What Does a Therapist Do, Exactly?

I am always amused with people’s reaction when they find out that I am a psychoanalytic psychologist. One of the most common reactions that I receive is, "So, are you reading my mind?" To which I typically reply in jest, "Don’t worry; Voldemort and I didn't train at Hogwarts together."

Laughing aside, a real confusion takes place when I try to explain to them what a therapist actually does. Maybe they expect something pragmatic, or perhaps it’s my inability to articulate what I do in not-so-philosophical terms, but people often look puzzled, as though they would never be able to understand how therapy works and what the therapist’s role is.

So, I decided to put together a description of what a psychoanalytic psychotherapist does. This is not, however, a list of practical duties and responsibilities, as one would normally find. Psychotherapists work with the whole spectrum of the human experience, and it would be quite difficult to reduce it to mere pragmatism. Hence, I will approach this from an emotional perspective, attempting to name some of the experiences that happen in the powerful encounter of two people who bravely venture into exploring the complexities of the mind.

So, what does a therapist do, exactly?

– Tolerating: the therapist needs to be able to tolerate uncertainty, to bear the pain and confusion of not knowing rather than imposing ready-made or omnipotent certainties upon ambiguous situations or emotional challenges. This is what the psychoanalyst Bion called "Negative Capability." It takes a lot of experience and inner fortitude to be able to withstand the anxieties that the patient will bring, and to stay engaged with conflicting feelings without wishing to resolve them in a magical way. Negative capability serves the purpose of helping the patient feel they can bring out their worst and that the therapist won’t break down or react in a unthoughtful way. It can also help patients tolerate their own uncertainties and frustrations.

– Not knowing: although the patient may think that the therapist is omniscient and "knows it all," the therapist works from an unassuming and not-knowing stance. Nothing is taken from granted, everything is open for understanding and interpretation. The patient may wish for an instant answer or a solution to their suffering, but the therapist is there to help bring out the truth from within the person, rather than imposing his own onto the patient. She is there to promote insights that will come from within.

– No memory, no desire: the therapist is there to take in what the patient communicates with no memory and no desire, that is, with no preconceptions or prejudices and with no personal agenda. This promotes a space where the patient is free to say whatever comes to their mind, as the therapist is positioned in an open way, to receive what the patient is trying to communicate. This involves maintaining a thinking position, refraining from reacting to what the patient is bringing in order to help them understand how they are behaving and what kind of response they are inviting.

– Respecting autonomy: the role of the therapist involves championing the patient’s autonomy. A psychoanalytic therapist will rarely give advice or personal opinion, because the patient is the operator of their own life, but he/she will need to develop ownership over their experiences in life. The therapist is there to help the patient make sense of such experiences, to understand implications and motives and to help bearing the feelings with the patient.

– Container: the therapist has to be open to receive the patient’s most troubling projections and feelings. Being able to receive and accept the patient’s feelings is one part of the container function. The second part is to be able to help the patient make sense of their troubling experiences, to "digest" what they are communicating and to give back an understanding that can help the patient to give meaning to their experience.

– Formulating: the psychotherapist can help the patient put a name to feelings that had no name, that were experienced as dreadful or bizarre but were too difficult to be formulated into words. The therapist can help the patient to develop their own language to describe their experiences.

– Avatar: no matter how benevolent and helpful the therapist wishes or tries to be, ultimately she is on the receiving end of what the patient will make her out to be. And, if necessary, the therapist will need to bear to be seen as cruel, distant, dismissive or in whatever "just like father/mother/spouse/etc" position they may be put, in order to help the patient to understand and live through the conflicting relationships they carry within themselves.

– Emergence and integration: the psychoanalytic therapist is there to promote the emergence of what is unconscious to the patient, so symptoms and destructive patterns can lose their manifesting functions, giving way to understanding and self-awareness. The therapist is also responsible for helping the patient integrate the healthier and the more destructive parts of him/herself, so the patient can become less defended against these conflicting parts of their mind.

– Reality checking: the psychoanalytic therapist should be in a position to help the patient face a difficult reality they may be trying to avoid, be it within themselves or externally. The therapist should not shy away from the truth, even when it’s too painful, promoting reality checking and then helping the patient bear the resulting feelings. A lot of people come to therapy with an unconscious wish to resolve their problems without having to face reality. Some wish for a magical advice, others for a quick fix. In this sense, therapy can be a reality check in itself, as it can be a painful and lengthy process.

– Actions into thinking: the therapist is there to help patients turn acting-out into think-before-you-act. Therapy provides a space for exploration and thinking, in a sometimes painfully free way. But actions can sometimes be an evacuation for undigested experiences, and the therapist is there to help the patient develop a sort of internal buffer, a thinking space that will allow them to give meaning to the urging impulse to act-out.

This is not an exhaustive list. Nor is it an ideal of a therapist. Therapy is a process, an experience between two persons who work together to understand the most inner feelings, conflicts, difficulties and ways of behaving. And as every human experience, it’s filled with nuances and variations, the kinds that make life interesting and beautiful.