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.

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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.