Thoughts on Therapy
Updated: Aug 25, 2020
Donald Winnicott (1896-1971) is one of my favorite psychotherapy writers and a frequent go-to theorist. Winnicott, a pediatrician and psychoanalyst, is perhaps most famous for the "good enough mother" concept: the idea that we are not aiming for perfection in parenting and other growth relationships; that the effort of care over time--- even with and sometimes especially because of the inevitable stumbles and ruptures-- is what counts most. Interesting side note: Winnicott's gut feeling about this has been pretty well borne out by attachment researchers, who now say that successful, well-attuned parents "get" (mentalize) their kids about 30% of the time. Winnicott's concepts, including "good enough," the "holding environment," and his ideas on "play" fundamentally inform my therapy practice.
Winnicott once wrote the best description of therapy I've ever read. He said:
Therapy is two people playing together.
If the client isn't able to play yet, the first goal of therapy becomes learning how to play.
This is profound. Clients often walk in to therapy with a lot of blind hope, and aren't really sure how therapy works or how to use the time-- or how to ask how to make it work. And therapists are still trying to figure it out too. There's over 400 therapies, and the list is growing. Common Factors research is still very much ongoing. Therapy is also incredibly idiosyncratic, and hopefully is tailored to the very specific needs, goals, and personhood of the client. Therapy for a chronically terrified person with childhood trauma can be very different from therapy with an adult surviving their first sexual assault. Depression and anxiety treatment can significantly differ from therapy designed to help someone with a vague sense of "off" or someone who has struggled interpersonally for decades. CBT, DBT, EFT, ACT, MBT, TFP? Attachment-based therapy, relational, intersubjective? Solution-focused, non-directive? Analytic, active? Ego-based, defense-based?
Any and all of these can be useful, and I think this is where Winnicott's tidy advice can be most helpful and instructive. "Playing" in therapy, in my view, is the ability to view yourself outside of yourself and talk about it. This is the core skill, the common goal and "mother" of all therapies. Increased awareness and increased ability to feel safe with more awareness is something all clients can take with them, regardless of the specific treatment focus. ACT therapists talk about "defusing" from your experience by being able to more objectively observe it. This is a key skill as well in DBT and other therapies using mindfulness. Second-wave CBT is essentially using thought records and other worksheets to build up and internalize a stronger observing ego to reduce the fear-driven mind. Freud's idea of putting ego where id was is not so different. MBT explicitly prioritizes the skill, especially in the interpersonal context. A primary assumption and goal of Rogerian therapy is that clients will develop a more open relationship to multiple momentary feeling states without having to commit to any of them.
Whenever my clients have questions about how to "do" therapy, I make sure to include this core skill as part of the explanation. We talk about getting better and better at being able to think and imagine backwards and forwards, and to reach inside towards their current feelings and experience. We practice being able to defuse from emotion enough to look at it and explore it without running from it. We work together to make finding and expressing all feelings a safer experience. I encourage clients to not censor themselves: to use their courage to expand and deepen what they talk about in therapy, and to feel more comfortable talking about what it's like to talk and feel (process). All of these are versions of successful play, and I'm trying to help clients build up these skills.
What about when clients can't play? Winnicott had the wisdom to realize "playing" in therapy isn't always the easiest or most natural thing. It can feel utterly strange to try watching your mind and feeling your feelings. Many people have no idea they can express something and not own it forever, not get in trouble for it, or keep it in the "tentative" realm. It is often a genuine eureka moment when a person finally realizes their insides want to be heard, or that they can experience something intensely and be able to sit with it and examine it instead of being forced into action or avoidance. My clients are often shocked at first to learn that they can tell me how they are feeling about therapy and about me and that we can explore it. Sometimes they are even more shocked to find they are allowed and encouraged to wonder out loud what I'm thinking, and that I will likely share it if they ask.
Practical Tips For Improving Your Ability to "Play" in Therapy
Are there ways to get better at this? Yes, absolutely. Getting better at the core skill can help you make real progress in your therapy and your life.
Idea #1: Freud coined the term the "fundamental rule" to describe how important it is for the client not to censor themselves in therapy. He wanted his patients to try as much as possible to be honest, to go where their minds went without curating it, and to get better at saying and naming when they were avoiding and censoring. The "fundamental rule" still holds up in a lot of ways. Work on being ever more courageous in therapy. And, have your therapist join you to periodically assess the habits you've both built up in therapy. It's important to check in now and again: are you doing therapy, or are you "doing" therapy?
Idea #2: Mindfulness. This is at the heart of all therapies that try to build up observing capacities. Practice it regularly. If you're not sure how to do it, ask your therapist for help. Yes: it is okay to practice mindfulness in session with your therapist.
Idea #3: Learn about the concept of "defusion" in Acceptance and Commitment Therapy. ACT does a phenomenal job of describing and exploring the core skill through this concept.
Idea #4: Embrace the idea of "tentative." Mentalization Based Treatment (MBT) is a therapy that helps people get better and better at the core skill-- especially under stress. One of their major principles is helping clients learn to recognize when they are reactive and absolute, or unwilling/unable to look at multiple points of view. Learning to approach your thoughts, feelings, and conclusions with a degree of curious tentativeness can be empowering and freeing.
Idea #5: "Share the Dilemma." One of my favorite professors taught me the importance of this technique. It can be a wonderful way for anyone with some anxiety to bridge into "play" and more complex conversations. If you're not sure how to talk more honestly about your feelings-- especially if the feelings are in conflict or if you're worried about getting into trouble-- try sharing that dilemma. "One part of me feels like this, or wants to be able to say or do that, but another part of me thinks or feels something else. I want to explore this on the one hand; on the other hand, it makes me feel nervous and I don't want to hurt anyone's feelings."
Idea #6: Use "can I check" with your therapist and others. Another useful phrase to help bridge into "play" in therapy. If you're wondering how something you're saying is sounding or what reactions it is generating in another, you can ask to "check it out" with the other person.
Idea #7: "As if." This is a really important concept in dynamic therapies, and an important achievement in therapy. A therapist and client have a real, actual relationship. And, there will be times when the therapy relationship helps you get back in touch with really important experiences and feelings from previous relationships that helped build your world. You might notice yourself having reactions when relating to your therapist. There are countless examples! Maybe you don't like they way they clear their throat; maybe you feel giddy and lose yourself a bit when they give you a compliment; you might have a moment of wanting to shout at them for this or that; or maybe you realize you don't like their office chair because it reminds you of feeling embarrassed about your own home when you were young.
Whatever it is, being able to talk about these feelings "as if" is really important. It won't help you much to think, "stop thinking and feeling that! You're supposed to concentrate on therapy." In that moment, what you're thinking and feeling is the therapy. And it also won't help you so much if the feelings feel SO real that you quit therapy instead of talking about it. The sweet spot is to have a conversation along the lines of,"I know you're not actually my parent, but I'm having a reaction right now that feels as if you were. It makes me so mad and I feel like a little kid again when you nod your head like that." That's a high level of play between you and your therapist that can lead to so many good things in your therapy.
Idea #8: Keep a journal, and/or use worksheets. For anyone more visually-oriented instead of verbally-oriented, this can be a great way to build up your skills.
Idea #9: Know when and why a therapist is giving you quiet space. Some people love a quiet therapist. Many don't, and ask instead for an "active" therapist that will weigh in, give advice, question your thinking, and teach skills. There is nothing wrong with wanting that (and asking for it), and many therapists are very helpful in those ways. However, Winnicott here again is instructive: in his writings, he cautioned therapists not to jump in too early with observations and advice, out of fear it would ruin the "play." Think about that. A client might need some skills right away (breathing, relaxing, anger management); however, as soon as there is a direction of teaching, the client is less free to explore. Advice can be incredibly helpful; however, if an advice-relationship between therapist and client gets built before the client is really good at play (read: being able to consider and modify or reject the advice, being able to expand on the advice, give honest feedback to the therapist) then there is a real risk of the client nodding their head to make the therapist happy instead of really living their own life in the therapy space. If you're unsure about quiet space in your therapy, or want more or less of it, be brave and have that conversation with your therapist!
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