough.


The first image is Picasso’s The Red Armchair, from 1931. Next comes Classical Head, a sculpture by Elie Nadelman, created in 1909/10. The third figure is featured in Stefan Kaegi’s Uncanny Valley. It is followed by the work of an unknown artist of the Fang culture, a Central African ethnic group. It is thought to date from the mid to late 19th century. Finally comes Sleep Muse, a 1910 sculpture by Brancusi. All but the Kaegi are sourced from the Art Institute of Chicago.

17 thoughts on “Inside the Patient in Therapy: What’s Going On?

  1. Therapists aren’t magicians…. or mind readers…. I often wish they were. Interesting article. I’m never myself in her office. Always analysing and over thinking. What does she mean? What is the right think to say? I feel bad for her. She tries to help.


    • I agree that magic would help. Still, if both parties are dedicated enough, much good can happen. It is worthwhile for the therapist to ask whether his client feels the need to be a “good” patient. If she doesn’t, then the decision to raise the issue would be in the patient’s hands. I had some useful and important discussions when one or the other of us brought the concern up. There may be things she can then do or say to make you comfortable and accepted. Good luck with this!

      Liked by 1 person

  2. “Active ingredients could include … feelings about the therapist.”

    “Patients, if they place a high value on the relationship, sometimes ponder how to respond. They wish to say the “right” thing — to be “good.” Self-consciousness in this setting isn’t unusual.”

    These things you mention, can literally tongue tie a patient. As one of those who developed very deep feelings toward the therapist, I found that I had to measure every word that came out of my mouth, to try to be sure I didn’t sound stupid or pathetic. That whatever I said or brought forward would not result in the therapist thinking badly of me or create/amplify any negative feelings in him toward me. After a time, it became more important that he like me than that he help me. Doesn’t that defeat the purpose of therapy?

    Liked by 1 person

    • Yes it does. It is also incumbent on both parties to discuss this. The very fact that the therapist continues to see the patient is usually an indication he has not found anything the client has said to be disqualifying. The effort made by the counselor to find a way to help, to suggest alternative treatment approaches, to recommend possible medication, etc. all tend to demonstrate his or her persistence. Therapists are human, so they can be frustrated. The best of them are dedicated. They keep trying. Thanks for commenting, Brewdun. I’m sorry your experience did not overcome this hurdle.

      Liked by 2 people

  3. I find that since recording sessions my experience is vastly different. I literally come away with chunks of the session I don’t remember us discussing at all, really big and important stuff too! It’s like having two sessions for the price of one: you get the real life experience in person and then the mop-up experience afterwards of picking up the missed bits on the recording! Works a treat. Also, my concerns often are lessened slightly when I listen back to hear the tone of voice was much kinder than I realised at the time. It’s a complex thing but it really seems to work.

    Liked by 1 person

  4. Thank you, LovingSummer. I’m pleased to hear it, both because you are helped, but also as reinforcement of the idea such methods can be widely useful and easily managed. Be well!


  5. Reading your account of what it entails for a therapist to do their job monitoring the patient’s body language, breath, eyes, verbal and nonverbal cues, I imagine the hour must be exhausting and draining for them! As for the need to be the “the good” patient, another post that is hitting the nail on the head for me! 🙂


  6. Thanks, Nancy. The ability to observe the patient becomes automatic for a therapist. It is, therefore, less exhausting than it sounds. I would say, though, the challenge of doing this on a virtual platform is greater, in part because the counselors cannot see as clearly as they would face-to-face, have access to a view of the entire body, nor hear as distinctly.

    Liked by 1 person

  7. It’s weird, while I dissociate a lot in my daily life, when I’m with my therapist I find I’m mostly completely present. I tend to remember my sessions with laser precision. The pauses, the words spoken, the order of things, and even the sounds outside and exactly when in the conversation it started. Of course, there are those rare occasions where I DO dissociate or have a fuzzy recollection of certain points in our appointment. Sometimes remembering so much is useful, but other times it can be a hindrance, especially when I go over and over something stupid that I maybe said, or the way in which I worded something. Even things my therapist said, the way she said it, wondering whether she meant it that way, or if I had taken the wrong message, etc. I think I maybe analyze and pick things apart way too much. Thankfully, I’m completely comfortable with asking clarifying questions and discussing things that came up regarding our previous appointment after the fact, in the next session. I have the tendency to only fully comprehend the session when I’m back at home and going over it in my head. Sort of like a delayed response. Sometimes I wonder whether I’m “doing therapy wrong”. Thanks for this post. 🙂


    • I don’t think you are doing it wrong, Rayne. Indeed, those who are less “present” than you are in session or “forget” what happened soon after and don’t work between sessions, while not “wrong,” find the process less beneficial until such tendencies are addressed. Thanks for your thoughtful comment, Rayne.

      Liked by 1 person

      • That makes sense. I agree that therapy is so much more beneficial when we do the work between sessions. And sometimes it’s during those times when the greatest revelations appear. Have a wonderful weekend. 🙂


  8. Thank you and same to you, Rayne.


  9. I finally found a great therapist who understands dissociation and DID. Indeed, online therapy sessions are harder for both of us, but we make it work for now. My therapist has helped me and my alters to work with the trauma details at a slower pace, which really helps me feel less triggered when an alter brings something up. I still have a hard time accepting the alters’ accounts of their lives and mine, but perhaps that is the crux of DID, sadly. Sometimes I wish my therapist were a family member or a best friend. It is hard to see her only once or twice a week. I wish I had close relationships with others like my therapist.


    • drgeraldstein

      Wonderful news! As a general rule in DID, each of the alters original purpose was to shield other parts of the system. As this is uncovered they tend to come to terms with each other. Good luck!

      Liked by 1 person

      • It is no picnic, lol. Thank you, Dr. S. 🙂 Our system is okay but still acclimating to one another.


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s