How therapy progresses depends a great deal on who the therapist is, their style, and how they work, even for approaches like cognitive-behavioral therapy which are often presented as following a formula or manual. Therapy is, as they say, “operator-dependent”.

The therapist’s self, and the way it is wielded, is key to whether therapy works. Each patient-therapist pair follows a unique path, even if the ultimate goals of therapy are the same. Within relatively rigid constraints, therapy can unfold in many different ways.

How Does Therapy Work?

There are many different ways to arrive at desired therapeutic outcomes—a more secure, confident sense of self, better relationship and professional function, treatment for depression, anxiety and other conditions, reduced negative thinking, better self-understanding, and so on. Goals also evolve over time, making defining goals itself a meta-goal of therapy.

Therapies share “common factors,” the extent to which the therapist is supportive, empathetic and validating. Some approaches are more directive, appearing to follow a recipe while still being very much about the therapeutic interaction. Others are more exploratory, like psychoanalytic/psychodynamic therapy, focusing on developing insight, seeing how developmental patterns repeat and using that awareness to change contemporary patterns.

Regardless of therapy type, therapeutic effectiveness is tied to the quality of the relationship between patient and therapist—the “therapeutic alliance.” Even for computer-based therapies, the way the interface is designed is a key aspect of whether people use it and how much they benefit—up to and including designing empathic AI avatars to deliver doses of therapy.

Understanding how therapists make use of “the self” means getting into the details of very individual experiences, extracting recurring themes, and grouping those themes into organizing categories.

The Use of the Self

Using an approach called “Interpretive Phenomenological Analysis”, researcher-therapists Sleater and Scheiner, in their paper Impact of the Therapist’s “Use of Self” (2020), conducted semi-structured interviews with therapists of varying levels of experience. They analyzed the transcripts of those conversations, and developed a model based on three major factors which emerged from their work, as follows:

1. Connection: Using oneself to develop and cultivate a therapeutic attachment with each patient was seen as key. Therapists discussed how they made use of the self to foster connection. One way was self-disclosure. Three types of self-disclosure emerged: overt self-disclosure (sharing relevant personal information in the service of connecting), inadvertent self-disclosure (sharing something unintentionally, for example through one’s appearance or name indicating ethnicity), and unconscious self-disclosure (for example, having a strong emotional reaction to something a patient’s says).

Personality was a factor. Therapists noted how they balanced acting as they would in usual social settings with maintaining a therapeutic demeanor. The “blank slate” therapist can be off-putting, but an overly familiar therapist feels wrong, too. This balance between spontaneously “being yourself” and thoughtfully tailoring what one discloses is a key aspect of adjusting individual personality to circumstances. Being aware of one’s personality traits and tendencies to react (“countertransference”) is important for therapists to be good at doing.

For example, a therapist who has a tendency to be perfectionistic may be more or less aware of that. Considering how pushing patients might lead them to feel criticized rather than supported—even if it comes from a desire to help—is a good use of the self. A therapist who is aware of their own self-critical nature stays in touch with that, notices when it kicks up, and uses that awareness to temper their approach and better assist the patient with understanding his own experience.

Therapists identified that their unique view of life, their “worldview,” was an important part of connection. Being aware of their own beliefs and experiences, and how they had led them to find their own place in the world, was essential for locating themselves in relation to patients.

2. Awareness:How can a therapist make use of the self without being aware of what is happening in nuanced ways, while at the same time not getting caught up the details so much that they get bogged down?

Therapists noted how crucial it is to be aware of the unique nature of each therapeutic dyad, a factor grouped into “Relationality and Intersubjectivity”. This refers to both understanding the fine elements of the therapeutic interaction as well as making room for each person’s unique perspective—even when therapist and patient do not always agree on what things mean.

Therapist use of self was grounded in awareness of mutuality and vulnerability, an understanding that they were in it together with the patient. Without become vulnerable and being in it together, therapy grinds to a halt. Therapists learn to use the self in such a way as to become authentically involved while also maintaining boundaries. More experienced therapists were able to be more emotionally vulnerable with patients while still keeping within appropriate bounds, reporting less defensiveness as they had become more skillful and experienced practitioners.

Therapists used knowledge of attachment theory in their use of self. Being aware of different patients’ attachment styles, and how their own attachment styles meshed or clashed, was key. Being aware of one’s attachment allows the therapist to situate herself in relation to the patient.

Noticing, for example, maternal feelings coming up around a particular issue or at a specific time can allow the therapist to use that information to help enhance the therapy. Ignoring responses like this, or acting on them without reflection, can interfere with therapy, even lead to poor decisions and boundary violations.

Therapists noted how important it was to be aware of bodily experiences, especially feelings of anxiety. It’s easy to be up in one’s head, dissociated from the body. Being tuned in to the body, before, during and after sessions, gives important clues to what is happening with individual patients. Noticing bodily reactions is critical for understanding countertransference, as sensations are easily split off from thoughts about what is happening.

3. Wellness: In order for therapists effectively to use the self, they have to take care of the self. This factor has historically been downplayed or ignored. Nowadays, it is becoming clearer that self-care is a necessary part of dealing with any stressful work situation to avoid burnout, depression and moral injury. A key factor for therapist wellness was having expanded awareness in the form of a compassionate internal supervisor, keeping track of and enabling healthy decisions.

The research identified two levels of self-care: fundamental and supportive, respectively referring to supervision plus personal therapy as needed, along with physical self-care and work-life balance. Cultivating a self-compassionate attitude toward oneself allows one to learn from experience.

Further Considerations

Given the importance of the therapeutic alliance and common factors for different forms of therapy, understanding the best ways for therapists to use the self is essential for both training and practicing therapy.

The current research identifies and spells out three over-arching, and interrelated aspects of using oneself most effectively. Future research might look at how different factors correlate with treatment outcomes. Training programs can consider adding material to enhance therapist use of the self, especially around body awareness and performative skills, typically not addressed directly, which enhance use of the self.”

This work is important for therapists but is also informative for folks who deal with people regularly and want a framework for understanding how to use themselves to effectively connect.

Originally published in Psychology Today on January 26, 2020

References