What Are You Supposed to Talk About in Therapy?

One of the questions I'm most frequently asked is, "What are you supposed to talk about in therapy?" It's not surprising that this question comes up with such frequency. After all, most doctors take the lead with their patients. They ask where it hurts, how it happened, when they noticed. They make a diagnosis and write a prescription.

With therapy, in contrast, the doctor follows the patient. The patient tells the doctor what he is feeling, and the doctor listens closely and tries to grasp his experience. He may make a diagnosis, but he won't write a prescription (unless he is a psychiatrist and wants to add medication). He tries to help the patient come to terms with his feelings. To name them. To think about them. And to act on his reflections.

So, what are you really supposed to talk about it therapy? Talk about anything you feel strongly about. Your boss, your boyfriend, your wife, your mother. The election, the war, health insurance, your taxes. A book, a poem, a movie, a painting. Especially about something that's gotten under your skin.

The key is to talk in a personal way. Discussing the nuances of military strategy can take you away from your troubling feelings. Discussing your sadness at the death of a friend, your anger at the poor treatment of the wounded vets, or your frustration with the politicization of the military conflict can bring deeply held feelings out into the open. The payoff in therapy comes from talking about your feelings. Talking about your ideas can be a defense.

At the end of the day, it doesn't matter what you talk about as long as you talk about how it makes you feel. Like the leaves of a tree, the things we talk about are connected. Follow them deep enough and you'll get to the root.

Your anger at the poor treatment of the wounded vets, for example, may remind you of your fury toward those who hurt animals. This may call to mind a painful memory from childhood in which you saw a pack of angry boys kill a cat. That may remind you of bitter fights between your parents in which you saw your mother being struck by your father. Suddenly, your feelings about the wounded vets have more meaning. You see why you feel as upset as you do.

Which is not to say that every feeling should be traced to its origin. Or that each feeling is rooted in some agonizing trauma. But it is to say that if something is really bothering you, there may be more at stake than you might think from the surface. Tracing the feeling inside can reveal these connections, make the feeling less confusing, and help you think about its significance. It won't take it away, but it will help you to deal with it. A good way to create the emotional space within which to feel a great deal more free.

Pain vs. Suffering: A World of Difference

There's a comment in an essay by Sylvia Boorstein that has proven extremely suggestive for me. Boorstein is a therapist, a meditation teacher, and a yoga instructor. Her essay appears in a book edited by Stephen Cope entitled Will Yoga & Meditation Really Change My Life? "I was consoled by the idea of the end of suffering," she writes playfully,

long before I had any ability to calm or focus my attention. I remember the chagrin I felt when, after some significant period of practice, I realized that I had confused the promise of the end of suffering with the end of pain, which was what I really had hoped would happen. I was embarrassed not to have figured out something so obvious -- really, what could I have been thinking? (17)

Boorstein doesn't explain the difference between suffering and pain, but it's clear that the distinction is powerful for her. This difference seems to come from the The Four Noble Truths, but I leave it to those who know Buddhism to say for sure.

Whatever its origin, I find this distinction very useful. It suggests that there are feelings that cannot be avoided that arise as the result of the most human experience. The death of a child. The collapse of a marriage. Violation of one's body. Rejection by a parent. These are a few of the commonplace traumas that define what it means to live in this world, to be subject to change, to be a victim of chance. These are a few of the traumas that cause pain.

The difference Boorstein points to implicitly suggests that how we manage our pain determines whether we suffer. If we sit with our pain and don't try to block it, we have a chance to experience it, understand it, and act on it. We may not be happy about it, but we learn to accept it. And with this acceptance comes insight and wisdom.

If, on the other hand, we try to avoid pain, this invariably leads us to suffer. Drinking, doing drugs, abusing sex, binging and purging. Or any of the myriad other ways we numb ourselves. All these attempts to avoid pain make things worse. First by bringing harm to ourselves and often others. Second by leaving our pain unattended. Rather than gaining wisdom by dealing with our pain, we add suffering to the mix by trying to avoid it.

This is the state that most of us are in when we finally decide that we're ready for therapy. We know we are suffering. And we know we're in pain. Even if we don't know the difference between them.

The work of psychotherapy is to bring an end to suffering by helping us to deal with our underlying pain so we no longer have to anesthetize ourselves. This work requires us to turn our gaze inside, to notice how we feel, and to reflect on our feelings. Though challenging, it allows us to get to know ourselves so we don't live in constant fear of who we are. It doesn't eliminate the pain that comes with life but it does eliminate the suffering we add to it.

Maybe it's not the happiness we hoped for, but it's light years away from the place where we started. And there's nothing like distance to give us perspective.

The Pain of Life and the Life of Pain

Every once in a while I have the following discussion:

Patient: All I'm asking is that you take the pain away.
Me: I wish I could do that.
Patient: What does that mean?
Me: As far as I can tell, pain is part of life.
Patient: So what am I doing here?
Me: Learning to manage it. . . .
Patient: I hoped you'd get rid of it.
Me: You wanted a cure.
Patient: That's what doctors do -- they make it go away!

At these moments I find I'm the bearer of bad news. Pain is part of life, and there's no way around it. The best we can do is learn how to manage it. That's the only way to stay healthy despite it.

All the same, it's second nature to try to avoid it. And it's amazing how clever we can be when it comes to it. We abuse drugs, we abuse alcohol, we abuse sex, we overwork, we under eat, we overeat, we overexercise, we oversleep, we pull our hair, we pick our skin, we obsess, we check the locks, we count words, we get into fights, we cut ourselves, we kill ourselves -- just to find a way around feeling the pain.

Unfortunately, these strategies tend not to work. Or at least not to work on a permanent basis. Otherwise, why would we ever give them up?

Often our strategies fall apart in a crisis. We get sick. We get fired. Our relationship crumbles. That's when we're forced to take a look at ourselves. It's when they're overloaded that our defenses tend to crack.

And that's when those old, painful feelings leak out. And what a toxic stream that looks to be! Rage toward a father who had an affair. Fury toward a mother who demanded perfection. Helplessness before an uncle who sexually abused us. Humiliation at the hand of a sadistic older brother. They are old. They are raw. They are untouched by time. Unlike a good wine, they don't mellow with age.

Which is why it's important to let these feelings see light. To sit with them. To get to know them. To think about why they're there. To bring the wisdom of experience to bear on their meaning. To make sure they don't secretly distort our perception.

That's what it means to deal skillfully with our pain. Therapy can't get rid of it but it can help us to manage it. So we finally have a chance to move out of the past. So we finally have a chance to move into the present.