Why would someone come into my office to be a patient in psychotherapy? Why would he decide to subject himself to the inconvenience, the considerable expense, the uncertainties, and the discomfort of confiding in a stranger, while contending with stigma and shame?
A patient comes to a psychiatrist for relief from his suffering. The word patient itself comes from patiens, patientis—“enduring pain and suffering.” Human suffering takes many forms. People may feel unhappy, lonely, angry, or sad. They may have symptoms—obsessive, compulsive, anxiety, so-called depression, panics, phobias, paranoia, delusions. People have character behaviors that get them into trouble—drinking, drugs, gambling, eating (anorexia, bulimia, overeating, bingeing). sexual perversions, impulsivity, rages, emotional isolation, narcissism, echoism, sadism, masochism, low self-esteem, and psychotic and manic states. They may have crises in their lives—divorce, death, loss, illness, rejections, failures, disappointments, traumas of all kinds, and post-traumas.
However, suffering does not exist in a vacuum. It flows from our damaged plays of consciousness. Since there are built-in fault lines to every problematic play, the way we break down follows along those fault lines. The way a person breaks down reflects the way he is constructed. Suffering is the manifestation of something having gone wrong in one’s characterological play.
To attend to a patient’s suffering, we must explore his inner play. This exploration is the journey of psychotherapy. It proceeds through a responsive conversation between therapist and patient. What transpires is far more than the cognitive content of the words. It is the exploration of a patient’s invisible, unique inner drama—his cast of characters, the feeling relatedness between them, and how they developed by virtue his formative environment of deprivation and abuse. People often misunderstand the word explore. They take it to mean “figure out, analyze, find some answer, or come up with an explanation.” Explore means to venture into new and unfamiliar territory, where there is no map. My patient has no map of his internal play, and neither do I. I do have experience with journeys into these unknown terrains, having been an explorer on many expeditions.
However, the transformative process in therapy, ultimately, does not turn on this exploration, per se. It follows from the responsive engagement between us. Emotional holding allows one to digest and mourn the internal play. And finally, it is responsiveness and holding with the patient’s Authentic Being that fosters the writing of a new play, grounded in authenticity and love.
Therapy from the beginning to the end is a responsive engagement between my patient and me. A new patient comes to my office because he is suffering. I need to hear the nature of his suffering. I need to know something about his circumstances. And I need to get a preliminary sense of his characterological world and how it got to be the way it is. The first few sessions will be focused on this discovery. This is the evaluation. I am evaluating the nature of his situation in order to be in a position to address what would be involved in dealing with it. New patients often think when I use this word that I am evaluating them in relation to a judgment about their worth and value, or evaluating whether I would accept them into therapy or reject them. This is not the case. I am, in a preliminary way, getting to know them. Likewise, they are evaluating me based their impression of me. They are, in a preliminary way, getting to know me. We are on equal footing, and all the processes that will ensue are purely human.
A new patient sees how I comport myself, how I dress, and my manner. Since my office is at home, he notices the house, the landscape, and the interior landscape of the office. Most important, he evaluates how I deal with him. We are two strangers, meeting. Am I someone he would be interested in working with?
A new patient gets a sense of who this stranger might be. This does not mean there is any focus on my personal life. Getting to know me does not mean knowing about me. I am not the center of the therapy. The subject of psychotherapy is not me or my internal play. It is the characterological world of my patient. Consequently, the “knowing about” will focus on the patient, not me. The subject of the exploration is, of course, him. In this regard, it differs from a social relationship, where the “knowing about” includes both parties. As we will see, my patient knows a lot about me anyway, just from my office and my manner. But more important, the real issue of knowing each other isn’t “knowing about”. It is about “being with,” in feeling. My patients come to know me very well and very intimately, without knowing a lot of facts about me.
There are no formulas at the beginning of therapy or at any point during the therapy. As I open the door for the first time, I am open to the various impacts this new person makes on me: his appearance, his style of dress, the manner of his greeting, his response as I usher him to his chair. I do not study these things. I simply notice their impact on me. As I ask what brings him to my office, he tells me the specifics of his suffering. I listen to the content, and I feel the emotional impacts of his presence. I am responsive to whatever presents itself. I may continue the discussion of his “problem,” or I may shift my response to the state of feeling that is present or the state of feeling that is conspicuously absent. If the person is reticent, I may be active in my engagement and actively responsive to what is presented. If the person floods the discussion, I may interrupt. If the person is tangential, I may refocus. If the person tells me his story, I may quietly listen. From the beginning, therapy is a responsive engagement.
The culmination of the evaluation usually results in the first connection between patient and therapist. Just to have someone hear the pain of the suffering without ridicule or diminishment is a form of emotional holding. This is amplified when there is shame involved. The initial symptom is always a veil for a deeper pain. When this is touched upon and addressed in the evaluation sessions, the patient is reached in his real pain. He feels understood and listened to.
All throughout the evaluation, I resonate with the emotional actuality of the patient, and address it responsively. It is only when the patient’s real self is touched that he feels known and engaged. This takes many forms. Sometimes it means translating anxiety or so-called depression to the anger it actually is, and inviting unacceptable feelings to be felt. Sometimes, it means sitting with a painful sadness, and encouraging it to be felt rather than avoided. Sometimes it means addressing the hollowness, emptiness, or feelings that don’t ring true, in order to reach the real person. In all the different forms, the therapist reaches and touches the real person with real emotional contact. Sometimes, this is the first time in a lifetime. This constitutes an important engagement and often brings some relief.
When a patient’s suffering is linked to a preliminary understanding of the context of his inner world, he also feels understood. Connections are made to the salient issues of his family of origin. These deeper connections are made to his characterological position by which he has protected himself from intolerable emotional suffering. This links an understanding of his present pain to his internal world and how it got to be this way. It is ultimately his internal character, forged in relation to his early family, that determines the particular symptoms from which he suffers. I either give a running commentary of response or a session of feedback about all of these things to address what the therapy will be dealing with. This in itself usually makes the patient feel understood, known, and not so alone.
Even when some temporary relief takes place during the evaluation, as is often the case, this is not the treatment, and it is short lived. This is the just the prelude. The evaluation isn’t much different from the false intimacy of two people sitting next to each other on a long train ride. One may confide very private stuff to this stranger. The conversation feels very intimate, but it is an anonymous false intimacy, predicated on never seeing this person again.
The beginning of therapy is but an introduction to a stranger, making a first and an essential emotional contact. But we will see each other again. We will deepen our exploration. We will move toward a trusting closeness, which is not anonymous. Real trust always has to be earned. And as always happens, the patient’s internal dramas and cast of characters will make their presence felt. In order to find our way, we always have to slog through the characterological dramas. They always come alive in the office. This is the hard part. In order to reach the patient’s Authentic Being, we have to grapple with this odyssey. It is only as this takes place that real trust can emerge.
Robert A. Berezin, MD is author of Psychotherapy of Character, the Play of Consciousness in the Theater of the Brain