Therapy in Magnolia, Texas 77354
Decisions, Decisions
Choosing to attend therapy is, in itself, a difficult task. It could mean that one is absolutely fed up with their symptoms and wants them removed, or in some cases want their symptoms to work like they used to. Often it is at the request of others that someone is motivated to attend therapy. Further adding onto the difficulty in choosing to attend therapy or counseling as it may be called, selecting a therapist can be difficult. What type of therapist should I get? Then, considerations of price, modality, theoretical orientation, expertise, and specializations add onto the list of things to consider. Yet research suggests that it is not the type of therapy that is offered, but more about the common factors that beneficial therapy has, and namely the therapeutic alliance (Opland & Torrico, 2024; Stubbe, 2018). Now while common factors typically include empathy and congruence, touched on below, one consideration that some patients may find beneficial to consider would be the clinician’s orientation. For our purposes here, clinician orientation will be used interchangeably with clinician style.
Common therapist styles include directive and non-directive. Which is not to be confused with the categorization of theoretical orientations which can be labeled under directive and non-directive categories. The former includes styles such as CBT, DBT, and Solutions-Focused whereas the latter include person-centered and existential. Here, I aim to discuss more than a simple theoretical orientation, but a complex dynamic focused on clinician orientation to the patient. Orientation may be thought of as style of relating. So how does clinician orientation impact therapy? A simple question with a simple answer. It determines the degree of reactivated maturational development—or how much of a patients’ agency is promoted by the clinician’s involvement in the creation, management, and maintenance of alternate ways of being with and without a symptom. Let us explore some examples of both directive and nondirective clinicians.
Clinician Orientation and Limitations to Agency and Maturation
Directive Limitations
Let us begin with a directive dynamic. Key considerations may be what motivates their relational dynamic and how that relational dynamic creates, manages, and maintains alternate ways of being with and without symptoms. It is this writer’s assumption that a directive style is driven by a desire to control outcomes. The patient is viewed as at the end of their maturational development meaning that maturation is not the goal, but rather how to utilize strategies to get the most out of the level of maturation a patient is at when they present to therapy. For instance, a patient who presents therapy for anxiety with a directive therapist may be implored to keep a log, to implement breathing techniques, to argue against their thoughts, and to expose themselves to an anxiety inducing scenario to deaden their reactions. In this, the clinician assumes responsibility for the patient’s life standing in as someone who pretends to know that a patient can live a “happier” life by implementing prescribed actions. The prescription of actions often comes in the form of suggestion. Therefore, the directive therapist all but removes patient autonomy and treats the patient as a child whose judgment is not to be trusted. For the directive therapist a patient’s symptom becomes a design bug which can be controlled if the right input is provided. As the patient seeks treatment for the bug, they are provided with self-help tools to use outside of session. They are not so much treated as given a tool belt with tools. What is more curious is that these tools are in effect mass produced or justified by “replicable studies of efficacy” and determined by the clinician’s knowledge of what constitutes “commonly beneficial” to assist the patient achieve what is thought of as “normal.” Thus, as a patient presents with a symptom that does not dissolve under the weight of a hammer that is cognitive reframing or some such combination of techniques, the patient’s symptom is now beyond the field of correction. What then is the directive therapist to do besides tell the patient they now have to learn another strategy to make the first strategy work. However, additional questions remain such as: does the evidence these strategies work come from personal experience or from a statistical average that some patients may not fit neatly into? By way of rational reasoning, it may be assumed that a patient’s agency and maturation are limited by what the clinician has personally experienced or what the theory they ascribe to prescribes.
Non-Directive Limitations
In turning towards non-directive clinicians, we will begin by positing some theoretical doubt into the originating theory and follow up with speculating the motivations behind choosing non-direction and how a non-directive clinician creates, manages, and maintains alternative ways of being with and without symptoms in the patient. It is this writer’s assumption that a non-directive stance assumed by a clinician is motivated by permissiveness. A patient seeing a non-directive clinician finds themselves limited not by the clinician’s experience but by theirs alone. Carl Rogers pioneered the person-centered theory preaching three factors for patient growth: Empathy, Congruence, and Unconditional Positive Regard. For Roger’s and his followers, there is a key point in the theory which stands as supportive cornerstone and most detrimental crux of the theory suggesting: people are internally motivated toward achieving positive psychological functioning. I require no supportive evidence in proposing this is not true. I am confident the reader can search within themselves to see that this is not the case. Perhaps an alternative view is that people are motivated towards familiar discomforts if there is a guarantee of familiar comforts.
Returning now to analyzing how a non-directive clinician influences a patients ability to create, manage, and maintain alternative ways of being with and without symptoms let us consider a patient who presents to therapy for depression. While they are not given suggestions, or tools for how to “cope” with their symptoms, they are provided with the space to mature only as they wish. When articulating the experience of depression, the distress it provokes, and the impaired life they suffer, a non-directive clinician is likely to provide reflections of meaning, summarizations, and otherwise parroted re-presentations to the patient. While the patient is fortunately unburdened by a clinician’s suggestions and develop a sense of agency, they are unlikely to experience a development of maturation required to find their unique alternate ways of being with and without symptoms. Whereas the degree of reactivated development is limited by the clinician’s prior experience as to what works and doesn’t work with a directive clinician, the non-directive clinician’s patient is limited by their ability to tolerate distressing thoughts and affects. Thus, maturational development is unlikely to occur beyond a point where unfamiliar comforts are attained.
Psychodynamic Limitations and Prioritizing the Investigation of Unspoken Unknowns
Further, it is this writer’s understanding that a beneficial therapy places the utmost importance on increasing agency and providing opportunities to mature. Maybe it is best to suggest that psychodynamic clinicians are not likely to fall into directive orientations, nor non-directive, because they seem to straddle on the lines of both prescribing only the continued articulation of what is unconsidered, and remaining open to wherever speech will bring the patient. And it is because they are neither directive nor directionless that the patient’s agency and maturation are equally influenced. The only direction is to continue the expression of novel thoughts and explore the symbolic web of their identifications. Literature and experience dictate that agency and maturation are acquired, typically, via psychoanalytically influenced clinicians who prioritize language, discourse, and unspoken unknowns. It is doubtful that a psychodynamic clinician will prescribe tools of support, strategies to cope, or parroted re-presentations. Psychodynamic clinicians rely on a close listening of themselves and of the patient to identify what has not been said. Because it is the omission of detail, the repetition of themes, and what appears as a mistake in speech that provides the best outline for what is unaccepted, unfamiliar, and uncomfortable. But a follow up question by dissenters would be, “well why is speaking about unacceptable, unfamiliar, and uncomfortable topics and concerns most beneficial?” Because entertaining, playing with, and considering the unaccepted, the unfamiliar, and the taboo topics avoided in polite society is a demonstration of maturity. Especially so for the speaking beings we are.
Further, a psychodynamic clinician is typically willing to experience the discomfort that comes from a patient’s lived experience, their demands for results, a patient’s resistance to considering uncomfortable unknowns, and lastly to experience their own maturation identidem. Commonly, psychodynamic clinicians are in supervision for many years, because their orientation to the patient via language is determined by the degree to which they are willing to entertain unfamiliar topics alongside the patient. How this works in session varies by clinicians but consider the following. A patient who presents therapy for anxiety and depression is not likely to be provided with a worksheet or a strategy, nor are they permitted to stay within societies definition of polite topics of discussion. A psychodynamic clinician is likely to provoke the patient to speak on their identifications with anxiety and depression exhaustively to the point in which all conscious considerations are explored. At which point they turn towards an interpretation of what has been left unsaid. Here, the patient is now provided with opportunities to mature that would have not be capitalized on if left to strategies and empathic reflections. Simultaneously, while the patient is now considering alternative ways of being the patient’s agency is being increased because the patient is afforded the opportunities to decide the accuracy of the interpretation which prompts additional maturation. In this way, the patient’s treatment follows along through adversity towards Kantian enlightenment: “Enlightenment is [a person’s] emergency from [their] self-imposed immaturity.”
Before continuing, I permit dissenters to assert that this exposition is biased. They may go on to say such things that this is nothing more than prejudiced generalizations of clinician orientations of which I would agree. However, it does not subtract that a psychodynamic clinician practicing within the framework presupposing an unconscious largely ignored by popular psychology is familiar with the discomfort of unspoken unknowns and is therefore more apt towards embracing the patients distress that accompanies the utilization of free will and becoming more mature.
In conclusion, choosing to attend therapy is difficult but not as difficult as deciding what one wants from therapy. Is it normality, complacency, or an increased agency and an ability to experience discomfort with maturity?
