Continued from last post: therapy is exceedingly complex, and a good therapist is able to juggle and integrate all 7 of these layers.
The client’s content
This is the surface of the therapy. It’s the story that’s being told, and includes the reasons that the client gives for entering therapy.
The client’s body language and context
The next layer involves more observing, and also integrating some history or culture. For example, a client may be upset that her boyfriend didn’t call her before he left for some international travel. There is the story, but then there is the context—what does this mean to her in the context of this relationship, her past relationships, her attachment style, etc.
This part may be more art than science. In theory it can be taught, but it’s definitely the area where I’ve been failed the most as a client. I also know that as a therapist that I have failed clients in this way. So there is no doubt it’s tricky. What is it?
A great example is from the show In Treatment (Season 2, ep1). There is a scene where therapist Paul is meeting new client April. She describes her frustration and annoyance with her previous therapist: the therapist told the same joke twice, implied that April was angry with her autistic brother for taking up her parent’s time and called April too many times after April decided to quit therapy without notice. Paul reflected back that he could tell a lot from those complaints: that April doesn’t like to be told things twice, she is fiercely loyal to her family and that if he fails to engage her she will disappear. Paul was reflecting the subtext of what April was telling him, and it earned him some initial trust from her. It takes a lot of intuition and inference and it gets a lot easier as the relationship with a client progresses
The therapist’s responses, including countertransference
It’s inevitable that we are impacted by our clients; in fact, if we aren’t, I would argue that the therapy is failing. Often, I can use my responses to guide me. If a client is talking to me and I get an image of a tornado, or pieces of information flying around too fast to grasp, I reflect that back to them. Without fail, clients report that that’s how it feels in their heads, so we then pause to slow things down a bit before proceeding.
Sometimes clients remind us of ourselves, or people in our past (or present), or their situation is all too reminiscent of personal experience. This is countertransference, and it is crucial for the therapist to observe it and be aware of how it is impacting their response to the client.
The interaction between the therapist and client
The relationship between therapist and client has its own flavor and character. Any two people will bring out certain characteristics in each other, and the therapeutic relationship can have a rather potent influence. A good therapist will notice the pitch and tenor, the volume and quality of the relationship and like a good conductor, adjust it as necessary.
The therapeutic techniques in use or to be used
This is what a lot of graduate school and trainings focus on—the actual interventions. It’s the content of so many of the books on my shelf. But without the other layers, these are useless. Every year, after students have been practicing using Trauma-Focused Cognitive Behavioral Therapy and preparing to see their first clients, someone freezes and asks, “Wait, how do I know when to introduce these skills?” Knowing how to integrate techniques appropriately is key.
The disposition of the session with respect to the client’s goals and/or therapeutic progress
It’s also important to imagine the session itself as a point on a journey toward some destination. This is often second nature to clinicians who work in settings with a limited number of sessions. Clinicians who practice a particular therapeutic method with fidelity also usually know where they are (although that’s not always the same thing as knowing where the client is).
The disposition of the therapy is a conversation that should take place between both individuals. Irvin Yalom asks for feedback at the end of every session, and I encourage my students to regularly check in with their clients about how things are going.
What other layers have you found helpful? Or what are some aspects of these layers that you feel are especially important?