Three Truths about Psychoanalytic Therapy (Spoiler: It Is Evidence-Based!)

Much of the collective understanding about psychoanalytic therapy (or psychodynamic therapy as it’s also called) comes from clichés, jokes, and New Yorker cartoons. My favorite cartoon shows a dog lying on an analytic couch saying to his therapist, “They throw the ball. I get the ball. They throw the ball. I get the ball. What is the point?” The dog’s existential gloom leapt off the print right into my heart, and then onto my refrigerator door, where the cartoon remained for years, making me giggle whenever I reached for a cold glass of water. 

love wit, but, unfortunately, it doesn’t always leave room for truth. I will continue to laugh at these cartoons and I hope you will too. At the same time, I deeply believe in the power of psychoanalytic therapy not only to heal suffering but also to create a greater sense of freedom. I think there’s plenty of space for humor and truth, but it’s important that the former doesn’t undermine the latter, potentially keeping people from something that could really help them. 

In short psychoanalytic therapy focuses on connecting with emotions or other core aspects of experience that either have not gotten enough attention or have been too painful to feel. Here are three common misconceptions about psychoanalytic therapy and their accompanying truths. I hope they clarify the truth while still leaving in the funny!

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Misconception: Psychoanalytic therapy is only about the past.

Truth: Psychoanalytic therapy focuses on the present. 

Do you know the phrase, “if it’s not one thing, it’s your mother”? In the Saturday Night Live version of my life, which occasionally plays in parallel to my actual life, this is the tagline for psychoanalytic therapy. While it’s catchy, it is, like many commercials we see every day, both true and untrue. 

It’s not true because the focus of psychoanalytic therapy is always on the present. In each moment the therapist is wondering: What is this person’s immediate experience? What is she showing me about herself in how she’s relating to me right now? How has what I just said impacted her? In this way, psychoanalytic therapy is not about mom at all. It’s about what’s occurring right now in the room. 

At the same time, the satirical tagline is true in that the past is always alive in the present. The way people learn to relate to themselves and others is developed in early childhood and, thus, is fundamentally shaped by primary caregivers. Those early relationships are woven into the very fabric of the person’s being and, therefore, can’t help but show up in the present. 

 

Misconception: Psychoanalytic therapists are distant and silent. 

Truth: Psychoanalytic therapists are focused on connecting and can talk a lot. 

A friend recently asked me about psychoanalytic therapists. “Do they talk?” he inquired with complete sincerity. Clearly the makers of the Freud bobble head chose a popular fable to capitalize on: the blank stare, the chin dipping up and down atop the stiff plastic body, the obvious silence. When I shared my friend’s concern with a colleague, she joked, “Sometimes I don’t shut up!” 

Deciding what to say and when to say it is, of course, part of the art of psychotherapy. All talk is not equal, and neither is all silence. Whether the therapist talks a little or a lot, she is always thinking about and feeling with the person’s inner world and trying to make contact with the core of that experience. 

 

Misconception: Psychoanalytic psychotherapy is not evidence-based.

Truth: Psychoanalytic therapy is as empirically supported as other therapies. But, wait, there’s more!

In his paper, “The Efficacy of Psychodynamic Psychotherapy,”[1]Jonathan Shedler surveyed the major research on the effectiveness of psychodynamic therapy and compared it to other therapies, including cognitive behavioral therapy (CBT), which is commonly thought to be the only evidence-based method of psychotherapy. 

He found that psychoanalytic therapy is at least as effective as CBT. For statistics fans, the effect size for psychoanalytic therapy ranges from .69 to 1.46 across studies. In comparison, the effect size for CBT ranges from .58 to 1.0 across studies. For those who fell asleep halfway through the word ‘statistics’, just know that .8 is considered a large effect in psychological research while .5 is considered a moderate effect, so the efficacy of psychoanalytic therapy is actually very high. Shedler also found that the benefits of psychodynamic therapy not only endure, but also increase over time, even after therapy ends. In comparison, the benefits of evidence-based non-psychodynamic therapies tend to decay over time. Put that in your Freudian cigar and smoke it!

Even more fascinating is Shedler’s finding that the methods that make CBT and other non-psychoanalytic therapies effective are psychoanalytic. Wait, what? Yep. When researchers look at what therapists are actually doing (by reviewing videos or transcripts) as opposed to what they state or believe they are doing (“I am a CBT therapist.”), the active ingredients are unacknowledged psychoanalytic elements. These include engaging in unstructured, open-ended dialogue, drawing attention to feelings judged to be unacceptable by the person, and discussing the therapy relationship. 

There are several other misconceptions about psychoanalytic therapy that I’ll address in a later article. But, based on these first three truths, I submit to you that the dog with the existential crisis in my beloved New Yorker cartoon made a smart decision in jumping up on that psychoanalytic couch! If you’d like to learn more about psychoanalytic therapy, call me at 415-824-3242. If you’re looking for a therapist and I’m not the right match for you, I will give you referrals to my trusted colleagues. 


[1]Shedler, J. (2010). The Efficacy of Psychodynamic Psychotherapy. American Psychologist65(2), 98-109.

 

What Knowing Your Strengths Does (and Doesn’t Do) for You

A common element of leadership coaching is a 360 review. This is an assessment of a client’s leadership skills and abilities by colleagues all around the client(supervisors, peers, and direct reports), hence “360.” I have conducted, interpreted, and reviewed hundreds of 360s with leaders over the past decade, and a recurrent theme is that people pour over their areas of development while barely eyeing their strengths. 

Once when I asked a client her thoughts about the strengths identified in her 360 report, she responded, “I skipped those.” Another said, “Oh, yeah, I forgot to look at those.” A third said, “what I am supposed to do with those?”

It’s biologically hard-wired into us to look for threats. We had to be on alert for wild animals that might kill us. There wasn’t a lot of time left over to smell the roses. While we no longer have tigers charging at us, we have the modern-day psychological equivalent: the criticism. The criticism is also known as the constructive feedback, the area of development, or, simply, the weakness. Regardless of its name, it can be psychologically processed as a threat.

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Some clients’ fear begins prior to opening their 360 report. They experience dread and anxiety and postpone reading it. Others open it immediately and head directly to the areas of development, combing over them like an archeologist with a tiny brush. Both are responses to the fear felt inside. The threat becomes the focus, leaving no space to take in the good. 

What do we miss by not acknowledging our strengths?

When we don’t know our strengths, we don’t know what we uniquely bring to a situation. This can limit our ability to know what we like or want to do. It can also limit our ability to impact the world around us. Both of these scenarios can create confusion, boredom, or frustration.

One client unhappy with her job started coaching with me. She felt her options were limited by her lack of formal education in her chosen field. Through our work together she learned that in addition to her technical knowledge, she had tremendous strengths in the process aspects of work: providing clear structure for teams, facilitating group discussions, and resolving issues in order to move projects forward. These abilities were so natural for her that she not only didn’t notice them, but also didn’t value them. We all know that these skills are needed and that not everyone has them. With her new awareness she was able to seek greater leadership opportunities in which to use these skills. As a result she was more fulfilled at work and contributed even more to the field she cares so much about.

Another client had innovative ideas for improving his field, but wasn’t sure how to bring those ideas to the external world. As we worked together he became not only clearer about strengths but also more confident in his leadership skills. He had the ability to organize large systems, break down complex visions into understandable actions, and build strong relationships. Now he had the realization that he could leverage these natural abilities to create great organizational change. His idea is now front and center in his organization.

The better we know our strengths the more we can experience joy in our efforts. We also become more confident in our abilities, actually “owning” our qualities, abilities, and skills. With more clarity and more confidence, we are better positioned to impact our environment. 

While knowing our strengths helps us in ways outlined above, there is at least one big misconception about what knowing our strengths can do. As much as our culture wants to counteract the inner critic (you will recognize this voice inside as the one that tells you in big and small ways how bad you are) with positive affirmations about ourselves, I have yet to experience, witness, or read about this actually working. 

Why doesn’t it work? Because the inner critic cannot be reasoned with, which is essentially what reciting our strengths to the inner critic is an attempt to do. Inner critic: “you are lazy.” Voice of reason: “I am hard-working.” Sounds logical, but please let me know if you’ve had long-lasting effects from this type of intervention. To further understand the workings of the inner critic, read here.

With that caveat, how can you take in your strengths? Here are a few ideas.

1. Notice the type of work or work activities you engage in during the day are so natural for you that you almost forget you’re doing them. 

2. When someone acknowledges your contribution (tip: they might say “thank you” or “you did that so well”), ask them what specifically you did well

3. When you or someone else identifies a strength of yours, breath it in like you would the scent of a fragrant flower or a fine wine: slowly take it in, explore it as it comes in, savor it – not simply to enjoy it, but to really know it

By the way, if you’re worried that acknowledging your strengths will make you arrogant, please heed this story. Remember the client who was unhappy with her job at the beginning of coaching? She worried that accepting her strengths would expunge her humility. In fact, humility was one of her strengths. But it was not the only one. Her inner critic was twisting her humility and using it against her (that inner critic is insidious and subversive!), saying, “if you’re really humble, you don’t have any strengths.” Not accepting her other strengths simply kept her limited (that’s the goal of the inner critic!), not humble. She was able to not only acknowledge, accept, and utilize her strengths toward a meaningful end, but also to do so with humility. 

Post-Holiday Blues? Take Your Vacation Back to Your Regularly Scheduled Life

Perhaps, like me, you had the good fortune to take a break from your regularly scheduled life over the holidays. Without all of your usual responsibilities you probably had more time. More time to spend with family and friends.  More time to engage with activities. (No matter if that activity was skiing, reading, or binge-watching “Keeping up with the Kardashians.” You will not find a drop of judgment here.)

Beyond the additional time for people and activities, though, this unfettered time allows us to move in our more natural way. This presents us with the opportunity to see something about ourselves that perhaps we don’t always remember when we are busy with our scheduled lives. 

If you took a holiday break, I wonder what you noticed about your experience. What did you gravitate to? What did you love? How did you differ from your usual way of being? 

During my vacation I was reminded how much I love to attend fully to everything that I do, even those activities that I usually try to simply check off my list, like household chores. I’m often trying to get those done so I can focus my attention on what I typically consider to be my life—my work, my relationships, my personal practices. But over vacation I noticed how much I enjoyed not simply going through the motions, but actually enjoying the movements themselves. 

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I particularly noticed this at mealtimes. I liked being in my kitchen, standing at the cutting board preparing food. I enjoyed watching vegetables sizzle on the stove and placing the meal on the plate. Eating was good, but I couldn’t believe that I enjoyed the cleaning up just as much! There’s something so utterly satisfying about completing a task—from beginning to end—and fully engaging with each step along the way with integrity and care. 

Standing at the sink, I felt the warmth of the water. I sensed the scraps of food washing away from the plate. I saw the sparkling clean dish emerge from the suds. Though part of my attention was on the activity of washing, another part of my attention was on my internal experience. I was feeling present, joyful, contented. 

I know. This sounds manufactured at best and like a bold-face lie at worst. But I swear, I’m not making this s**t up. I’m just as surprised as you are. Believe me, two weeks ago I would have told you that washing dishes is one of my top three least favorite chores. But, there I was: loving the dishes. 

Perhaps, like me, you were sad about the end of the holiday break. Not because you don’t enjoy your work. (If you’re anything like me, you actually very much love what you are lucky enough to be paid to do.) But because you felt the loss of the precious time to be reconnected with something you love. 

I wonder what you enjoyed during your vacation and what associated internal experience you anticipated having to leave behind. For me I was sad about the idea that I would have to return to a schedule that doesn’t leave time for me to be besotted by my kitchen sponge and my garbage disposal. 

But I soon realized I could take my way of being during vacation back to my regular life. As I walked home from boot camp that Monday morning after the holidays, ready to start my first day back, I reminded myself of my rediscovered love: attending fully to the moment. I may not have as much time to gaze at the brilliant redness of that bell pepper or to arrange those green beans artistically on my plate, but whatever time I do have, I reminded myself I could soak in it, like a warm bath. 

This is not so much a standard New Year’s resolution as it is a reminder of a truth about myself. I don’t have a plan to attend to each and every moment of my day (exhausting!). Nor do I intend to tell a mean little voice in my head to chastise myself whenever I get distracted (ouch!). I simply want to remind myself of what I love. 

Interested in taking your vacation back to your regularly scheduled life? Here’s a DIY project for you. 

  1. Ask yourself these two questions—what did I enjoy about my holiday break? How was I being in those moments?

  2. Come up with a simple, but meaningful phrase that captures that way of being.

  3. Use that phrase each morning to remind yourself of that way of being.

  4. Don’t try to do anything differently or be anything different.

  5. Notice what happens.

  6. (Optional) Let me know what you observe.

Now, go enjoy your regularly scheduled life. 

Who Should I Talk To: My Hairstylist or a Therapist?

Have you ever joked that your hairstylist knows more about your personal life than your family does? Or, perhaps a friend has said her hairstylist fixes more than just her hair. Stylists definitely hear this from their clients: “You’re like my therapist!”

What is the difference between talking to a hairstylist and talking to a therapist? And, more importantly, whom should you talk to? (We promise to bottom line the answer to this question at the end of this article!)

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Hairstyling appointments can resemble psychotherapy sessions in a few ways. Both involve you seeking help from a trained professional. Both occur in an intimate space. Both take about an hour (unless you go for those lilac highlights!). And, both usually involve you talking about your life (a little or a lot) while a professional listens.

Let’s break these down to see the similarities and differences. 

Seeking Help

For both hairstyling and psychotherapy, you may know exactly what you want, generally what you want, or simply what you don’t want. With a stylist perhaps you’re ready for bangs, you want to look more professional, or you’re just tired of your current look. Either way you want the professional to understand your need and use her expertise to meet it.

Though there is a bit of back and forth with a stylist—“Bangs will look great on you, but I suggest we make them a bit longer.”—hairstyling is essentially a transactional service. You ask for something, and the stylist provides it.

With therapy you may know you want to be in an intimate relationship, want to be happy, or want to feel different. An issue you bring to therapy, however, is likely to be more complex and have deeper roots (pun intended) than you are able to see by yourself. While hairstyling is a transaction, therapy is about what happens between the therapist and the patient over time. The therapist cannot simply handover a treatment. The relationship itself is the treatment.

Space

The spaces in which you meet with a stylist or a therapist share some similarities. There is closeness. There is focus on each other. There is a bubble in which your work together resides. The hairstyling bubble, however, is not usually contained in a private space, and hairstylists, though perhaps individually discrete, are not required to maintain confidentiality. They may refer to you by name to other clients or say something, albeit benevolently, that would identify you to other clients.

Therapists, by law, ethics, and clinical best practice, cannot share anything about you to anyone (with few exceptions). The implication here is probably obvious. There is a greater sense of safety in a therapy room than in a styling salon. This emotional safety may take time to develop with a therapist, but ultimately there is more freedom to express, and thus understand and process, feelings such as shame, anger, worry, confusion, sadness, and hopelessness.

Time

Haircuts take approximately one hour. Similarly, therapy sessions are usually 50 minutes. Aside from duration, however, time also involves frequency. Salon appointments are recommended every 6-8 weeks. Therapy, on the other hand, occurs at least once per week if not multiple times per week. Does this difference matter?

Hairstyling is an immediate “fix” to a problem: split ends, dulled color, or an outgrown style. Therapy extends beyond symptom relief to psychological development. This might include the capacity for meaningful relationships, the ability to maintain a realistic sense of self-esteem, or the facility to face challenges with more creativity.[1] Developing these capacities not only takes time, but also happens in the context of a consistent, regular relationship. While support from your stylist every other month can feel great, you’re not likely to resolve your trust issues while getting shampooed.   

Talking While Being Listened To

In an intimate setting people tend to chat. It’s sort of a cultural norm. Some people will share a little. Some will share a lot. A few will not talk at all. Those who do talk may share personal or emotional material. Others may prefer a less personal interaction. Some may focus on the other person more than on themselves. Obviously there’s a wide range of possibilities.

Regardless of what a person says (or doesn’t say), how the listener listens determines how they respond, and, thus, what the talker receives. Of all the differences between hairstyling and psychotherapy, this may be the most important. In fact, our title question is probably better asked as: who should listen to me? 

Hairstylists are likely listening the way most of us are. They hear the content of your story. They hear your emotions. They likely want to protect, support, and encourage you. As a result, they are likely to empathize with you, “side with you,” and give you ideas about what you should do.

Therapists, and particularly those practicing psychodynamic psychotherapy, hear the story and the emotions, but also listen on a variety of deeper levels. They listen for your underlying needs, such as the need not to be infringed upon, but also not to be left to figure out difficult things on your own. They listen to what may be too scary, shameful, or unknown to be expressed. They listen for how you relate to your own mind and emotions.  

These various ways of listening enable the therapist to help patients know themselves, process their thoughts and emotions, and develop psychological capacities. Over time, patients are better able to understand and tolerate their own thoughts and feelings, leaving them equipped to live with more freedom. 

So, who should you seek help from?

SEE A HAIR STYLIST IF you want a haircut, hair color, new style, or updo with a side of chatting, empathy, listening, and perhaps tidbits of advice.

SEE A THERAPIST IF you are struggling with relationships, not feeling good enough, having trouble making decisions, experiencing regular distress, resentment, or worry, or are feeling lost or hopeless.

 

[1] Shedler, J. (2010). The Efficacy of Psychodynamic Psychotherapy. American Psychologist, 65(2), 98-109.

Why Telling Your Inner Critic to F*** Off Isn’t Always Enough

Inner Critic (n): internal voice that judges you

Examples: “You’re selfish.” “You’re a terrible friend.” “You’re a fraud.”

You are probably quite familiar with your inner critic, but if you’re not, the best way to identify its presence is to notice when you feel bad about yourself. If you feel bad, you can be certain your inner critic isn’t far behind. It’s cleverly personal and brilliantly insidious, ensuring that its words strike at the heart of your fears while barely leaving a fingerprint.

If you’ve tried to deal with your inner critic, you have no doubt read or been given advice about how to manage or combat it. A first step is often identifying the inner critic as a voice that comes from inside you, but is not you.

After that, common guidance includes: don’t believe it, replace its criticism with positive affirmations, be compassionate with yourself, and tell it to f*** off. Have you heard any of these? Or, tried them?  

If you have, perhaps some of these practices helped you gain freedom from your inner critic, allowing you to live more spontaneously and fully. But perhaps that freedom has been fleeting or you haven’t felt free at all. Maybe you’ve wondered if there is more to the inner critic’s story. If so your instincts are accurate.

The inner critic is a complex phenomenon that is rooted in very early relationships. Its original mission was to protect you by internalizing messages from the people around you about what was safe and what wasn’t. With the inner critic’s help, “Watch out for cars, Johnny” turned into life-saving wisdom about protecting yourself from harm.

Due to various experiences, the well-intentioned inner critic at best develops mission creep and at worst entangles us in a dependent relationship with something that appears to be protecting us while simultaneously condemning us. This is an excruciatingly complicated and painful psychological dilemma.  

Let’s look at this in more detail. First we must imagine ourselves as a very small child, an infant really, because that is when this complex relationship begins. As you read the following, remember that infants are many years away from the capacity for rational thought and, thus, cannot yet understand such concepts as boundaries between people or cause and effect.

With that foundation, let’s imagine being an infant who is experiencing intense sensations, like hunger, or big emotions, like fear. If that child is left alone with these experiences too often or for too long*, he has to make sense of them and manage them himself.  How is he to do this? Recall the inner critic’s mission to protect the child? This certainly seems like a job for the inner critic. You’re experiencing pain from hunger? You’re scared? Let me help you.

(*Important note: This description is not about parents or caregivers. Even the best caregiver cannot meet a child’s every need at the moment he has one. What is being described here is the child’s internal experience in response to his environment.)

What happens, though, when that child’s inner critic attempts to help him make sense of his inner world?

Infants and children are completely dependent on their caregivers for everything from food to the development of their nervous system. If an infant isn’t getting his needs met, he is not psychologically in a position to be angry with his caregiver for not meeting his needs (though he will cry for his needs to be met). Within the infant anger could likely jeopardize the relationship on which he depends for his very livelihood. (Besides which, infants don’t yet have an awareness of self versus other, but I’ll leave that complexity for another day.) Instead the inner critic is there to place the problem on the infant. The internal message is something like, “Your needs are too great” or “You shouldn’t need anyone.” Obviously these aren’t actual cognitive thoughts for the infant, but are nonetheless experiential messages to him.

To the rational, adult mind, these conclusions may sound like ridiculous jumps in logic. Isn’t it obvious that the infant simply has basic needs? But from the inner critic’s perspective, they are protective thoughts. If the infant is the bad one, then there is always the hope that all he has to do is be good and eventually he will get what he needs. If he blames the outside world, that would leave him at the very vulnerable mercy of others, powerless to get even his most basic needs met.

Remember the “dictionary” example of the inner critic at the beginning of this article? “You’re selfish” might actually be the inner critic’s best effort to make sense of a scenario in which an infant’s need for food or soothing wasn’t met.

Beyond internalizing seemingly protective yet ultimately isolating messages, the infant becomes attached to his inner critic in the same way that adults get attached to loved ones. The inner critic is always right there to intervene, whether that intervention is helpful or not. This creates a real relationship, and, as we all know, breaking up is hard to do, especially with a lifelong companion.

As we can see the inner critic’s messages are not merely harsh statements that can be simply ignored, overwritten, or pushed away. They are strong statements about oneself that are deeply embedded in the context of relationship. Problems that arise in relationship often, if not always, need to be healed in relationship. Trying to deal with these alone reifies the underlying problem of being left alone. 

Originally posted on psychedinsanfrancisco.com