Module 11: Foundations of Therapeutic Practice

Why Do We Do Therapy?
At its core, therapy exists because human suffering is real, varied, and often
too complex to navigate alone. While support from family and friends is
invaluable, it has natural limits — loved ones carry their own emotional
stakes, biases, and blind spots. A therapist offers something distinct: a
trained, neutral presence whose sole focus is the client's wellbeing.

Therapy addresses needs that everyday support cannot:

-​ Emotional processing — Many people carry experiences they have
never been able to fully articulate or make sense of. Therapy creates a
structured space to do exactly that.
-​ Behavioural patterns — Humans often repeat patterns that hurt them
without understanding why. Therapy helps identify, examine, and
change these cycles.
-​ Mental health conditions — Disorders like depression, OCD, PTSD, and
schizophrenia involve neurological and psychological processes that
require evidence-based clinical intervention, not just social support.
-​ Life transitions and crises — Grief, relationship breakdown, academic
pressure, identity confusion — these are moments when professional
guidance can prevent temporary distress from becoming chronic
dysfunction.
-​ Self-understanding — Therapy is not only for people in crisis. Many
people seek it to understand themselves better, improve relationships,
or grow as individuals.

The need for therapy, in short, is the need for a safe, boundaried, professional
relationship built entirely around healing and growth.

Structured vs. Unstructured Therapy

One of the first things students notice is that not all therapy sessions look
the same. Some follow a clear agenda, homework assignments, and
measurable goals. Others feel more like open conversations that go wherever
the client leads. This is not inconsistency — it is intentional design.

Structured Therapy
Structured approaches follow a defined framework. Sessions have a clear
purpose, often a sequence of techniques, and measurable outcomes. The
therapist takes an active, directive role.

Why it works for certain clients and conditions:

-​ Clients dealing with specific, diagnosable conditions (panic disorder,
phobias, OCD) benefit from targeted, step-by-step interventions.
-​ It gives clients a sense of predictability and control, which is especially
helpful when they feel chaotic inside.
-​ Progress can be tracked and adjusted systematically.
-​ It is time-efficient — particularly important in settings with limited
resources.

Examples: CBT, DBT, REBT, Exposure and Response Prevention.

Unstructured (or Less Structured) Therapy

Here, the client largely directs the session. The therapist follows rather than
leads, creating space for whatever needs to emerge. There is no fixed agenda.

Why it works for certain clients and conditions:

-​ Clients processing grief, existential questions, or identity struggles
need room to explore without being redirected.
-​ It honours the client's autonomy and internal wisdom.
-​ Deep relational wounds — particularly those involving trust — often
need a relational experience first, before any technique is introduced.
-​ It allows unconscious material to surface naturally.
Examples: Person-Centred Therapy, Psychoanalytic/Psychodynamic
Therapy, Existential Therapy.

The Key Insight

Structure is a clinical decision, not a preference. The question a therapist
asks is: what does this particular client, with this particular presentation,
need right now? Sometimes the answer is a worksheet and a goal. Sometimes
it is simply being heard without interruption for fifty minutes.

Why Do We Need Different Therapeutic Approaches?

If one therapy worked for everyone, there would only be one. The existence
of dozens of modalities is not confusion in the field — it reflects the genuine
complexity of human psychology.

1. People Are Not the Same

A teenager with social anxiety, a middle-aged man processing childhood
trauma, and an elderly woman adjusting to loss are all suffering — but the
nature, origin, and expression of that suffering differ dramatically. No single
lens captures all of it.

2. Problems Operate at Different Levels

Different therapeutic approaches target different levels of human
experience:

Level Focus Approach

Thoughts Distorted beliefs and CBT, REBT
cognitive errors
Emotions Emotional regulation, DBT
distress tolerance
 Behaviour Maladaptive habits and Behavioural Therapy
avoidance
Relationships Interpersonal patterns, Psychodynamic, IPT
attachment
Meaning Existential concerns, Existential,
identity, purpose Humanistic
Narrative How we story our own Narrative Therapy
lives
Body Somatic trauma responses Somatic therapies,
EMDR

3. Evidence Tells Us Different Things Work for Different Conditions

Decades of clinical research have established that certain approaches have
stronger evidence bases for specific presentations:
-​ CBT is the gold standard for anxiety disorders and depression.
-​ DBT was specifically developed for borderline personality disorder and
chronic suicidality.
-​ EMDR has strong evidence for PTSD.
-​ Psychodynamic therapy shows particular strength for
personality-level and relational difficulties.

4. The Therapeutic Relationship Itself Varies

Different clients need different relational experiences from their therapist.
Some need a warm, non-directive companion (humanistic). Some need an
expert who gives them tools (CBT). Some need someone who will gently
challenge and interpret (psychodynamic). The modality shapes the
relationship, and the relationship is often where healing actually happens.

5. Culture, Context, and Worldview Matter

Therapeutic approaches developed largely in Western, individualistic
contexts. Adapting them — or choosing approaches that more naturally
accommodate collectivist values, spiritual frameworks, or culturally specific
expressions of distress — is an ethical and clinical necessity, particularly in an
Indian context.

Closing Thought
Therapy is not a one-size-fits-all prescription. It is a discipline that asks its
practitioners to hold both scientific rigour and deep human sensitivity at the
same time. Understanding why different approaches exist is the foundation
for eventually knowing which approach to reach for — and when.
 Five Core Therapeutic Approaches

1. Cognitive Behavioural Therapy (CBT)

Origins
CBT was developed by Aaron T. Beck in the 1960s, originally as a treatment
for depression. Beck, a psychiatrist trained in psychoanalysis, noticed that his
depressed patients had automatic negative thoughts that psychoanalytic
theory did not adequately address. He began systematically studying these
thought patterns and built a structured, evidence-based framework around
them.

Why Was It Made?

Beck found that existing therapies were either too long-term and
unfalsifiable (psychoanalysis) or too focused on behaviour alone. He wanted a
therapy that was time-limited, testable, and focused on the present — one
that patients could actively participate in rather than passively receive.

Core Idea
CBT is built on the principle that thoughts, feelings, and behaviours are
interconnected — and that changing one changes the others. Specifically, it
argues that distorted or unhelpful thinking patterns drive emotional distress
and problematic behaviour. By identifying and restructuring these thoughts,
clients experience emotional and behavioural change.
The famous cognitive triad in depression involves negative views of the self,
the world, and the future.

What Happens in CBT?

-​ Psychoeducation — Clients are taught how thoughts, emotions, and
behaviours connect.
-​ Identifying Automatic Thoughts — Catching the fast, reflexive
thoughts that arise in distress.
-​ Cognitive Restructuring — Challenging and reframing distorted
thoughts using evidence.
-​ Behavioural Activation — Encouraging engagement with activities to
counter withdrawal.
 -​ Thought Records — Written exercises tracking situations, thoughts,
feelings, and alternative responses.
-​ Homework — Between-session exercises are central; CBT is highly
skills-based.
-​ Socratic Questioning — The therapist uses guided questions to help
clients examine their own thinking rather than simply telling them
what to think.

Best Used For

Anxiety disorders, depression, OCD, eating disorders, insomnia, health
anxiety.

2. Dialectical Behaviour Therapy (DBT)

Origins
DBT was developed by Marsha Linehan in the late 1980s. Linehan, who later
disclosed her own experience with severe mental illness, was a researcher
attempting to apply standard CBT to chronically suicidal women diagnosed
with Borderline Personality Disorder (BPD). She found that pure CBT felt
invalidating to these clients — the focus on change without acknowledgment
of their pain caused many to drop out.

Why Was It Made?

Linehan needed a framework that could hold two seemingly opposite truths
at once — that clients needed to change and that their suffering was
completely valid. This tension is the 'dialectic' in DBT: the synthesis of
acceptance and change. She also drew from Zen Buddhist mindfulness
practices to build the acceptance side of the model.

Core Idea
DBT operates on the biosocial theory — that BPD and related difficulties arise
from a biological emotional sensitivity combined with an invalidating
environment. The therapy teaches clients concrete skills to manage
overwhelming emotions, tolerate distress, and build a life worth living
without resorting to self-destructive behaviour.
The Four Skill Modules

Module What It Teaches

Mindfulness Present-moment awareness; the foundation of all
other skills.
Distress Tolerance Surviving crises without making things worse.
Emotion Regulation Understanding, naming, and managing intense
emotions.
Interpersonal Maintaining relationships while preserving
Effectiveness self-respect.

What Happens in DBT?

-​ Individual therapy — Weekly one-on-one sessions addressing the
client's specific challenges.
-​ Skills training group — A psychoeducational group where the four
modules are taught.
-​ Phone coaching — Clients can contact their therapist between sessions
during crises.
-​ Therapist consultation team — Therapists meet regularly to support
each other and maintain fidelity to the model.

Best Used For

Borderline Personality Disorder, chronic suicidality, self-harm, eating
disorders, substance use, PTSD.

3. Rational Emotive Behaviour Therapy (REBT)

Origins
REBT was created by Albert Ellis in 1955, making it one of the earliest
cognitive therapies — predating Beck's CBT. Ellis, originally trained as a
psychoanalyst, grew frustrated with how slow and ineffective psychoanalysis
was. He began directly disputing clients' irrational beliefs, which was
considered radical at the time.

Why Was It Made?

Ellis believed that people were making themselves miserable through
irrational, absolutist thinking — and that a therapist who simply listened
empathetically without challenging these beliefs was doing the client a
disservice. He wanted a therapy that was active, direct, and philosophically
rigorous.

Core Idea — The ABC Model

-​ A — Activating Event: Something happens in the world.
-​ B — Belief: The person's belief about that event (rational or irrational).
-​ C — Consequence: The emotional and behavioural outcome.

The crucial insight is that A does not cause C — B does. It is not what
happens to us but what we believe about what happens that determines how
we feel. Ellis later added:
-​ D — Disputation: Actively challenging the irrational belief.
-​ E — Effective New Belief: The rational alternative that replaces it.

Common Irrational Beliefs

-​ Demandingness — "Things must go the way I want."
-​ Awfulising — "It would be absolutely terrible if this happened."
-​ Low frustration tolerance — "I cannot stand discomfort."
-​ Global self-rating — "Because I failed at this, I am a total failure."

What Happens in REBT?

-​ Identifying the irrational belief driving distress.
-​ Vigorously disputing it — logically, empirically, and pragmatically.
-​ Replacing it with a rational, flexible alternative.
-​ Encouraging unconditional self-acceptance, unconditional
other-acceptance, and unconditional life-acceptance.
-​ The therapist is often direct, even confrontational — the style is
intentionally active.
Best Used For
Anxiety, anger, depression, guilt, low self-esteem, perfectionism.

4. Emotion-Focused Therapy (EFT)

Origins
EFT was developed by Leslie Greenberg (along with colleagues Sue Johnson
and Laura Rice) in the 1980s. Greenberg, influenced by both humanistic
therapy and attachment theory, wanted to bring emotion back to the centre
of therapeutic work at a time when cognitive approaches were dominating
the field.

Why Was It Made?

Greenberg believed that emotions are not problems to be managed — they
are information. Cognitive therapies, in his view, were too focused on
changing thoughts and not enough on helping clients actually experience
and process their emotions. He argued that many people are either
overwhelmed by emotion or disconnected from it — and that true healing
requires learning to access, tolerate, and make meaning of emotional
experience.

Core Idea — Types of Emotional Responses

Type Description Therapeutic

Approach
Primary adaptive Direct, healthy response Access and
to a situation (e.g., grief validate.
after loss).
Primary Deeply rooted, unhelpful Transform
maladaptive emotional responses (e.g., through
shame from trauma). experience.
Secondary Emotions about emotions Uncover what lies
(e.g., anger covering beneath.
sadness).
 Instrumental Emotions used to Explore function.
influence others (e.g.,
performed crying).

What Happens in EFT?

-​ Empathic attunement — The therapist closely tracks and reflects the
client's emotional experience.
-​ Emotion coaching — Helping clients identify, name, and make sense of
emotions.
-​ Two-chair dialogue — Used for internal conflict — the self-critic vs.
the experiencing self.
-​ Empty chair technique — Used to process unfinished emotional
business with someone from the past.
-​ Meaning-making — Helping clients construct a coherent narrative
around their emotional experiences.

Best Used For

Depression, trauma, grief, relationship difficulties, low self-esteem,
unresolved interpersonal issues.

5. Psychodynamic Therapy

Origins
Psychodynamic therapy descends from Sigmund Freud's psychoanalysis,
developed in the late 19th and early 20th century. It evolved significantly
through the work of theorists like Carl Jung, Melanie Klein, Donald
Winnicott, Heinz Kohut, and John Bowlby. Modern psychodynamic therapy is
a contemporary, more flexible descendant of classical psychoanalysis —
shorter, less rigid, and more relational.

Why Was It Made?

Freud observed that many of his patients had symptoms — paralysis,
amnesia, compulsions — with no physical cause. He concluded that the mind
contains unconscious processes that drive behaviour and experience without
the person being aware of them. Psychoanalysis was created to make the
unconscious conscious. Later theorists shifted focus toward relationships
and early attachment as the core of psychological life.

Core Ideas
-​ The unconscious — Much of mental life operates outside awareness.
Past experiences, particularly early relational ones, continue to shape
present functioning.
-​ Defence mechanisms — The mind protects itself from anxiety through
strategies like repression, denial, projection, and rationalisation.
-​ Transference — Clients unconsciously transfer feelings from past
relationships onto the therapist. This is not a problem to be avoided
but clinical material to be explored.
-​ Attachment and early experience — The quality of early caregiving
relationships creates internal working models that govern how we
relate to others throughout life.
-​ Insight as healing — Understanding why we are the way we are —
particularly the unconscious roots — is itself therapeutic.

What Happens in Psychodynamic Therapy?

-​ Free association — Clients are encouraged to say whatever comes to
mind without filtering.
-​ Dream exploration — Dreams are viewed as windows into unconscious
material.
-​ Transference analysis — Examining what the client's feelings toward
the therapist reveal about their relational patterns.
-​ Exploration of defences — Identifying how the client protects
themselves from painful awareness.
-​ Linking past and present — Drawing connections between current
patterns and early experiences.
-​ The therapeutic relationship — A corrective relational experience;
being in a safe, boundaried, attuned relationship is itself healing.

Best Used For

Personality difficulties, chronic relationship problems, depression with
interpersonal roots, trauma, identity issues, existential concerns.
 Comparison Tables

Table 1: How These Therapies Differ

Feature CBT DBT REBT EFT Psychody

namic
Developer Aaron Marsha Albert Leslie Freud +
Beck Linehan Ellis Greenber successo
g rs
Decade 1960s 1980s 1950s 1980s Late
1800s
onwards
Core Focus Thoughts Emotions Irrational Emotiona Unconsci
and + skills + beliefs l ous, past
behaviou dialectics experien relations
r ce hips
View of Emotion Central; Follows Primary Tied to
Emotion follows must be belief informati unconsci
thought regulated on ous
conflict
Therapist Role Active, Active, Active, Empathic Reflectiv
collabora validating direct, , attuned e,
tive challengi interpreti
ng ve
Session Highly Structure Structure Less Open-en
Structure structure d d, structure ded
d directive d
Time Frame Short-to- Long-ter Short-to- Medium Medium-
medium m medium term to-long
term term term
Homework Central Yes — Yes — Minimal Rarely
diary disputati
card on
Key Technique Thought Chain ABC Chair Free
records, analysis, disputati work associati
restructu skills on on,
ring training transfere
nce
Philosophical Cognitive Zen Stoic Humanis Psychoan
Roots science, Buddhis philosop m, alysis
Stoicism m + CBT hy attachme
nt theory
Empirical Base Very Strong Moderate Growing Moderate
strong (esp. -strong , strong
BPD) long-ter
m

Table 2: What These Therapies Share

Commonality How It Appears Across Approaches

Therapeutic alliance All five consider the quality of the therapist-client
relationship fundamental to outcome.
Goal of reducing All aim to alleviate psychological distress,
suffering regardless of method.
Attention to emotion All engage with emotion — they differ only in how
and at what level.
Role of self-awareness All aim to increase the client's understanding of
themselves in some form.
Non-judgmental All require the therapist to approach the client
stance without moral judgment.
Individualised All adapt their application to the specific client's
treatment needs and context.
Belief in capacity for All are founded on the assumption that people can
change and do change.
Focus on patterns All identify recurring patterns — of thought, belief,
emotion, behaviour, or relationship.
Use of the therapeutic In all five, what happens between therapist and
relationship client is clinically meaningful.
Attention to the past All acknowledge that history shapes the present,
though they differ in how much emphasis they
place on it.
 What a Therapy Session Actually Looks Like
A note before reading: These are illustrative session structures — they
represent a typical session within each approach, not a rigid script. Real
sessions breathe and adapt. The purpose here is to give you a felt sense of
how each approach organises the therapeutic hour.

1. A CBT Session
Typical duration: 50–60 minutes
Overall feel: Collaborative, purposeful, agenda-driven

Opening (5–10 minutes)

The session begins with a brief mood check — often using a quick rating
scale (e.g., 'On a scale of 0–10, how has your mood been this week?'). The
therapist and client then collaboratively set an agenda for the session. This is
not the therapist imposing a plan — it is a joint decision about what to
prioritise.

Homework Review (10 minutes)

CBT takes between-session work seriously. The therapist reviews whatever
was assigned last week — a thought record, a behavioural experiment, a
scheduled activity. What did the client notice? What was difficult? What did
they learn? This grounds the session in real-life experience rather than
abstract discussion.

Main Work (25–30 minutes)

This is the heart of the session. Depending on where the client is in
treatment, this might involve:
-​ Identifying and examining an automatic thought triggered during the
week.
-​ Working through a thought record together.
-​ Cognitive restructuring — examining the evidence for and against a
belief.
-​ Designing a behavioural experiment to test an assumption in real life.
 -​ Psychoeducation about a concept relevant to the client's presentation.

The therapist uses Socratic questioning throughout — guiding the client to

examine their own thinking rather than simply telling them what is distorted.

Homework Assignment (5–10 minutes)

A new between-session task is collaboratively designed. It should be specific,
manageable, and directly connected to what was worked on today.

Closing Summary (5 minutes)

The therapist asks the client to summarise what they are taking away from
the session. The therapist also asks for feedback: 'Was there anything today
that didn't feel right or that you'd like us to do differently?'

2. A DBT Session
Typical duration: 50–60 minutes (individual); 90–120 minutes (skills group)
Overall feel: Structured but warm; validating and challenging in equal
measure

Individual DBT Session

Opening — Diary Card Review (10–15 minutes)
The client brings a diary card — a weekly self-monitoring tool tracking
emotions, urges, and skill use each day. The therapist reviews it together
with the client. The diary card immediately surfaces what the session needs
to address.

Target Hierarchy
DBT individual therapy follows a strict priority order when deciding what to
address:
-​ Life-threatening behaviour (self-harm, suicidal behaviour) — always
addressed first.
-​ Therapy-interfering behaviour (missing sessions, not completing diary
cards).
 -​ Quality-of-life issues (relationship problems, work, housing).
-​ Skills building.

Chain Analysis (20–25 minutes)

If a crisis or problematic behaviour occurred during the week, the therapist
conducts a behavioural chain analysis — a detailed, step-by-step
reconstruction of the sequence of events, thoughts, emotions, and actions
that led to the behaviour. The goal is not to assign blame but to identify
exactly where a DBT skill could have been inserted.

Solution Analysis and Skills Application (10–15 minutes)

Once the chain is mapped, therapist and client identify which skills might
have helped at each vulnerability point. They may practise a skill together in
session.

Validation Throughout
A DBT therapist continuously validates the client's emotional experience
throughout the session, even while working toward change. The dialectic of
acceptance and change is not a technique applied at one moment; it is the
texture of the entire session.

DBT Skills Training Group

Opening Mindfulness Practice (5–10 minutes)
Every group begins with a brief mindfulness exercise. This settles the group,
brings everyone into the present moment, and models the foundation skill.

Homework Review (20–30 minutes)

Group members share how they practised skills during the week. The
facilitator draws out what worked, what didn't, and why.

New Skill Teaching (40–50 minutes)

A new skill from the current module is introduced — explained, discussed,
and often demonstrated or role-played.

3. An REBT Session
Typical duration: 50–60 minutes
Overall feel: Active, direct, intellectually engaged — sometimes
confrontational in a warm way

Opening — Problem Identification (5–10 minutes)

The therapist asks the client what they want to work on today. REBT is
present-focused and problem-specific. The client identifies a situation that
caused them distress.

A — Clarifying the Activating Event (5 minutes)

The therapist helps the client describe the situation clearly and factually —
stripping away interpretation to identify what actually happened versus what
the client added to it.

C — Identifying the Consequence (5–10 minutes)

What did the client feel? What did they do? The therapist helps them name
the emotion specifically — not just 'bad' but anxious, ashamed, furious. The
distinction matters because different emotions often point to different
underlying beliefs.

B — Uncovering the Belief (10–15 minutes)

This is the detective work. The therapist asks: 'What were you telling yourself
about that situation that led you to feel this way?' The goal is to surface the
irrational belief — the demand, the catastrophising, the global self-rating.
The therapist listens for absolute language: must, should, always, never,
awful, unbearable, worthless.

D — Disputation (15–20 minutes)

The core of REBT. The therapist actively challenges the irrational belief using
three types of disputation:
-​ Logical — "Does it logically follow that because you want something,
you must have it?"
-​ Empirical — "Where is the evidence that this is actually awful rather
than very inconvenient?"
-​ Pragmatic — "Is holding this belief helping you or hurting you?"
E — Establishing the Effective New Belief (5–10 minutes)
The session moves toward constructing a rational alternative — flexible,
preferential rather than demanding. For example: 'I would strongly prefer to
succeed, but I do not have to. Not succeeding is disappointing, not
catastrophic.'

Closing and Homework (5–10 minutes)

The client is assigned a task to practise the new belief — often written
disputation exercises, rational self-statements to rehearse, or recommended
reading.

4. An EFT Session
Typical duration: 50–60 minutes
Overall feel: Slow, attuned, emotionally alive — the therapist closely tracks
the client's inner experience moment to moment

Opening — Arriving and Attuning (5–10 minutes)

Unlike CBT or REBT, an EFT session does not begin with an agenda. The
therapist checks in gently and pays close attention not just to what the client
says but to how they say it: tone, body language, what is present in the room
right now. The therapist is already tracking emotion from the first moment.

Following the Emotional Thread (20–30 minutes)

The therapist follows the client's emotional experience rather than leading it.
When something emotionally significant arises — a shift in tone, a moment of
hesitation, eyes filling — the therapist slows down and moves toward it
rather than past it.

This might sound like:

-​ "Something just shifted when you said that. Can we stay there a
moment?"
-​ "What's happening inside you right now as you say this?"
The therapist uses empathic reflection and evocative responding — language
that draws the client deeper into their experience rather than away from it.
The goal is not to talk about emotion but to help the client be in emotion
safely.

Identifying Emotion Markers

Marker What It Signals Intervention

Self-criticism, Two parts of the self Two-chair
internal conflict in conflict. dialogue.
Unfinished business Lingering hurt, anger, Empty chair work.
with someone or grief toward
another.
Unclear or Confusion about what Focusing /
overwhelming is felt. clearing a space.
emotion
Vulnerability Secondary emotion Empathic
beneath presenting masking a primary exploration.
emotion one.

Chair Work (15–20 minutes, when indicated)

When an emotion marker appears, the therapist may invite the client into
chair work — never forced, always gentle.

In a two-chair dialogue, the client moves between chairs, voicing the

self-critical part and then the experiencing self — allowing an internal
conflict to become an actual dialogue. Often, the critic softens, and
underneath it, vulnerability emerges.

In the empty chair technique, the client speaks to a significant person from
their life — a parent, an ex-partner, someone who has died — expressing
what was never said. The therapist supports this process, helping the client
access and articulate emotions that have remained unspoken and unresolved.
Meaning-Making and Integration (10 minutes)
After an emotionally significant piece of work, the therapist helps the client
make sense of what just happened. What did they discover? What does this
tell them about themselves? The session slows to allow the experience to
settle.

Closing (5 minutes)
A gentle landing — checking in on how the client is feeling before they leave
the room. Because EFT sessions can open significant emotional territory, the
therapist ensures the client feels grounded before the session ends.

5. A Psychodynamic Therapy Session

Typical duration: 50 minutes (the traditional 'therapeutic hour')
Overall feel: Open, exploratory, unhurried — like thinking aloud with an
unusually perceptive companion

No Fixed Agenda
There is no predetermined structure. The client begins wherever they begin.
What the client chooses to talk about, how they begin, what they avoid, what
arrives unexpectedly — all of this is information.

Opening — Free Association

The client is encouraged to say whatever comes to mind. The therapist
listens for themes, patterns, contradictions, and what is not being said as
much as what is. Silences are not rushed to fill — they may carry meaning of
their own.

The Therapist's Listening Stance

A psychodynamic therapist practises what Freud called evenly suspended
attention — listening without latching onto any one thing, allowing broader
patterns to emerge. While the client speaks, the therapist is tracking:
-​ Recurring themes across sessions.
-​ Contradictions between what is said and how it is said.
 -​ The client's defences — what they move away from, minimise, or
intellectualise.
-​ What is being stirred up in the therapist's own emotional responses
(countertransference) — a valuable clinical signal.

Exploration of Defences
When the therapist notices a defence operating — the client laughs when
discussing something painful, suddenly changes the subject, becomes vague
— they may gently draw attention to it.

Example: "I noticed you moved away from that quite quickly. What's your
sense of what happened there?"

Transference Work
At some point in most psychodynamic sessions, the therapeutic relationship
itself becomes material. The client may express frustration with the
therapist, feel dependent, feel criticised — and the skilled psychodynamic
therapist recognises these responses as windows into the client's broader
relational world.

Example: "I'm wondering if what you're feeling toward me right now

connects to what you described with your father?"

Linking Past and Present

The therapist looks for opportunities to draw connections between what the
client is experiencing now and earlier relational experiences. This is not
about blaming the past — it is about helping the client understand the
invisible threads that connect their history to their present patterns.

Interpretation
When the therapist has enough understanding, they may offer an
interpretation — a tentative suggestion about an unconscious dynamic at
play. Good psychodynamic interpretation is offered as a hypothesis, not a
declaration.
Example: "I wonder if part of what makes it so hard to assert yourself at work
is connected to how unsafe it felt to need things from your mother."

Closing (5 minutes)
The therapist may draw the session to a close by noting recurring themes
from today, or simply allowing the session to end with whatever has
emerged. The ending itself — how the client responds to the session
concluding — can be clinically meaningful.
Summary: Session Structure at a Glance

Element CBT DBT REBT EFT Psychody

namic
Session Mood Diary card Problem Gentle Open —
opening check + review identificat check-in, client
agenda ion emotional begins
setting attuneme wherever
nt
Who sets Collaborat Therapist Client Client Client
agenda ively (target brings leads, leads
hierarchy) problem, therapist entirely
therapist follows
leads
Main Thought Chain ABC-D-E Empathic Free
activity records, analysis, disputatio tracking, associatio
restructur skills n chair n,
ing applicatio work transferen
n ce
exploratio
n
Homework Central — Yes — Yes — Minimal Rarely
reviewed diary card disputatio assigned
every + skill n
session practice exercises
How Linked to Validated Examined Directly Explored
emotion is thought, and as entered as signal
handled restructur regulated conseque and of
ed through nce of processed unconscio
skills belief us
dynamics
Therapist High — High — Very high Moderate Lower —
activity active and validating — direct — listening,
and following reflecting,
 structure and challengin and interpreti
d teaching g deepening ng
Use of Collaborat Validating, Vehicle Empathic Primary
relationship ive tool coaching for container clinical
relationsh challenge material
ip
Session Client Commitm Homewor Groundin Themes
closing summaris ents k g; noted;
es; reviewed assigned; emotional ending
homewor rational landing itself
k set belief observed
reinforced
Pacing Steady, Structure Brisk, Slow, Unhurried
task-orien d but intellectu emotional ,
ted responsiv ally active ly attuned explorator
e y