Elizabeth was a first-year college student who was finishing up a short period in psychotherapy subsequent to the breakup of a relationship with her boyfriend. In our final session, she expressed feeling good and looking forward to the future—but she also made a comment that caught me off guard. She said that she wished she knew how to be a “deep” person. Not knowing how to respond in the moment, I said something reassuring about being who she was, and that depth would take care of itself.

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Since that time, I have often thought about the concern she expressed and wondered if my response did her justice. What, exactly, had she meant by wanting to be a “deep” person, and had I, in effect, brushed it off?

Several years after working with Elizabeth, another situation emerged that appeared to be related. One of the students in my counseling lab was expressing confusion about a practice session with another student who had brought up an issue to talk about but had seemed unable to elaborate it in any meaningful way. “What do you do,” the student-counselor asked, “when the client can’t say anything more about their problem—when there’s just nothing more there?”

My response was immediate: “Oh, believe me, there’s always more there!” As an afterthought, I added, “You may never get to it, but there’s always more there!”

I was a little surprised by the emphatic certainty with which I uttered this comment, and I have thought about this, too, on several subsequent occasions. What made me so sure that there is “always more there”? It seemed that in the years since I had worked with Elizabeth, I had learned more about what “depth” is, and that I had learned it in a deeper way.

I’d worked with hundreds of patients since Elizabeth. I had seen case after case in which patients who had presented in a defensive or superficial manner in therapy had subsequently opened up to reveal poignant, sometimes moving, emotions underlying their problems. And on other occasions, I had seen patients who had persistently avoided opening up, but in ways that made clear why they could not afford to do so.

Ironically, as I have come to appreciate the meaning of depth, the field of psychotherapy has moved in the opposite direction. In some ways, the field has been a victim of its own success, as increasing demands for therapy and concerns about costs have led to the development of faster, more cost-effective, and more problem-focused approaches to treatment. These more structured approaches are often favored by third party payers and others concerned with the efficient use of resources. Unquestionably, these approaches can be more practical, more down-to-earth, and more immediately helpful to many patients with discrete and clearly defined problems; it might even be argued that they are more democratic and empowering, as they have removed much of the mystique that previously allowed some therapists to elevate themselves as shamanistic elites.

But I fear that the move we have witnessed in the clinical field toward more symptom-focused therapies also represents a retreat from the very real insights underlying the discoveries that are possible in psychotherapy. These insights include an appreciation of the complexity of the dynamics that underlie many forms of human suffering and the degree to which these dynamics sometimes involve co-optation of individuals by familial, social and institutional forces.

A few years ago, I discovered an example of the latter when I wrote a detailed critique of a videotaped therapy session conducted by Aaron Beck¹. Beck’s patient Mark was suffering from anxiety about his performance as a manager on his job. In the session, Beck used guided discovery to help Mark see that he suffers from “social anxiety,” that such anxiety is perfectly normal, and that it can be reduced by learning some simple techniques of self-acceptance and reassurance. A close review of the video, however, suggested that Beck’s focus on a pre-categorized symptom blinded him to some important underlying dynamics. The job in which Mark was experiencing so much anxiety was one in the clothing industry where he was caught in an inescapable conflict between his superiors, who were forcing him to set progressively lower piece-rates, and the workers, who were blaming him for the cuts in their pay. It seemed never to have occurred to Beck to ask Mark how he felt about the job itself. Instead, Beck repeatedly directed Mark’s attention away from the job and labeled his problem “social anxiety.” In doing so, Beck unwittingly aligned himself with Mark’s superiors and failed to explore his feelings about his role at work, the meaning and significance of these feelings, and what he might do about them.

Thus, while symptom-focused therapies can be genuinely empowering in some situations, cases like this suggest that they can also be disempowering if they fail to consider the personal histories and social forces that shape the symptoms that clients bring to the therapy. And more than this, they may leave the client alienated from his or her own internal experiences, values, and feelings—that is, from the underlying issues that led the client to seek psychotherapy in the first place.

The student-client who was unable to elaborate her problem in the counseling lab had not yet discovered some of the depth of her own internal life. Interestingly, I came to know this student quite well over the next few years as she learned more about herself. She worked in several stressful jobs, including doing manual labor and, later, human service work in a poorly governed agency that created more problems than it solved. The stress from these experiences led her to a time in therapy and a period of soul searching about her values and goals. Eventually, she decided to pursue a career in a health-related field with an emphasis on doing in-depth interview research. She had come to be a different person, and a deeper one, than the student I had originally known.

Returning now to my session with Elizabeth, I doubt that her wish to be “deep” indicated a need to reopen her treatment. But if I had it to do over again, I would ask her more about what she had meant: Who were some of the “deep” people she was thinking about? What kinds of traits suggested depth to her? Had she ever experienced any of these traits in herself? Perhaps these questions would have led nowhere. But then again, they might have touched her in some way and given her something to think about in the future.

After all, there’s always more there.  


1 https://psycheandsense.com/empiricism-and-psychotherapy/

File under: The Art of Psychotherapy, Musings and Reflections