It was some time into practice before I understood how being a therapist contributes to one’s own growth. I found this assurance from my best mentors rather mysterious. Sure, I’m a better listener, but what did they really mean? From my vantage point now, it seems obvious, and it is more than being attuned. On the surface, it is about being able to hear stories of suffering and watch someone struggle, while not falling apart oneself or imposing one’s own experience on someone else. It’s intuitive that listening to hardship is emotional for both the teller and the hearer, but it is much more than that.
When we begin to understand emotion—where it originates, what it means, and the behaviors and feelings it pulls for in others—we get a deeper sense of what’s happening. The contemporary reality in which feelings arise and the past which contributes to intensity together give us a deeper sense of the meanings involved. Learning to allow oneself to be steeped in the experience of another while retaining a solid foot on one’s ground, not being pulled completely in, is where some of the challenge lives, and growth happens. To be able to think clearly, tolerate feelings, reflect on meaning, and return this to another, rather than reflexively join them, punish them, or impose one’s own feeling-driven interpretation, is a skill set difficult to articulate. But I see myself moving through the world very differently now. I am more attuned to the other, aware of my hypothesis about their experience, aware of the fragility of connection, the difficulties in earning this, retaining it, and offering space to refuse overtures and not take that personally.
Because we eschew the importance of feelings in many of our environments—feelings are for wimps, wusses, they are weak, don’t bother me with your feelings, showing feelings is shameful—we can move through our day blithely unaware of the firmament available to us. There is no joy without sadness, or peace without a willingness to wrestle with our own dark sides. We give up so much by falling prey to the misunderstanding that stoicism is a marker of strength, or that shame is something to be deeply buried and forgotten or avoided. Temporary circumstance can necessitate muting emotion for a time. We have to function in multiple environments after all. But those well versed in inviting feeling in become expert at navigating the ebb and flow of these vicissitudes, rather than being tossed about by them, helpless in the storm. This is part of what makes a good therapist, and part of what a good therapist is attempting to share.
In medicine, this looks like understanding more than just the miraculous decrease in maternal morbidity reflected by the altered population of our cemeteries where infant and young mother took up enormous space a hundred years ago. Monitors, medication, surgical expertise, all changed this tragic demographic. Although today, modern political priorities have pushed back some of the positive gains of maternal fetal obstetrical medicine. Mothers now die unnecessarily as a direct result of laws that fail to account for the nuances of obstetrical science. This is a topic for urgent advocacy and a concerted focus on the bigger picture. But I am also interested in how medical care unfolds in emergency.
We rarely think about the repercussions of our interactions with patients in medicine, as they are experiencing something happening to them, while we are experiencing taking care of them. Recognition of a patient’s fear and anxiety, acknowledging this with the reality—maybe we don’t get the outcome that we want here vs. “Is my baby going to be OK?” or “Am I going to die?”—has the potential to either mitigate or contribute to PTSD later. And this is part of what I mean when I talk about growth as a therapist in actively listening to the fears of others. There is an impact in this interaction and an impact in being deliberate with that knowledge.
In therapy, it is working to recognize and alter underlying expectations towards a healthier, happier way of being. So, what are the pieces that lead in this direction, for both of us, experiencing a very different journey together? There are many layers of validation.
There is validation, recognizing, and acknowledging how someone is feeling. By comparison, there is hypothesizing a feeling that proposes exploration of a deeper meaning, which, in the process, also validates. Simple validation goes a long way towards someone feeling seen. In addition to a direct reflection of what was expressed, an indication that associated feelings were also received is critical. One can additionally offer a summary of underlying themes, a deeper validation. These are essential skills for any therapist, and a minimum needed to begin effective work. On the other hand, sometimes validation is incorporated into a statement with a primary goal of unearthing pre-conscious material. This isn’t technically validation; rather, it folds information-seeking into a validating statement. For example, “You must be really disappointed in me; I didn’t give you the response you were looking for. Have you been disappointed like this in the past?” An invitation to feel disappointed in someone who cares, to talk about that, to feel safe in that, and to explore possible origins of expectation are some goals for which this statement paves the way. We must, of course, take care as clinicians to recognize our own disappointment in our actual failure when addressing the other’s upset in an unfulfilled expectation. Sometimes we do screw up (and badly!); it isn’t just the other’s past come roaring to the surface. And we must be forthright in acknowledging our very real shortcomings when they happen, in order to deserve ongoing trust. This is a relational experience missing in many childhoods, sometimes with profound consequences.
In order to understand this intervention, it is important to understand what is meant by the term preconscious. In a psychodynamic framework, it observes something that an individual might be on the cusp of seeing themselves, not unreachable, but not quite understood or realized. An example of this might be someone who has begun to feel doubtful about assumptions they have carried for a lifetime—my mother did that because she cared; I don’t deserve to be loved, everyone disappoints me, and I am powerless in relationship. The searching question begins to challenge some of these assumptions, while also asking for memories that might begin to generate connections towards a different underlying meaning. Shapiro in her articulation of this would refer to it as the adaptive information network to be actively processed in the trauma modality, eye movement desensitization and reprocessing or EMDR. A dynamic clinician understands this as Object Relations, but both are leaning into memory and how meaning was made from a child’s perspective. One way to conceptualize this is to think of it as a relationship blueprint with governing rules that guide us outside of our awareness. Wrapping narrative around experience gives us something to more deliberately explore—true or false, and if so, why? What is the evidence for or against? What are the deeper implications? One role that therapists take is to provide consistent support against some of the underlying so-called truths that we witness in action. In particular, we are interested in those which generate chronic, unnecessary suffering.
Feelings and emotions are potent memory markers, burning traumatic events into our minds for our later protection. Feelings of deep shame, humiliation, fear, especially experienced as a child, are carried with us, both within and outside of awareness. But what happens with those kinds of events before our brains even recognize emotions or have a name for feelings? Our preverbal experiences, according to psychodynamic theory and increasingly supported by the neurobiological sciences, turns out, are critical.
So, what does this mean for patients or clients? In addition to feeling heard, one begins to develop a deeper understanding for self, for one’s feelings, for where these originate, why they matter, and that they matter. Faced with an impossible dilemma in childhood, coping often comes in the form of dismissing feelings—as irrelevant, annoyances to be stuffed, indicators of weakness, to be embarrassed by, terrified of, or simply to be completely denied. And yet they are fundamentally our best protectors, a reflection of who we are, our values, and what makes life meaningful. We cannot typically squelch one without squelching them all. As noted above, we don’t actually have joy without allowing a full measure of sadness. This means we feel and face in the present moment, while understanding and incorporating, or putting to rest, painful contributions from the past. They are our guides through the thorny tangle of life, trustworthy, if we allow them space to be and to breathe. Poorly understood, dismissed, or denied, they drive behavior rather than guide us, and get us into trouble in our adult lives. So, feelings are a big part of what we are getting at as therapists, to name, to accept, to understand, to begin to recognize where they come from, what they are telling us, and, above all, to experience them. We earn trust by hearing our clients and patients, and together we learn peering through the thicket of the infringing past. There are technical terms for this, including pitfalls and barriers to understanding and growth, which must be recognized and effectively navigated in the therapeutic process. But these are subjects for another discussion. Physicians, therapists, patients, and clients, those both offering and seeking help, all of us have much to learn about feelings, how we regard and experience them, how they guide our relationships, our work, and our lives.
Maire Daugharty is an anesthesiologist.