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The Power of the Therapeutic Relationship

Long-term depth-oriented psychotherapy is based on the notion that development is a relational process.  Most people who come to therapy have had a less-than-optimal family environment where the development of the Self was thwarted.  In long-term therapy, the therapist provides the client with a sort of “stand-in” experience for the parent who wasn’t adequately attuned to their child Self. – Carol Gould

In today’s fast-moving world, instant gratification has come to be expected.  With just the click of a mouse, we can have just about anything we want.  Human interactions are pared down to a minimum as phone conversations and even email communication is replaced by texting.  People spend a lot of time on Facebook, Twitter, and Instagram.  Our busy lives make it harder to connect with others face-to-face in real time.

People come to therapy for a variety of reasons, but usually the root cause of the pain is relational.  We are unhappy because we don’t feel connected to people, or to ourselves.  We long to feel connected to others but don’t know how to make the connection, or our attempts to connect fail.  Anxiety and depression are the symptoms of this loneliness.  Often, people who come to therapy want and expect immediate relief from their pain.  They want “tools” to help them “fix” what is “wrong” with them, and hope to emerge from a few therapy sessions feeling happy and whole.  They feel frustrated and impatient when the results they anticipate aren’t forthcoming.

Although there are some therapeutic techniques that are effective in helping people manage anxiety and depression, such as mindfulness-based cognitive behavioral therapy, there is another aspect of psychological pain that goes beyond mood disorders.  Many people who seek therapy suffer because they have little or no sense of Self.  Without a robust sense of Self, people may have difficulty forming or maintaining relationships, finding meaningful work, and feeling a general satisfaction with life.  This is where the power of the therapeutic relationship comes in.

Research has shown that the quality of the therapeutic relationship is the most accurate predictor of a good therapeutic outcome.  Why might this be?  From birth, we can’t function without a caregiver to keep us safe, warm, and fed.  Similarly, our psychological health depends on having caregivers who are responsive to our emotional needs.  Our sense of who we are develops in part out of important types of interactions between us and our parents, what certain psychological theories call “self-object functions.”  What this means, basically, is that as children we internalize the nurturing and responsive words and actions of our parents.  When this process goes well, we learn how to identify feelings, manage our impulses, and soothe ourselves when we’re upset.  When our parents actively engage with us they help us learn that the world is a safe place that can be called upon for help.  We learn how to identify our interests, develop our strengths, and cope with frustration and failure.  We learn how to establish goals and strive to meet them.  When this process doesn’t go well, children develop defensive strategies to combat overwhelming feelings of insecurity.  They grow up to be adults with low self-esteem, mistrust of others, and an inhibited sense of Self.

Long-term depth-oriented psychotherapy is based on the notion that development is a relational process.  Most people who come to therapy have had a less-than-optimal family environment where the development of the Self was thwarted.  In long-term therapy, the therapist provides the client with a sort of “stand-in” experience for the parent who wasn’t adequately attuned to their child Self.  The therapist’s caring and focused attention provides the client with a sense that her thoughts and feelings are important.  The therapist’s nonjudgmental attitude allows the client to gradually trust that she can explore painful or shameful feelings and experiences without fear, increasing her capacity to tolerate those feelings and reducing the need to engage in defensive behaviors that have served to protect the vulnerable Self.  The interpersonal aspect of therapy allows the brain to “rewire” itself so that painful memories and undermining beliefs are replaced with new experiences that are positive and expansive.

Another important aspect of long-term therapy occurs when the client experiences the therapist as having failed them in some way.  For example, the therapist may be late for the appointment, or raise the fee, or simply misunderstand something the client said.  These ruptures are actually a necessary part of the psychotherapeutic process, in that they are inevitable and allow the client to explore her feelings around the rupture.  This long and slow process allows a safe space for the unconscious feelings and motivations to emerge and be explored, facilitating the development of the Self and providing the client with a different experience of herself and herself-with-other.  For some people, the experience of talking with someone who is genuinely interested in them is a first.  Sometimes it doesn’t even matter what is talked about in the therapy hour; the consistency and the security of the attachment is the first step of healing.

Lasting change takes time, patience, commitment and courage.  The development of Self is a long process that requires a safe, reliable, and supportive relational environment to flourish.  When a person has missed out on that experience in childhood, long-term therapy can provide another chance.

Carol Gould

Carol Gould

Carol Gould has had a private practice in Noe Valley since 1995, working with individual adults and couples. Her work is informed by Self Psychology, Relational psychoanalytic theory, Control Mastery Theory, and Intersubjectivity Theory. She has been trained in John Gottman’s couples therapy model and Emotionally Focused Therapy. She is available for clinical consultation to other therapists.

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  1. Lisa Knudson on July 2, 2013 at 2:27 pm

    Wonderful article Ms.Gould! Thanks for sharing.

    Lisa Knudson LCSW

  2. Leah on July 2, 2013 at 11:49 pm

    Dear Ms. Gould,
    Thank you for your post. What a beautifully articulated summary of the way psychodynamic therapy works. The insurance industry and our cultural landscape of speeded-up and superficial communication have indeed taken a toll on mental health treatment. The treasure that Freud, Jung, Kohut, Winnicott, and our many brilliant colleagues have bestowed upon our civilization is in grave danger of being lost. That treasure of course, is psychoanalytic psychotherapy. I agree with you wholeheartedly that (whether we call it psychoanalytic, psychodynamic, or depth psychotherapy) this deep transformative work we do takes time, commitment, patience, and courage.

    To your comments I would only add that Self and other psychological disorders aren’t just from poor parenting; I have found in my practice a significant population who’ve had excellent parenting, but still need and benefit from psychodynamic psychotherapy. Some patients of mine seem to have a genetically determined Self disorder, (the genetic or constitutional piece is yet to be fully understood); others have been traumatized by relational experiences outside of their families.

    Whatever the etiology, these clients come to us with very deeply ingrained challenges that often require long-term deep work for lasting change. Again, many thanks for your post, Ms. Gould.

    Leah Seidler LCSW