The title of this blogpost was going to be Peer Support Versus Psychotherapy.
That’s because the tweet that prompted it basically said psychotherapy is a completely white supremacist practice that’s so deeply and intrinsically hierarchical (as in the doctor-patient asymmetry) that it can only harm anyone who receives it. Peer support, on the other hand, the tweet claimed, is a much older and far less hierarchical practice that constitutes a much better alternative.
Put another way, it argued that not only has peer support been around much longer than psychotherapy, but it’s better. Why? Well, because all psychotherapy is always and everywhere authoritarian and coercive, whereas peer support is egalitarian and liberating.
Ok so there are numerous levels of bullshit and ignorance in that tweet, each of which probably deserves a blogpost of its own (especially the white supremacist part, sheesh). What I decided to do is focus on one, the notion that talking to a friend is always and everywhere better than seeking out or consulting a current therapist.
That was when it occurred to me that the whole notion of opposing therapy to peer support was bullshit, even though I’m about to make a sharp contrast between the two.
So I changed the “versus” to an “and.” Then I was going to tweet what I’m about to say. However, as I started to put a couple of drafts together, I realized that they might work a lot better in narrative format.
What I want to do is point out at least one really important way in which psychotherapy differs from peer support, specifically with regard to a certain kind of expertise that therapists have and peers typically don’t.
Specifically, I wanted to talk about what therapists call the use of self in therapy. This is the way psychotherapists (at least ones like me, topic for another time) use their lived experience, in the moment, to help people better understand themselves. This can, in turn help folks find their own ways out of complex situations.
Peer Support
A lot of us have been in the following situation: a friend comes to us with a personal problem. They may or may not be in a distressed state.
Sometimes our job is to help them problem-solve and find solutions. But far more often than not, I think, our job as friends is just to sit there, listen, and provide emotional support.
But let’s say our friend comes to us with their troubles, says they don’t know what to do, and asks for our help figuring out what to do. What do we say?
Imagine a friend tells you they’re in a bind. They’re expected to show up at Aunt Edna’s for Thanksgiving. However, every time they go, she goes on and on about politics in a way they feel is frankly quite racist. Your friend has politely asked her to refrain from such discussions at family gatherings, but she completely ignores them.
In addition, Aunt Edna never stops — despite being asked repeatedly — making comments about people’s weight, your friend included. More often than not, it leaves your friend feeling ridiculed, ashamed, and embarrassed.
You tell your friend the answer is simple: just don’t go. They reply that it’s not that simple. You wonder why. They say that if they don’t go, then there’ll be hell to pay: they’ll never hear the end of it from Aunt Edna or the rest of their family for being such a bad family member by skipping out on Thanksgiving.
You say ok, that makes the decision a difficult, but still straightfoward one. Why subject yourself to that kind of abuse while a captive in someone’s home? If you don’t go, then at least you can deal with the subsequent fallout from the comfort and safety of your own home, on your own terms.
Heck, you might even get lucky enough never to be invited to Aunt Edna’s again.
As you’re saying this, you’re kind of pleased with yourself. You managed to come up with what seems like really sound and clever advice that your friend is bound to thank you for.
Then something totally unexpected happens. Your friend gets even more agitated, tears beginning to swell, telling you it’s not that simple. They accuse you of not just oversimplifying their situation, but not understanding them at all. Then they storm off.
You feel terrible. In addition, you’re left feeling bewildered and somewhat irritated with your friend for taking out their anger on you. Especially when you were only trying to help them!
Countertransference Analysis
All of us in such a situation base our response completely upon what our friend has told us. After all, what else is there?
The psychotherapist knows there’s something else. There’s an additional entirely separate knowledge base plus set of tools available to anyone willing to put in the time, training, and personal psychotherapy or psychoanalysis.
And that is the therapist’s own thoughts, feelings, and fantasies as the discussion takes place.
The technical name for the use of these tools in therapy is countertransference analysis. Countertransference, as I and like-minded therapists use the term, refers to the sum total of reactions that the therapist has to a patient at a particular time.
A much narrower view of countertransference, one that you’ll see cited in the literature a lot, is of the therapist’s specific reactions to the patient’s own transference (transference being the thoughts, feelings, and expectations that the patient brings into the therapy based on their relationships with significant others in the past).
There are times when that conceptual issue clinically matters more than others. Either way, what the therapist does differently than the peer or friend is listen as much to their own gut as they do to the person talking to them. I’ll use a hypothetical example to show how and why.
Let’s look at the same conversation taking place inside a therapy office instead of on the street or in your living room.
Psychotherapy
If someone describes such a dilemma to me in my office, I might also suggest some possible courses of action, but I’d keep the list brief. This is because of the unlikely but important possibility that there’s some simple course of action that might solve the dilemma.
Then I listen carefully to their response. Let’s say in this case the response is the same: that I’m not getting what an impossible situation they’re in, and that I’m being of no help to them whatsoever by trying to offer possible solutions.
And then I wait to see what I’m feeling. Specifically, what I’m feeling now that I wasn’t feeling before said response.
Possibility One: Constriction.
In this scenario, I’m aware of a sudden feeling of being caged in. I may or may not feel claustrophobic, or imagine ropes tying my hands. It feels like my patient is putting me in an impossible situation, where no matter what I offer by way of advice is going to be shot down by them.
I think to myself that this could be how my patient feels treated by her Aunt Edna and her family: constrained and coerced, without any good choices.
If I have enough corroborating data (e.g. from previous interactions, their history, dreams, or psychological testing) I formulate a hypothesis. Then I try it out.
I tell my patient it feels like that they’re not just telling me — but perhaps more importantly showing me — what it feels like to be in a completely impossible situation. With absolutely no clear exit signs over any number of available doors, all of which lead back to the same room. And then I listen again.
One possibility is that they may agree completely, relax into the couch, and go on to tell me a lot more about how boxed in they’ve always felt around their family. Or around someone else in their life. That discussion may or may not include a history of being bossed around and misunderstood by relatives and/or their family of origin.
It may or may not lead to an immediate solution. However, it’s named and brought into the light an important part of the problem that had, until now, been working in the background: the unwritten assumption that others get to make the rules and our job is to follow.
This not only suggests to all involved that the rules can be rewritten. It puts the patient in the driver’s seat with regard to what particular and concrete steps to take.
Possibility Two: Frustration.
Another possibility, as in the case with the peer, is that my patient might get angry with me. They might say that I’m just stating the obvious, that this (perhaps yet again) doesn’t help them whatsoever, and what the F do they pay me for anyway. Then I listen to my own feelings again.
Typically in these situations I’m starting to feel a little bit annoyed that some combination of I and/or what I have to offer is suddenly being devalued. I may also be aware of a walking-on-eggshell feeling, worried that whatever I say next is bound to anger them even more.
Once again, if I have enough data to support it, I formulate a hypothesis and then test it out.
By the way, if anyone ever tells you that psychoanalysis or psychotherapy isn’t empirical, tell them to look up the meaning of the word “empirical” and get back to me.
First, I ask my patient to bear with me for a moment. I say that what is most clear to me, right here and right now, is how frustrating their situation is. And that right behind that is how frustrated they are with me because what I’m saying isn’t helping.
Then I tell them I suspect something’s going on at a deeper level, something that may potentially suggest a way out of this dilemma. But that in order to determine that, I need to know the answer to a few questions.
Usually by this point my patient is curious and says sure.
Then I ask them if, growing up, they ever felt they had to walk on eggshells around a parent or other adult whose sudden and intense anger was hard to predict. Let’s say they say yes (this is sadly not uncommon).
I might then ask if they could ever stand up to this person when they had a disagreement; let’s say to have their feelings or views on a particular matter taken seriously, especially when it came to them. If they said yes before, they’re very likely to say no here.
I go on to ask them if they ever felt fully comfortable telling such an individual that they were angry with them. Again, the answer is likely to be no or not really.
I then suggest that what’s bothering my patient the most right now is of course, this situation. But that what’s uniquely uncomfortable about it is this bolus of anger they have in their belly that has nowhere to go, largely because they’re afraid it would either devastate their Aunt Edna or come back at them like a boomerang from their family.
I may or may not add my sense that they got painfully little training standing up to domineering individuals, to say nothing of outright bullies. In its place, a whole lot more training doing what others asked of them. And that this would piss anyone off.
And that while they in no way came in here planning to do this, their unconscious found a way to let out a little bit of that steam towards me. This, in turn, provided them at least a moment’s relief from the tremendous pressure building up inside them. (I may or may not share that it also provided me as valuable a clue as to what’s going on.)
I could also add that this pressure is probably painfully familiar to them each and every time they step inside Aunt Edna’s house.
Again, if everything aligns, this opens up new possibilities. My patient may have been so scared of their own anger — especially towards family members — that they effectively ignored it, never imagining themselves as anything but noncompliant, misbehaving, failing to live up to standards, or some other form of “bad.” And they may begin to wonder how this affected their self-image and self-esteem, often from the earliest of ages.
They might begin to question their relationship to their anger, including the possibility that they can use it to set limits, especially with people used to getting their way through exploding, shaming, or blaming.
If things don’t align, we go back to the drawing board. We explore the dilemma’s landscape some more to see what we’re missing or overlooking. Sometimes it’s something so obvious that it’s hidden in plain sight. Sometimes it’s something that takes time, trust, and hard work to discover.
Peers and Therapy
I have had countless conversations like these over the years, in a number of Aunt Edna situations. They happen in workplaces, romances, friendships, and marriages, as well as within families and extended families.
You may or may not have been in one yourself. You most certainly know or are connected to someone who has.
With more or less individual variation, what therapists are trained to do is first of all observe and take as total an inventory as they can of their own reactions and feelings. Then, instead of just expressing or acting them out, using them as data in the service of the therapeutic relationship.
As therapists, we don’t just give advice and we don’t just listen. We do a whole lot more; specifically, a whole lot more that takes years of training and practice, as well as our personal psychotherapy or psychoanalysis.
Few of us are blessed with peers with all the answers to all our problems. For the rest of us, there’s psychotherapy.
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