Synopsis: Many people have no idea how or why psychotherapy works. A well-known psychotherapist describes what therapists are thinking while the patient is talking and how these thoughts guide treatment.

Host: Nancy Benson. Guest: Dr. Drew Permut, Clinical Professor of Psychology, George Washington University and author, Inside Your Therapist’s Mind: How a Psychotherapist Thinks and Why It Works

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What Your Therapist is Thinking

Nancy Benson: Most people may figure they know how psychotherapy works. We’ve all seen TV shows and movies where somebody’s in therapy. But everything you know may be wrong.

Drew Permut: People’s ideas about therapy, unless they’ve been in therapy themselves, are often kind of cartoonish. It’s kind of like the New Yorker cartoon of the guy lying on the couch and the analyst scribbling in his notes. It’s mostly nothing like that.

Benson: Dr. Drew Permut is Clinical Professor of Psychology at George Washington University. He says that cartoons, TV shows and movies miss the most important part of a psychotherapy session — what the therapist is thinking about while the patient is talking. That’s why he calls his new book, Inside Your Therapist’s Mind: How a psychotherapist thinks and why it works.

Permut: The therapist is not just listening; the therapist is using all of his or her training to attune to the patient and actually join in their subjective world. Over time, and if you’ve really worked at this, you can feel what the patient feels, which is often not pleasant. You’re going to feel shame, you’ll feel anger, you’ll feel all kinds of intense feelings. It’s the only way you can know what’s really going on. The other part of the training is to be able to keep at least a piece of yourself apart so you can actually observe that as it’s going on.

Benson: So, Permut says during a therapy session the therapist is analyzing not only what the person on the couch is saying, but also their own reaction to it.

Permut: There are times when I will be talking to somebody and they’ll be talking kind of matter of factly about something, and I feel deeply depressed. Okay, is there something going on? Am I dealing with something? But, if I can be reasonably certain that it’s not about me, and that’s part of learning to be honest with yourself, then I can start to say, okay, I think what’s happening here is this person is repressing how depressed they feel, and that’s why their having so much trouble. That gives you a tremendous insight into not only what the other issues are, but how they’re defending themselves by not allowing themselves to feel the feeling.

Benson: So, rather than pushing away things that pop into their minds, therapists encourage them. Permut says it’s amazing what the unconscious mind can tell us.

Permut: Stray thoughts [like] a song will come into your head, [or] a phrase will bump around in your mind. It doesn’t mean that you’re distractible. Often those things are clues to something else that’s going on. You’ll start hearing a song, and then you’ll say the name of the song, or some of the words in the song will be like a caption to something that’s going on with the person. That’s straight out of the unconscious. There’s no way you can manufacture that. You’ll meet somebody that says, ‘Oh you’re a psychologist. Does that mean your reading my mind?’ It’s actually more often I’m reading my mind. That I am watching the other person, but I’m paying a lot of attention to what I’m thinking.

Benson: So, does that qualify as intuition? Permut says yes, but it’s trained and refined.

Permut: Somebody without intuition, without a good intuitive sense, could not go into the field. I don’t know if that can be taught, but it can be refined. You have to be good with people and you have to notice nuances, but you have to learn how to dig into it.

Benson: Permut will eventually ask patients about their childhood. But many of them are resistant. Often patients wonder what life as a kid has to do with their current problems. But Permut says we’re built on our past. Maybe someone is a chronic procrastinator because their parents were extremely critical growing up. But successful therapy requires the patient to eventually spill those past secrets that they’ve told no one else.

Permut: They can do that because they see that you have been respectful, that you have taken your time; you’re not rushing them, you’re not forcing them to talk about something that they’re uncomfortable with. You know what those things are or you can sense what they are, and you speak a language that is meaningful to them. This may be the only way that they can let you know this thing. After all, if somebody doesn’t want to talk about it, it means that it’s terribly disturbing. You’re going to go in and force them to talk about it? It’s not going to happen.

Benson: But that doesn’t mean therapists just tread water in the meantime. They have to earn a patient’s trust. So, sometimes a therapy session may sound like anything but.

Permut: If you’re going to work with men and you know sports, well, I mean there’s a million ways to make sports analogies to issues in life, or military history, or literature, or art, or music — just to be a real person; you have to be connected to the world. And from the outside, sometimes somebody looking in would say, ‘What on earth are they talking about?’ This TV show or they’re talking about how you like the way Dustin Pedroia makes the double play. What are they doing here? Sometimes it’s extremely important, because you’re talking between the lines. You’re not only making contact and developing rapport, but there are meta messages, as we would say.

Benson: Now, to do all of this, therapists have to know their own minds really well. They need to know when an intrusive thought is their own, and not coming from the patient. That’s why Permut believes every good therapist should go through therapy himself.

Permut: It’s impossible to have the deep kind of awareness that’s necessary to separate out your own foibles in doing such very, very emotional work. When you’re sitting with patients they stir up all kinds of things. It’s not just a matter of being disciplined. You have to know what’s being stirred up in you, and you have to know what your vulnerabilities are. If you see enough people, you’re going to see people who remind you of your mother or your father or your sister or your brother. Things are going to be stirred up for you and it’s going present blind spots. If you haven’t been thoroughly analyzed, you’re going to miss it and it’s going to distort your treatment.

Benson: That’s not really a danger if you’re seeing a psychiatrist. But Permut says that’s not necessarily a good thing. A couple of generations ago, psychologists and psychiatrists both used psychotherapy for most of their patients.

Permut: Psychiatrists, clinical psychologists and clinical social workers, basically we’re all trained together and we each had our specialty areas — psychcologistic testing — social workers did family work and psychiatry took medication. But 90% of what we did was the same, so we were all taught to think deeply and to look at underlying dynamics. It was very exciting.

Benson: But that’s changed with the advent of psychoactive drugs, which psychiatrists can prescribe, but psychologists can’t in most states.

Permut: In the 70s and 80s, psychiatry rebranded itself as brain doctors and they became more interested in talking about medication and pinpointing the psychopharmacology of the symptoms and disorders. It took them, I think, in a disastrously wrong direction. The majority of psychiatrists now are biologists; they are psycho-pharmacologists. They barely know the patient. They see six patients in an hour and there’s only a dozen medications that they use. It’s very mechanical. It’s a field that’s lost its soul.

Benson: Permut says it’s true that some patients need medication. But for many patients, improving life may take psychotherapy as well. Therapists aim to help patients take control of their life and problems rather than simply dispensing drugs or advice. So, don’t be surprised when your therapist answers a question with another question. You can find out more about the book, inside your therapist’s mind, at Our production directors are Sean Waldron and Nick Hofstra. I’m Nancy Benson.

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