Posted by: thealienist | November 4, 2014

Psychotherapy as a Game of Discovery

Of all the games we play, I think that psychotherapy is the most fun, and for many, one of the most valuable.  Many of the games we play are games of discovery though they may be so only on a trivial level.  We might try golf to see if we are any good at it or to see if we can control our frustration tolerance.  We may use the Ouija board to learn some deep, dark, mystical secrets.  We may play Truth or Dare to find out things about our friends.  But the most intense games of discovery are certain types of psychotherapy.  The reason that I like the game of psychotherapy is that both the therapist and the patient can learn important things about themselves.

Let’s start by considering the playing field.  It is usually the therapist’s office, but it can be just about anywhere.  The only requirement is that the therapist and the patient both agree that this will be the space where the rules apply.  The rules will differ between different types of therapists and different needs of patients.  The rules may also change over time as the therapist and the patient negotiate them.  This is a key part of the therapy — the rules change as the players need them to change.  Some basic rules are often very stable:  1)  There are appointment times; 2) Both therapist and patient are responsible for keeping appointments; 3) Notice needs to be given for most cases of missing appointments, 4) Content of therapy sessions is private information and will not be disclosed except under certain circumstances (imminent suicidality or homicidality, court order, patient’s formal request), etc.   In my clinic, these rules don’t change.  Other rules, however, are subject to negotiation.  For example, I usually offer the following rules:  1) The patient’s thoughts are important and not to be ignored; 2) The patient’s behaviors are important and not to be ignored; 3) The patient may say or do anything during a session (short of actual or imminent physical harm to self or me or any action that would be an ethical violation) without restriction or punishment; 4) The therapist and the patient are each responsible for their own thoughts, speech, and behaviors;  5) Both the therapist and patient are allowed (and expected) to note rule-breaking behavior; 6) The patient decides how to evaluate progress in the game; etc.  It seems to me that most of the work or psychotherapy is negotiating these rules.  Once some form of these rules are agreed upon, the therapy tends to go quickly, though in some therapies the rules need to be repeatedly renegotiated.

Once the rules are negotiated (and often while the rules are being negotiated), the patient sets the goals for therapy.  This is also negotiated, because sometimes patients select goals that cannot be achieved.  I have frequently had traumatized patients come to my clinic and ask me to “make [them] forget about [their] trauma.”  I must refuse this and open negotiations to see if there is some other goal I can help them with.  We can usually find some goal (such as helping to make traumatic memories less disruptive to their lives) that we can agree upon.

The actual game-play of psychotherapy is in some ways unusual.  First, both players are not equal.  One is considered the expert in the field; the other is considered the expert on himself.  Second, all players are allies.  There is no opponent.  All will win together, or all will lose together.  Conflict and feelings of opposition can be expected, but once identified they should not be permitted to continue.  If the rules need to be renegotiated — do it.  If the goals need to be clarified or renegotiated — do it.  If one player is asking another to do more than they can do emotionally, physically, ethically, or legally — discuss your limitations and negotiate a new plan.  In fact, most of the work of therapy is done in negotiating and enforcing the rules.

The psychotherapy game is played in a transitional space.  There are few externally imposed, necessary rules to follow.  Most of the rules are negotiable.  Most of the goals are personal preferences not physical or logical requirements. The criteria for failure or success are chosen from arbitrary possibilities, not imposed by necessity.  Within the playing field of the psychotherapy session, new thoughts and behaviors are tried on, tried out, and evaluated.  Modes of living that might be dangerous in the real world are sampled, practiced, and modeled to see if they might be more meaningful and satisfying.  Parts of oneself that have been ignored or hidden out of fear or shame are taken out, understood, tailored to new purposes, and tested.  In the therapy session, it is understood that these things are real only in therapy.  They are in the process of becoming objectively real.  In the process of play, the patient (with the help of his therapist) is deciding what will emerge from the field of therapy into the real world.  In psychotherapeutic play, the patient both discovers and creates himself.  As a therapist, I am priveledged and excited to play a part in the process.

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