Therapeutic Fish in Relational Waters
The meeting of two personalities is like the contact of two chemical substances: if there is any reaction, both are transformed. - CG Jung
In this post I zoom in on an idea that I talked about in a previous post entitled, Why Does Therapy Work? It’s Not Why You Think. There I referenced a research study conducted in 2018 by the American Psychological Association that revealed that regardless of what style of therapy or counseling is being practiced, the outcome and efficacy of the treatment is determined by the nature of the relationship that develops between the therapist and the patient. I will briefly discuss several of the most common therapy techniques and then unpack why the relationship is more important than the technique in determining therapeutic outcomes.
The Fish: Common Therapeutic Models
The following is a brief description of some of the most common therapeutic techniques that therapists are trained in. These summaries serve as an overview, but are not a comprehensive description of each modality. As a word picture, I am calling the various therapy models types of “therapeutic fish”. They each differ from one another to some degree, but at the end of the day, they are all swimming in the same water. I will also describe the nature of the water.
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy (CBT) is one of the most commonly taught models of therapeutic technique and has been widely adopted by most masters level counseling, social work, and psychology programs. The basic tenets of CBT are that psychological struggles are rooted in faulty thought processes that lead to problematic behaviors and the goal of therapy is to identify the problematic ways of thinking, correct them, and that this will in turn lead to an improvement in one’s problematic behaviors. In this modality, the role of the therapist is to serve as one who helps the patient identify thought distortions, challenge these distortions with more “accurate” ways of thinking about one’s struggles so that they can adapt their behavior and live their life in a way that is more aligned with this new, more accurate way of thinking. CBT therapists often provide various forms of homework to their patients and, in theory, this process serves to reduce the patient’s symptoms.
Dialectical Behavioral Therapy (DBT)
Dialectical Behavioral Therapy (DBT) was adapted from CBT with specific aim to work with personality disorders, primarily Borderline Personality Disorder (BPD). DBT includes a combination of both individual psychotherapy and group psychotherapy. The core tenets include teaching skills in the following four categories: Core Mindfulness, Interpersonal Effectiveness, Distress Tolerance, and Emotion Regulation. This style of therapy is highly structured with a strong emphasis on providing skills that are intended to disrupt problematic thoughts and behaviors and replace maladaptive patterns with a more emotionally regulated ability to engage in one’s life and relationships with decreased conflict.
Acceptance and Commitment Therapy (ACT)
Acceptance and Commitment Therapy (ACT) is also an offshoot of CBT with an emphasis on the therapist helping the patient to turn towards difficult thoughts and emotions rather than avoiding or bypassing them. ACT utilizes various mindfulness based techniques as tools to observe, and accept one’s thoughts and feelings without judging them. From there the patient and therapist work on identifying core values to guide the patient’s behavior. The focus is on creating actionable and achievable goals that are in alignment with the identified values and making a commitment to following through in the pursuit of the decided upon goals.
Eye Movement Desensitization and Reprocessing (EMDR)
Eye Movement Desensitization and Reprocessing (EMDR) is an approach to working with traumatic memories and the subsequent mental, emotional, and behavioral struggles that develop as a result of the initial trauma. Unlike the other forms of therapy that have been discussed, EMDR is less of a “talk therapy” technique, but instead focuses on using a tools to create what is referred to as “bilateral stimulation” in the brain to reprocess the traumatic memories in a way that significantly reduces the disruptive power of the memory and improves overall functioning. Think of it like moving an email out of your inbox where it is constantly calling for your attention into the archived folder where you can still access it, but it isn’t always in your face with the same intensity. EMDR is well researched in the treatment of Post-Traumatic Stress Disorder (PTSD) and has been shown to be effective in many cases.
Internal Family Systems (IFS)
The name Internal Family Systems (IFS) can be confusing for some who assume that it is some type of family therapy. Note that, while wounds from one’s family of origin may come up, the family being referred to is one’s inner experience of various components of one self, i.e. inner critic, inner child, etc. IFS is sometimes referred to as “parts work” and is focused on the therapist helping the patient to explore the various internal parts that have an impact on how one views oneself and how they relate to their external world. The idea here is that there is a central “self” that is surrounded by a host of other “characters” that each play different roles and are often in conflict with one another. These characters are described as parts or subpersonalities and shape our thoughts, beliefs, and behaviors. The terms that are commonly used for the parts are:
Exiles: younger parts of ourselves that hold the wounds and fears that are typically experienced in childhood.
Managers: self-protective parts that employ various survival strategies in an attempt to protect the Exiles from experiencing the old pain in the present.
Firefighters: similar to managers in the attempt to protect the Exiles from pain, but tend to use defense mechanisms to distract the self from the pain.
The goal of IFS is largely about integration of these parts so that there is a more cohesive sense of self.
Somatic Therapies
Somatic Therapies focus on the mind-body connection. A somatic therapist uses a variety of techniques to help patients pay close attention to physical sensations in their bodies in order to explore “what is coming up” on a physical level that may also have emotional meaning. Feelings, after all, are not called feelings for no reason. We feel our emotions in our bodies before having a thought about them in our minds. Somatic therapy emphasizes that trauma “lives'' in the body and that it gets worked out through the body as well. The Body Keeps the Score by Bessel VanderKolk is one of the most well-known books exploring this idea. Most somatic therapies focus heavily on teaching various nervous system regulation skills and practices to help combat emotional states of fight, flight, and freeze.
The list of therapy types goes on and on. One website online listed more than 70 different styles of therapy and I am certain there are other lists that are much longer. In other words, there are many fish swimming in the therapeutic waters. For the sake of this blog, I would just like to highlight that the vast majority of therapy or counseling methods track with the following flow:
Therapist/Counselor receives specialized training in graduate school to learn to identify and diagnose based on identifiable symptoms. They complete a supervised internship and eventually receive a license to practice psychotherapy from their respective state licensing body.
From here, they usually begin to see patients in a variety of contexts ranging from community mental health settings, inpatient settings, and private practice settings.
With each patient, some type of treatment plan is created that describes the symptoms, declares which therapeutic techniques will be used to treat and reduce the symptoms, and estimates approximately how long the therapy will take to achieve the desired outcome.
Therapy sessions then focus on the therapist listening to the patient’s story, providing some psychoeducation around what the therapist suspects is either causing the problem or how they propose to help.
Therapist offers feedback, suggestions about tools and techniques for the patient to do, provides homework of some sort (journaling, meditating, physical movement, reading, etc.) and the patient and therapist regularly reflect on how the therapy is going and make adjustments as needed.
The Water: The Relational Psychodynamics
Psychodynamic is a term that acknowledges that we have unconscious or unknown parts and processes of who we are that are shaped by our early experiences in life and impacts how we live in the present moment. Relational psychodynamics describes how these unconscious processes take shape in relationships between people.
As previously mentioned, the 2018 research study by the APA gathered decades worth of research in an attempt to discover what determines the outcome of therapy. What shocked the world (at least the part of the world who read the study) was that the study revealed that regardless of which style of therapy is practiced, it is ultimately the quality of the relationship between the therapist and patient that determines the outcome. How can that be possible? I believe it is possible because humans are not mechanical engines with static components that simply need to be repaired or swapped out when something goes wrong. You can’t simply follow a manual and check boxes towards healing regardless of how “evidenced-based” a particular therapy model claims to be. If the relationship is off, and not being tended to, then there is a high probability that the outcome of treatment will be less effective, or possibly even make things worse for the patient.
Ask any therapist if they think that the relationship between themselves and the patient is important and you will most likely get a resounding yes. However, what most therapists mean when they say they are relational in their approach is that they are a good listener. They are empathetic and compassionate. They “hold space” for their patient to process their story. They validate the patient’s experience. They offer suggestions to help reduce symptoms and they may even confront their patients when they feel it would be useful to move them forward.
This can certainly be helpful, but this is not a complete picture. All of these things only include what the therapist and patient are consciously aware of doing during their work together. Again, returning to the fish analogy, these things would be akin to the way the different fish move, but don’t take into account the water in which they are swimming. The water can often be difficult to detect because we are completely immersed in it. The water represents the unconscious relational patterns that both the therapist and the patient get caught up in and co-create in the relational space between them.
I am deeply drawn to the relational psychodynamic frame because it's more than a theory or a technique. It is like the water that holds all of the different types of fish. Regardless of what theory or model a therapist is operating from, psychodynamics are always active and exerting influence. For example, one can be a CBT fish, a solution focused fish, an EMDR or somatic fish, an DBT, ACT, IFS, or Gottman fish, but they have no choice but to be swimming in psychodynamic waters. It's just a matter of whether or not one is open to considering that there is an unconscious parallel track running alongside one's conscious technique track. There is what the therapist and patient consciously know they are doing during their sessions, but the parallel line is the dynamic, and often unconscious patterns that are simultaneously taking shape between them. Are they willing to wonder and be curious about what else is happening in addition to what it is they think they are doing in therapy? If so, there is potential for deeply healing encounters to take shape as past wounds get recreated in the present moment hoping to be discovered and worked through in such a way that can repair the rupture that had been left in the past, but continues to haunt the present.
There are innumerable ways that this dynamic can take shape. For instance, on the conscious track you might have a therapeutic pair who get along very well. The patient is very motivated and so they come in and discuss their struggles with the therapist and are very eager to hear what the therapist will have to offer in response. The therapist, filled with empathy and unconditional positive regard, then offers some thoughts, feedback, and some type of homework for the patient to work on in between sessions. The patient returns the following week and is excited to report that they have completed the assigned homework and have even noticed a slight improvement in their symptoms. They express gratitude to the therapist and are motivated to continue on with therapy and take in what the therapist has to offer. The therapist also feels great about this. It feels good to see that one has had a positive impact and that the suggestions offered have been taken in and found helpful. This can go on for quite some time and on some level be quite helpful, but eventually what happens is that the therapeutic pair hit a bit of a plateau that I like to call the Therapy Lull. A lull in therapy often indicates that something in the relational psychodynamics is being activated and likely both therapist and patient are defended against allowing it to come fully into the room where it can be talked about. Sticking with the present example, it could be possible that the pair have unwittingly been pulled into a repetition from the patient’s past in which the patient had to earn love through high achievement, which was deeply wounding because they only feel loved for what they accomplished and not for who they are. Now this very dynamic is playing out between patient and therapist. In order to work it through to a healing outcome they must first allow themselves to become aware of the dynamic, discuss the associated emotional charge that comes with it and see it through until they can find each other again on the other side of it. It requires tremendous vulnerability for both people because to discover this means it could cause conflict in the relationship when conflict had not been present there before. The therapist has to own that they have found themselves in the same role that was once so painful for the patient. They have to acknowledge that they, like the original parent or caregiver, also have a self-focused need that is being met every time the patient “succeeds” with the treatment plan. The therapist’s need to feel effective and helpful is actually a significant driver in the direction the therapy has moved in historically. The lull arises as one or both of the people begin to have a sense that this is occurring. For the therapeutic couple this reality is too much to tolerate because they also genuinely care about one another. The patient doesn’t want to upset the therapist and the therapist doesn’t want to believe they have acted in a way that repeats the original wound and so this initial sense of what is happening gets pushed back out of awareness and the therapy begins to feel flat, stuck, or stalled. Many therapies actually end at this point, but if the pair is able to discover and tolerate this reality then they can begin to talk about it, feel it, and work it through. This process not only repairs the rupture that is occurring between the two of them, but also brings some healing to the original wound. The disavowed emotions can finally be felt, held and integrated. This is how lasting healing occurs. If the therapy ends before this working through occurs, then the original wound is reactivated. The original defenses and survival strategies are reinforced, and the patient goes back out into the world destined to repeat the pattern again.
In this light you can see that the style of therapy alone has much less impact on the outcome of therapy than the relational dynamic. The most technically precise application of therapeutic tools and techniques will eventually stall out if the unconscious parallel track remains unexplored.
Therapy can be very powerful and transformative and it often feels very vulnerable to reach out to a therapist for help. If you are considering this option for yourself, be sure to find a therapist that knows what kind of “fish” they are and also has a willingness to explore the relational “water” that you will be swimming in together.
1. See Jonathan Shedler’s article demystifying “evidenced based” models titled: Where is the Evidence for “Evidence-Based” Therapy?
