Levels of Action in Long-Term Psychotherapy

In much of the popular literature, psychotherapy is criticized or defended without a recognition of the enormous variety of psychotherapy available and without an acknowledgement of the complex differences in different psychotherapists. So asking yourself whether psychotherapy is useful or effective or helpful or needed should start with the question of what it is you are trying to do and how extensively you want to go at it. After all, if you are taking piano lessons, it makes a world of difference if you are trying to impress your girlfriend, play sing-alongs or launch a concert career. Likewise, if you are considering psychotherapy, it makes a difference what your deepest goals are.

Psychotherapy is an activity not unlike tennis. There is a give and take. You build your capacity as you practice with someone who hits the ball back. How your partner responds to your volleys impacts the skills you build and the success you have. And, of course, who the other person is matters. If you are playing with an aggressive person who slams the ball back all the time, you will develop one set of capacities and if you are with someone who is interested in the quality of the exchange, it will be different.

Most psychotherapy takes place on three levels. The first level has to do with solving problems. It is what might be called an interpersonal level. Questions like, “Should I divorce my wife?” or “Why am I not getting promoted at work?” or “How can I improve my relationships with my children?” are the types of questions that happen at the interpersonal level. At this level, you want ideas, techniques, skills, and solutions. You may come up with them in the conversation or the therapist may have ideas.

The interpersonal level is what most people think of as psychotherapy.  It is discomfort that brings people in; it is the success of solutions upon which they value the therapy; and it is techniques that represent this type of psychotherapy most clearly. It is easily measurable. That is why we see “psychotherapy” as if it is the same as this one level of action.  This is the level on which most cognitive and behavioral types of therapy work. It is a  task-oriented, problem-solving perspective.

At a second level of psychotherapy, the therapist and the client are paying attention to what is happening within the mind of the client. Many people do not have the patience for this level of attention. In looking at the dynamic within our own minds, we can see where we might be creating obstacles to pursuing what we truly want. We might recognize that we argue with people who try to take care of us. We might see that we do not allow ourselves more success than we believe we deserve. As we become more aware of these patterns, we can make different choices in how we respond to the world and how we talk to ourselves in our own heads. We can forge new patterns, new habits, of being in the world and with the people we care about. This level of psychotherapy has to do with insight, choice, and aligning our lives with our deepest values or ideals. It brings into our consciousness, our awareness, the subtle ways that we feel like ourselves in the world. And it allows us to open our minds to different ways of being.

The third level of action in psychotherapy cannot be put into words. It cannot be brought into cognitive awareness. It can be observed and talked about, but it cannot be directly apprehended. This level of action is what makes people suspicious of psychotherapy in general because it sounds like hocus pocus. At this level, the action of psychotherapy arises from the experience of being together with someone committed to taking care of us. At the most nonverbal, metacognitive level, this experience translates into being valued, which ultimately grows into our valuing ourselves. People dismiss this meaning with arguments and avoidance because it is so intensely unfamiliar to feel valued for ourselves. We tell ourselves, yes but the therapist is doing it for money. Or that we are just a “case.” Or that the therapist has other selfish reasons for being with us. It is difficult to imagine that another person would have the intention of understanding who we are in a real way with no other agenda than the pleasure of understanding us.

That therapist could have been a lawyer or a banker. But she (or he of course) chose to pursue a career where she made herself available to relationships of healing. She does not have to see me. She can engage or not engage with me depending on her own choices. There is no way around it. This is a person who has decided to set aside her own concerns and try to understand me in a deep way so that I can understand myself fully and come to value myself. How can I understand a relationship where it is not an equal exchange of value or even an equal exchange of behavior? How can I allow myself just to receive care without having to give it back?

Three levels of action in psychotherapy. If you want to play “Row Row Row Your Boat,” on the piano, it won’t take that long. If you want to play some sing alongs, you might have to work a little longer. But if you want to go as far as you can in learning to play your instrument, you are in for long-term piano lessons. It’s fun and it’s satisfying, and we only have this one lifetime. We might as well do something interesting with it.


About norasblog

I am a psychotherapist with a private practice in downtown Chicago.
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