Does Your Therapist Wonder Why You Said What You Said?

A recent article in a major journal suggests that therapists should be trained to constantly monitor how the relationship is faring and to intervene the moment things go awry (Westra and Di Bartolomeo, 2024). This has me scratching my head because I thought that’s what psychotherapy training was, is, and always should be.

The idea of taking the patient’s reaction to what the therapist says as a guide to keeping the therapy on track is at the heart of Bordin’s (1979) concept of the working alliance. Bordin suggests that, when things go off track, relationship repair profitably focuses on whether the dyad shares mutual goals, whether the tasks assigned to each person seem relevant to achieving those goals, and whether something is getting in the way of forming collaborative bonds between the two people.

The history of therapy scholarship has already gone far past the simple monitoring of whether the relationship is on-track or off-track as suggested in the recent article. Langs (1978) made the tracking of the patient’s responses the centerpiece of his “communicative approach” to therapy. He treated the patient’s response to the therapist as a metaphorical communication about what exactly was wrong with what the therapist said or did.

For example, a woman told her therapist that she shoplifts quite often and he expressed concern that an arrest would damage her life. She was reminded of a time when her father killed a litter of kittens when he was unaware that she wanted one of them as a pet. The therapist interpreted this story as a depiction of her experience of the admonishment to stop shoplifting. The therapist revisited the exchange, after supervision, and instead focused on what she got out of shoplifting psychologically. This example is from my chapter on this subject (Karson, 2018).

Langs’ and other psychoanalysts’ ideas about the meaning of patients’ reactions to therapists (called “derivatives”) have been appropriated (often without credit) by functional analytic psychotherapy (FAP). FAP therapists call these CRBs for clinically relevant behaviors. I would say that all patient behaviors are CRBs, but it requires an especially attuned, pattern-recognizing, and fallible therapist to appreciate that everything the patient says or does is a commentary on what the therapist has said or done.

The therapist should work to create a relationship in which the patient’s reactions to what the therapist says and does are expressed and attended to. That means implementing some form of the psychoanalytic technique of free association: saying whatever comes to mind, holding nothing back. It also means conditioning the patient to experience the therapist’s silence as welcoming rather than as withholding.

If the relationship isn’t comfortable with the therapist’s silence, then the therapist will say yet another thing before getting a chance to attend to the patient’s reaction to the previous statement or action. Indeed, every aspect of the therapeutic frame, from fee policies to confidentiality, is designed to facilitate the process by which the therapist can explore how the patient reacts unconsciously to each thing the therapist does.

Attending to feedback requires facility with metaphor. The stories and memories that patients are reminded of after therapists do or say something take the form of metaphor. This is mainly because metaphor is how we, the storytelling animal, think; indeed, words themselves are metaphors for conditions and actions.

Patients also use metaphors because people with less power, like patients, tend to need plausible deniability. Isaac Asimov, in his Guide to the Bible, said that’s the reason Jesus taught in parables: so he could say he was just telling stories when he was actually committing heresy. My favorite quote in the Bible (speaking as a therapy supervisor) is when Jesus tells a parable about bread and the disciples take him literally. He says, “How could you fail to perceive that I was not speaking about bread.”

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To me, after the therapist says or does something, whatever it was ought to be the most important stimulus in the therapy space. If what the therapist did has no effect on the patient, then that’s a big problem, because therapy depends on the therapist having an effect on the patient.

If, as is almost always the case, what the therapist said or did actually matters, then the patient, if given enough space, will respond to it in some way that depicts the patient’s experience of it. Good therapists want to know how the patient perceived their statement or action, and they want to explore with the patient any perceptions that run counter to the therapeutic agenda. This is what is meant by the idea that real therapy is immediate, not just a discussion of what happened elsewhere.