Talking to a Friend Isn't the Same as Therapy
Guardian journalist Zoe Williams has known integrative psychotherapist Julia Bueno since they were teenagers.
They have never before spoken about Julia's profession - how it works, why she does it, and whether Zoe is sceptical about the whole process. Welldoing put them together for a truth-telling session.
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ZOE: My prejudice about therapy is that it's every day, it really gets into your life, it goes on for eight years, the therapist doesn't say very much and you talk yourself into an answer.
JULIA: Therapy isn't like that. You are thinking about 'old school' psychoanalytic therapy, exaggerated by the arts and literature who rightly love Freud, and (maybe less these days) Woody Allen. Classic psychoanalysis, with the intensity you describe, has been dying out for a number of years. It's not bought up by the NHS nor the bulk of clients seeking psychological help.
Psychoanalysis may be appropriate for somebody who is very distressed and needs a lot of 'psychic holding'. It's a particular type of therapy with a discrete set of ideas that guide the therapist. I don't know if psychoanalysts have full private practices working at this intensity, as I don't know many psychoanalysts. I doubt it. I also think that for many clients, therapists can achieve similar therapeutic goals with a different way of working.
So for example, integrative psychotherapy, which is what I do, and what increasing numbers of therapists train to do. We meet with clients once weekly, probably over a matter of weeks or months rather than years. We wouldn't want therapy to become the focus of a client's life. I certainly don't hold back, I may be quite challenging, I'm not a 'blank screen' that an analyst aims to be, as this stance rests upon their theory to work. It's not crucial to the way I work.
But of course, how I work as an integrative therapist is different from the next integrative therapist, and the next.
When you say 'integrative', what are you integrating?
I was trained to assess - intellectually and clinically - more than one model of thinking about the human condition - how we develop, how we may suffer and how we may go on to heal from this suffering. I liked some ideas more than others, such as those of Freud, Klein, Jung and Bowlby - those pioneers of concern into our very early relationships that then serve as a blueprint for later relating. I also thought about humanistic thinkers such as Carl Rogers and Fritz Perls. More recently, I've trained in CBT, mindfulness and self-compassion work. So, I integrate lots - I won't ever stop as I won't ever stop learning - either formally, or from my clients or life.
The sum of all of this thinking enables me to hold in mind a set of 'rules' against which I can organise my thinking about my client's distress, and indeed how to soothe and resource him or her. These 'rules' are bendy though - they have to be as us human beings are so very different in our similarity.
I'd also describe myself as integrating various ways of working in the room. I may set homework, I may work with creative writing, I may get my client to talk to an empty chair, I have even gone for a walk with a client. I may be completely silent. Integration, I think, allows me to adapt appropriately to each client's needs. I can't imagine working clinically looking through one theoretical lens alone.
So who, generally, would come to see you as an integrative therapist?
People who make contact because I integrate tend to be those who have had previous therapy. People often tell me that CBT helped for a couple of months, but then they found themselves back where they started. This makes sense to me as we can't think our way out of tricky feelings – CBT doesn't pay enough attention to the troublesome feelings. Working through these feelings, beneath the thoughts, is an important part of the work.
Some have come to me in the wake of an analytic approach having found the silence from the therapist unhelpful or at worst quite punishing. I've also heard people describe a real frustration that they weren't offered 'here and now' tools, such as anxiety management. I advertise the fact I don't sit in silence.
What's your typical first contact?
People often present at a point of crisis, or at least at a tipping point when a pattern of behaviours repeats enough to be affecting the quality of someone's life – whether it's drinking too much or putting up with a crappy relationship. I may get an email late at night when something has happened to kick start 'action' - a row with a partner, or a big dip in mood or an anxiety spike. It can even be quite soothing to make the first contact. Occasionally people come prophylactically. I'm working with someone, for example, who knows that a lot of shit is about to hit the fan and wants to prepare herself emotionally.
People present with all kinds of troubles, but if I had to pluck a golden thread through those I hear about most (anxiety and depression), it will relate to a very poor self-relationship. Beneath the anxious thoughts, or depression or the pain of the past, much of the psychological work I do involves looking at how harsh we can be with ourselves, how we lack self-compassion and self-love.
It might go back into infancy, it may go back into adolescence, or it may go back to earlier adulthood. Some thing, or constellation of things, happened that shook your belief and love in yourself – a sense of 'I'm ok' in the world. It is always with good reason we constructed a dodgy sense of self, and this needs to be accepted and respected too.
And how long would it take to reach a resolution?
This depends – on the person, the problem, the client's commitment to the work, to how our relationship unfolds and, of course, finances. I'm still working with someone after five years, but I might work with someone for three months. I'm not a fan of six week contracts, although I think good talking therapy can be effective in the very short-term.
Research shows that whatever type of therapy you do, what matters hugely in 'reaching a resolution' is the quality of the relationship between the therapist and client. If it is good enough – trusting, loving, caring, respecting, this is healing in itself. It may even be a very valuable reparative experience for many people. But while the quality of the relationship is paramount, no therapist wants to foster dependence. The whole point of therapy is to finish the therapy. Or at least, that's how I see it.
And where do you stand on anti-depressants?
On the fence. Some clients approach precisely because they want to avoid anti-depressants. Either because they fear them or disagree with their oft-described 'numbing' effect, or because they tried them in the past and they didn't work. Therapy may well work without them. But I also work with people who are thinking about taking them and we work towards that. I've witnessed anti-depressants be very helpful and we have been able to change gear in the work as a result.
Sometimes I work with people who are already on anti-depressants, who weren't ready to see me or even make contact until they'd started taking them. This makes sense to me, because sometimes when you are deeply depressed or distressed you don't even want to brush your teeth or get out of bed.
I think they are most probably placebo, but placebo works for a lot of people – we know how very powerful placebo is. Even when we know it's placebo, that can help. If someone tells me they feel better after their third pill, then so be it.
What's the spectrum of problems that you see?
My private practice is self-selecting. Potential clients are therefore resourceful enough to research and decide upon me from their internet search, but also, if they're going to be paying £50-60 a week, they are likely to be in employment. So I tend to see unhappy people functioning 'ok' in the world. They might be really, really unhappy. They might be entertaining suicidal thoughts and may have a mental health diagnosis. But they're still managing to hold down a job and pay the bills, get dressed, go to work.
I think it's fair to say that those in my consulting room are of a different profile from those presenting at mental health teams or NHS services. When I worked in the NHS this was certainly the case. I saw many many clients finding daily life a great struggle.
What is the trajectory of therapy for a client? Does it differ for each?
Some people arrive with a problem, and then when they go a bit deeper into it with me, they revisit painful places that they haven't thought about. They may then connect up a painful past with a distress in the present. So it may be that they feel a bit worse because the psychic structures that held them together wobble.
Does it ever not work?
Of course. I know I've done a bad job along the way – but sometimes I won't know as clients may be too polite (or furious) to tell me. I can think of clients who find therapy a very difficult process where they struggle to connect with feelings – therapy demands that of us. I can think of somebody I saw who had finished a relationship and came to see me surprised by the strength of his sadness - it was the first time he had ever felt so vulnerable in adulthood. Yet he couldn't connect up with his sad feelings at all. He felt better over a matter of weeks, but I think that was largely due to the natural course of grief rather than the therapy. I don't think he really needed therapy. I did discuss this, I should add!
I also meet people who find therapy too difficult or depressing and want to stop. Some are threatened by how exposing it can feel - it demands an intimate relationship with me. And if you can't do it in the world, you're likely to find it very difficult with a therapist. I think that the therapeutic relationship will always somehow, cleverly, magically, reflect back what is going on in the world out there.
Do people who go to therapy tend to be quite searching, quite reflective people?
I think they tend to be. Therapy is 'work'. It isn't a psychological intervention that is delivered. Sometimes people misunderstand that. They may expect me to fix them, or deliver an aphorism that solves the issue. Sometimes I'm pushed quite hard to advise, but that's not my job. I have to let people make decisions – bad or good – with a greater consciousness, and then allow them to integrate their experience of doing so.
So given that, you will be enabled in this process if you have some measure of psychological insight and ability to reflect upon yourself. Therapy demands you to be able and willing to consciously pause, assess what's going on inside of your mind and body, and then learn to respond differently to how you were. I don't know if that is intelligence – a lack of psychological insight can be the mark a highly intelligent narcissist.
I think for therapy to be effective, you have to be up for work. Someone once used the midwife analogy with me and I like that. I can guide you when to breathe, when to stop, when to start, when to move position. But only you can push the baby out. You're giving birth to your new self.
And do you have to be in therapy yourself?
Speaking for my own training, I had to be in therapy for the five years. Once qualified, it's optional. I personally think it shouldn't be, so I've kept it up. But every therapist, however experienced, has to be in supervision, which is where you take your clinical work to a senior therapist of similar theoretical background. The supervisor will help you with difficulties, and it might be that in talking this through, you discover issues best dealt with in therapy – your personal issues that may intrude in the work.
How do you think you're different to how you were before you became a therapist?
I have a vastly improved relationship with myself, I no longer think I'm worthless. And that has taken a lot of very painful working through of early relationships and experiences that led me to believe that. I also have more tools to deal with the flotsam and jetsam of life. I am better able to work out where my feelings are coming from and to judge how appropriate they are. Of course, I don't get it right every time.
I'll give you an example. Last week, my boiler broke. No big deal but it felt like it at the time. Yet I woke up in the middle of the night in the grip of anxiety. I dealt well with this – breathing and grounding exercises, dampening down my fight or flight response. In the morning, still anxious, I realised I had made an unconscious association with a terrible flood I had had last year. I think the experience of the flood was particularly traumatic to me as I didn't have a safe home growing up.
Knowing all of this allowed me to soothe myself, instead of attacking myself for being anxious. No therapy in the world can remove life's distress, but mine has taught me how to respond to it with understanding and kindness.
Why can't I just go out for a drink with my friend?
Friends can be brilliant reality checkers. Unlike a therapist they can say 'Leave him! He's a wanker!', 'You look terrible with piercings!', but, generally, you are likely to be filtering when you chat with friends. We often don't want to 'burden' others or have them see us vulnerable. Friends also tend to be more goal-oriented, they want you to feel better fast. It takes a rare non-therapist friend who really wants to get into the nuances of how bad you may feel.
I've always been interested in psychotherapy as an intellectual exercise. The act of setting aside time to examine your life, whatever theoretical filter you're using, I've always thought of as inherently worthwhile, or at the very least, worth more than setting aside time to work on your glutes. But until I spoke to Jules in more depth, I don't think – paradoxically – that I fully appreciated its healing properties. I felt that you could gain wisdom but you couldn't necessarily do much to your wiring. Now, I feel as though my whole concept of “wiring" could be a misapprehension I picked up from my early relationships and maybe an integrative therapist could, erm, re-wire it for me!
Julia Bueno is verified welldoing.org psychotherapist in London and online