Many people wonder what goes on in a therapist's head during a session or what they are doing.
We listen, of course, but there's a whole lot more going on. All those years of education and training shape the thought process before, during, and after a session.
There are three general processes involved in helping people achieve meaningful change: approach and conceptualization, treatment planning, and treatment.
Approach and conceptualization involves having a general theory for understanding people and seeing how it makes sense for this individual. If you haven't taken a psychology course, you might never have thought about the questions, "What motivates people's behavior?" and "Why and how do people change?" Take a minute. Think about it. How have you changed?
Over the history of psychology there have been different movements that have inspired different approaches to answering these questions. Freud and the old school analytics talk about unconscious forces and our early life experiences shape our behavior. Then came the behaviorists saying that our thoughts and behaviors are based on consequences such as punishments or rewards or that it is based on learned associations. For example, people go to work because they get a paycheck (a reward or reinforcement) and they also have positive experiences (or at least enough positive experiences) that they learn that it isn't terrible (and maybe pretty good sometimes), so they go back.
Then about thirty years ago our experiences began to be seen as a function of the interactions of thoughts, behaviors, and emotions, within ourselves and in interaction with other people. For example, we have the thought that we can handle rejection, so we pursue relationships, and feel curious and adventurous. Even more recently, values-centered perspectives that integrate mindfulness have become popular. For example, if you value relationships, you may pay more attention during time with loved ones rather than fretting about the past or future, freeing you of having to think about future fears of rejection, improving your mood and quality of life.
Conceptualization involves mapping the approach to the individual and their current struggle, allowing the theory to help guide you to understand better the broader themes and connections in a person's life. For example, if I am using a values-based approach, I might explore (as I often do) what the person values and to whether they are able to live in a way consistent with those values, or a way that furthers their values. Areas of conflict, where people are feeling disconnected from their values then provides a lens for understanding current stress. (This is a significant oversimplification, but that's the general idea).
Then we use the conceptualization to guide the plan for treatment. So if you say it is a values conflict causing a problem for a person with symptoms of depression, you're not going to help them build coping skills, you're going to help them explore different ways to live in ways that is more consistent with their values. It should all generally line up. It should also be a plan that science agrees with. I'm not a fan of doing things just because I think they're good ideas or because they are warm and fuzzy; I do things because I have good reason to believe they will help. How do I know? Science. Researchers have spent generations comparing different approaches and different treatments, and seeing what is ultimately most beneficial.
Then you do the thing where you sit in the room with the person, and the treatment magic happens. You have a general idea or roadmap for treatment with specific techniques, again consistent with your theory and conceptualization, but you always have to bend and flex to where the client is at that moment and how s/he responds to each step you take on that map, making constant adjustments. After each session we have more information to enrich or adjust our work for the next time. It is not a journey of giving a solution but of guiding the person to where they might find the answers themselves, to where they may ultimately find peace.
It's a really exciting process, and for the most part, clients don't have to know about any of it. I prefer they not worry about, but leave that to me. I prefer my clients to just be themselves, that that is how they can make the most out of their therapy experience. When they are themselves, I can more clearly see their wonderful personalities and quirks and strengths, and then I can help them the best that I can, in turn.