A year of training in Intensive Short-Term Dynamic Psychotherapy (ISTDP) with ISTDP North has challenged how I understand my role as a psychotherapist. From discovering the extraordinary precision of working with unconscious emotional processes to recognising the limitations of my own familiar therapeutic habits, this reflection explores what it means to become a more effective therapist. I consider the importance of working directly with transference, understanding attachment and defensive processes, and moving beyond managing the weekly difficulties people bring to therapy towards addressing what may be driving them. Along the way, I've found myself reflecting not only on what I'm learning about psychotherapy, but on what the process is teaching me about myself.
Beyond the visible: a quiet interior inspired by Vilhelm Hammershøi’s The Four Rooms, reflecting the process of looking beyond familiar perspectives to discover what lies beneath.
November 2026 | Rick Cox, Psychodynamic Psychotherapist
As I approach the end of my first year of formal training in Intensive Short-Term Dynamic Psychotherapy (ISTDP) with ISTDP North, I've been reflecting on how much this experience has begun to change the way I think about psychotherapy, my role as a therapist, and what it really means to help someone change.
I've been interested in ISTDP for a long time. I first encountered the approach during my university studies in 2009, when I watched Allan Abbass demonstrate the extraordinary possibilities of working directly with unconscious emotional processes. It made an impression on me then, and the approach has continued to influence my clinical thinking throughout my professional development.
But there is a considerable difference between being interested in a therapeutic approach, understanding its theoretical principles, and beginning to appreciate the extraordinary precision required to practise it. Perhaps more unexpectedly, there is also a difference between recognising the limitations of our existing ways of working and becoming willing to change them.
I think that has been one of the most significant aspects of this year. My training hasn't simply introduced me to new techniques or a different theoretical framework. It has prompted me to examine some of the assumptions, habits, and therapeutic positions I've developed over several years of clinical practice, while considering what I might need to change in order to become more effective.
And I've discovered that becoming a more effective therapist might involve learning to relinquish some things I've become rather good at doing. That is an interesting position to find yourself in after several years of developing a professional identity.
Discovering How Surgical Psychotherapy Can Be
One of the things that has struck me most throughout my training with Dr Javier Malda Castillo and ISTDP North is just how surgical psychotherapy can become. I don't mean surgical in the sense of being cold, detached, or mechanistic, but rather the possibility of working with remarkable precision, identifying what is happening psychologically in the moment, understanding what may be preventing someone from experiencing their feelings, and making an intervention that directly addresses that process.
Watching experienced ISTDP therapists work has been fascinating. A client might begin describing an apparently ordinary situation from their week, and within a relatively short period, the therapist has identified an emotional conflict, recognised an emerging defence, monitored the accompanying anxiety, and begun helping the person move towards an experience they may have spent much of their life avoiding.
Sometimes this involves just a few carefully chosen questions, while at other times it requires slowing the entire process down. The most important intervention might be helping someone recognise what they have just done to themselves psychologically, particularly when an automatic defensive process has interrupted something emotionally significant.
What has impressed me most is the therapist's ability to maintain focus on the underlying psychological process rather than becoming absorbed in every detail of the unfolding narrative. There is an extraordinary economy to this kind of work, where nothing seems particularly rushed, yet very little appears wasted.
I'm beginning to understand that this precision isn't achieved by memorising techniques or learning the right questions to ask. It emerges from an increasingly sophisticated capacity to observe, formulate, intervene, and assess the client's response, continuously adapting the work according to what is actually happening.
Watching Javier demonstrate this has been particularly instructive. What appears almost effortless is the product of considerable clinical knowledge, experience, and an exceptionally disciplined therapeutic attention. There is something quite remarkable about watching a therapist remain calm and focused while navigating complicated emotional processes, recognising moments when anxiety requires regulation, when a defence needs addressing, and when the person might be ready to experience something more deeply.
It has also made me increasingly aware of the difference between understanding what an experienced therapist is doing and being able to do it myself. That difference is humbling, but it has also become one of the most motivating aspects of my training, because I'm beginning to see more clearly what I am working towards developing.
The Therapist I've Been and the Therapist I'm Becoming
Having worked psychodynamically for several years, I've developed a way of practising that places considerable importance on the therapeutic relationship, emotional safety, curiosity, and helping people understand themselves.
These remain fundamental aspects of my work, and I wouldn't want to lose them. I've witnessed meaningful changes in hundreds of people who have gradually developed greater self-awareness, begun recognising longstanding relational patterns, and discovered ways of understanding experiences that previously seemed confusing or overwhelming.
There is considerable value in having someone listen carefully, take our emotional experiences seriously, and help us make sense of what has happened in our lives. For people whose feelings have historically been dismissed, misunderstood, or ignored, the experience of being genuinely heard can itself be profoundly important.
I've spent years developing the capacity to offer that kind of therapeutic relationship, and I remain convinced of its importance. However, my ISTDP training has encouraged me to consider something that feels increasingly significant: sometimes the very qualities that help establish a therapeutic relationship can become part of a familiar way of working that is difficult for the therapist to move beyond.
I can listen attentively, explore thoughtfully, make connections, and help someone understand the relationship between their past and present experiences. But increasingly, I'm asking myself whether understanding alone is sufficient when the same psychological processes continue operating largely unchanged.
There are moments when I can recognise that a client is moving away from something emotionally important, perhaps through intellectualisation, rationalisation, minimisation, or an immediate shift into self-criticism. Previously, I might have followed the conversation, explored the meaning of what was being discussed, or allowed the material to develop in the hope that something significant would eventually emerge.
I'm beginning to appreciate that I may sometimes have been observing a defensive process without sufficiently helping the person recognise and address it. In other words, I may have understood something important about what was happening while not necessarily intervening in a way that helped change it.
This isn't about regretting years of clinical work or dismissing the importance of everything I've learned. It's about recognising that an established therapeutic stance can become familiar, comfortable, and perhaps occasionally too accommodating of the very processes that maintain someone's difficulties.
There is something uncomfortable about recognising that possibility in yourself, particularly when your intentions have always been to help. It raises a question that has become increasingly important to me: am I always helping the client move towards change, or are there occasions when my own therapeutic habits inadvertently help maintain the status quo?
I don't think this is a question that can be answered once and put aside. It's something I increasingly want to keep in mind throughout my clinical work as an invitation to examine how I might work differently.
Moving Beyond Putting Out the Weekly Fires
One of the most recognisable features of psychotherapy is that people understandably bring the events of their lives into the consulting room. A difficult conversation, a relationship problem, something that happened at work, another episode of anxiety, or a decision that feels impossible to make can all become the focus of a session.
These experiences matter, and they often provide important opportunities to understand the person's internal world. But what happens when the same difficulties continue to emerge in different circumstances, week after week?
We might help someone make sense of an argument, only for another argument to emerge. We might explore their anxiety about a particular decision, only to discover that the next decision produces much the same struggle. We might help someone understand why they continually put themselves last, yet find that this understanding hasn't necessarily changed what they do.
I've begun thinking of this as the problem of putting out the weekly fires, where therapy risks becoming organised around responding to the latest difficulty rather than examining the psychological processes responsible for its recurrence.
There is nothing inherently wrong with helping someone manage an immediate difficulty. Sometimes this is precisely what they need, particularly during periods of crisis, overwhelming anxiety, or significant life disruption.
But there is a distinction between helping someone navigate an individual problem and helping them overcome the psychological mechanisms that repeatedly generate similar problems. This distinction has become increasingly important to me, especially when working with people who have developed considerable insight into their difficulties but continue to experience the same patterns.
I've occasionally found myself experiencing a sense of frustration when familiar material returns, particularly when both the client and I seem to understand the pattern reasonably well. Rather than dismissing this frustration, I'm becoming more interested in what it might be telling me about the therapeutic process.
Have we identified the underlying conflict accurately, and have we recognised the defences that prevent emotional change? Are we continuing to discuss something that might need to be experienced differently, or are we becoming caught in a pattern of therapeutic conversation that feels productive without necessarily producing meaningful movement?
There is also an important distinction between recognising a repetitive therapeutic process and becoming frustrated with the person caught within it. I don't want my desire to become more effective to turn into an impatience with the pace of another person's psychological development.
The challenge is to remain compassionate without becoming passive, and to maintain therapeutic direction without assuming that I should want change more than the person I'm working with. This is something I am becoming increasingly attentive to, particularly when familiar difficulties continue to appear despite considerable understanding and exploration.
Rather than becoming completely absorbed in the content of each new situation, I'm learning to pay much closer attention to the psychological processes operating underneath it. What feelings have been activated, what happens when those feelings begin to emerge, does anxiety interrupt the experience? and becoming increasingly fanatical about what happens next!…
Does the person turn against themselves, intellectualise, minimise, withdraw, or become overwhelmed? What happens to their capacity to act on their own behalf, and how might these responses be connected to emotional conflicts that have remained unresolved?
The weekly difficulties remain important, but increasingly, I'm interested in what they reveal about the psychological organisation beneath them. Perhaps the most useful contribution I can make isn't always to help someone navigate the latest problem, but to help them understand why they keep finding themselves in remarkably similar psychological situations.
The Difference Between Understanding and Emotional Change
Coming from a psychodynamic background, I've always been interested in unconscious processes, attachment experiences, and the ways earlier relationships influence our present lives. Yet another important part of my learning has been recognising the difference between helping someone develop an intellectual understanding of their difficulties and helping them experience something emotionally that has previously remained inaccessible.
A person might understand perfectly well that they struggle with anger. They might recognise that expressing anger was dangerous during childhood, identify how this continues to influence their relationships, and explain the origins of their difficulties with considerable psychological sophistication.
All of this can be meaningful, but what happens when anger actually begins to emerge? Perhaps anxiety rises, or they immediately explain away the other person's behaviour. Perhaps the anger is redirected towards themselves, or the feeling disappears altogether as they begin analysing why they shouldn't be angry in the first place.
This is where ISTDP has helped me appreciate something important about the limitations of insight. Sometimes the difficulty isn't that the person doesn't understand what is happening, but that they have developed automatic psychological mechanisms that prevent them from fully experiencing and integrating certain emotions.
And those mechanisms may have been necessary for their emotional survival at an earlier point in life. What now appears to interfere with emotional development may once have served an essential protective function within an important attachment relationship.
I'm beginning to recognise how easily therapy can become an intellectually sophisticated conversation about emotional experiences that remain largely unexperienced. The therapist and client may arrive at increasingly elaborate explanations while the actual defensive process continues operating between them.
This has made me think differently about my own interventions. Rather than automatically offering an interpretation or making another connection to the past, I'm learning to consider whether the person might benefit more from recognising what is happening within them at that precise moment.
Sometimes the most important question isn't why they feel something, but whether they can remain present with the feeling long enough to discover what is actually there. The difference between discussing anger and experiencing it, for example, can be considerable, particularly when the person has spent much of their life automatically avoiding or redirecting that feeling.
Of course, this requires careful attention to emotional capacity and anxiety. The intention isn't to overwhelm someone with feelings they cannot yet tolerate, but to help them gradually develop the ability to experience emotions that have previously felt dangerous.
The more I learn, the more I appreciate that ISTDP isn't simply about intensifying emotional experience. It's about developing the precision necessary to know when emotional experience can be facilitated, when anxiety needs regulating, and when defensive processes need to be understood before the work can progress.
Working in the Transference
Perhaps one of the most significant developments in my thinking concerns the therapeutic relationship itself. I've always understood the importance of transference within psychodynamic psychotherapy, recognising that people can experience others through expectations, fears, and emotional patterns established in earlier relationships.
We also know that these processes can emerge within the relationship between therapist and client. But understanding transference theoretically is one thing, while learning to work directly with it as it unfolds in real time is quite another.
This year has made me consider how much psychologically important material can emerge between two people sitting together in a therapy session. A person may anticipate criticism where none is intended, assume their therapist is disappointed in them, or become compliant, withdrawn, or preoccupied with being a good client.
They may struggle to express disagreement, anger, affection, or a wish towards the very person who is trying to help them. These responses may reflect something of the person's earlier relational experiences, particularly when similar patterns have developed across important relationships throughout their life.
Previously, I might have recognised these possibilities while allowing the relationship to develop, perhaps interpreting them when the opportunity arose. I'm increasingly interested in what happens when these processes are approached more directly, while remaining attentive to the person's anxiety, emotional capacity, and the strength of the therapeutic alliance.
The client is no longer simply describing a difficulty they experience elsewhere. Something of that difficulty may be happening between us, offering an opportunity to understand and work with the process as it unfolds.
This requires a different kind of attentiveness from me, particularly when the narrative itself is compelling or emotionally significant. Rather than automatically following the story, I need to consider what is happening in the therapeutic relationship at that moment and whether an important psychological process is becoming visible.
Am I being experienced as someone from the person's past, and might an expectation of rejection, criticism, abandonment, or disappointment be influencing how they relate to me? Is the person responding to what is actually happening between us, or are earlier relational expectations shaping how they perceive and experience the therapeutic encounter? While they are talking to me about their feelings and problems, are they seeing me in reality?
I'm also learning to consider my own participation in these interactions. It can be surprisingly easy for a therapist to respond reassuringly when someone anticipates criticism, or to become particularly accommodating when a client appears anxious about expressing their wishes.
Sometimes reassurance is appropriate and necessary, but there may also be occasions when repeatedly providing it prevents the underlying expectation from becoming available for examination. The person may leave feeling temporarily reassured without developing a clearer understanding of why they anticipated criticism or rejection in the first place.
This is a subtle distinction, and one that requires considerable care. The point isn't to withhold reassurance or turn every interaction into an interpretation of transference, but to become increasingly aware of what is happening between us and whether our responses are helping the person develop greater emotional freedom.
I'm beginning to appreciate that working seriously in the transference isn't about sacrificing the therapeutic relationship in pursuit of technique. It is about making fuller therapeutic use of the relationship itself, allowing something that might otherwise remain implicit to become available for recognition, understanding, and emotional change.
Attachment-Based ISTDP: Understanding Why the Defences Were Needed
My growing interest in attachment-based ISTDP has added another dimension to this learning. Much of the psychological suffering we encounter in psychotherapy seems connected, in one way or another, to the complicated business of needing other people.
We need love, closeness, recognition, protection, and emotional connection, but these needs also make us vulnerable. When someone we depend upon becomes a source of fear, humiliation, rejection, or emotional pain, the resulting conflict can become extraordinarily difficult to resolve.
What happens when anger towards someone we love feels dangerous, or when expressing our own wishes threatens the relationship we depend upon? A person may learn to inhibit their anger, dismiss their needs, suppress their wishes, or redirect painful feelings towards themselves.
What began as an attempt to preserve an important attachment may eventually become a familiar way of relating to themselves and others. The person may continue organising their emotional life around expectations established much earlier, even when their present circumstances no longer require the same protective responses.
This is one of the aspects of ISTDP that I find particularly compelling. The defences are not treated as meaningless obstructions or evidence that someone is unwilling to change, but are understood in relation to the person's emotional and attachment history, recognising that they may once have served an essential protective function.
The question becomes whether those same processes are now preventing the person from living more freely. This has helped me reconsider the distinction between being compassionate towards a person's defences and inadvertently accommodating them.
It is entirely possible to understand why someone learned to minimise themselves, avoid conflict, or turn anger inwards while also helping them recognise how these processes continue to cause suffering. Indeed, I'm beginning to think that genuinely compassionate therapeutic work sometimes requires a willingness to address these processes more directly than I might previously have done.
This doesn't mean becoming confrontational for its own sake or assuming that every defence needs to be challenged immediately. But to remain sufficiently engaged with the person's struggle to help them recognise what is happening, even when doing so introduces a degree of discomfort into the therapeutic relationship.
The challenge is to do this with sensitivity, precision, and an understanding of what the person can emotionally tolerate. I'm increasingly appreciating that effective work with attachment difficulties requires both an understanding of why certain defences developed and the clinical skill to help someone begin relinquishing them when they are no longer necessary.
Josette ten Have-de Labije: Love, Care, Precision and Honesty
One of the highlights of my year was attending Dr Josette ten Have-de Labije's ISTDP workshop in Manchester in April. Josette's work, alongside that of Robert Neborsky, has become increasingly important to my understanding of this approach, particularly through their book Mastering Intensive Short-Term Dynamic Psychotherapy: A Roadmap to the Unconscious.
What struck me about her approach was the combination of remarkable precision and genuine relational warmth. There was something deeply human about the way she conceptualised psychological suffering, alongside an extraordinary determination to understand and address the processes responsible for maintaining it.
It challenged any notion that more active or focused psychotherapy necessarily means sacrificing warmth, humanity, or the therapeutic relationship. In fact, I came away thinking almost the opposite, appreciating how therapeutic precision might exist in the service of the relationship rather than in competition with it.
One of the central themes of Josette's work concerns the influence of what psychodynamic psychotherapy calls the superego. This is the part of our psychological organisation concerned with internalised standards, prohibitions, and judgements, which in its more destructive forms can become an extraordinarily harsh internal authority.
Someone may live under constant criticism, shame, guilt, or self-punishment without fully recognising how much of their psychological life is organised around these processes. Their own wishes and needs may be continually dismissed, while their capacity for independent thought and action becomes inhibited.
They may know what they want, yet repeatedly find themselves unable to pursue it, experiencing their own desires as somehow inappropriate, selfish, dangerous, or undeserved. Over time, these processes can become so familiar that the person no longer recognises the degree to which their psychological life is organised around them.
This has prompted me to think more carefully about the difference between a person's capacity to observe themselves and their tendency to monitor themselves through a critical, punitive internal voice. The two can look deceptively similar, yet they have profoundly different psychological consequences.
One facilitates understanding and psychological freedom, while the other can maintain the very suffering the person is trying to escape. Someone may appear highly self-aware while remaining caught in a continual process of self-surveillance, evaluating and criticising themselves rather than developing a genuinely compassionate understanding of their internal experience.
Josette's work has helped me appreciate how important it can be to distinguish between a person's constructive, healthy capacities and the destructive demands of an internalised punitive authority. In ISTDP, the therapist may temporarily function as a constructive counterweight to this harsh internal authority, helping the person recognise and challenge processes that undermine their autonomy and wellbeing.
What I find particularly interesting is the possibility that someone might spend years believing they are making their own decisions while remaining largely governed by internalised expectations and prohibitions established much earlier in life. This raises important questions about the relationship between psychological freedom and the capacity to experience our own feelings, wishes, and needs.
Josette's emphasis on love, care, precision, and honesty has stayed with me throughout the year. I think these principles describe something fundamental about the therapeutic attitude I'm continuing to develop: a willingness to look directly at painful psychological realities without attacking, humiliating, or abandoning the person experiencing them.
Her workshop also introduced a memorable metaphor involving the Flying Dutchman, the legendary ghost ship condemned to sail endlessly without reaching port. It seems a particularly fitting image for some of the repetitive psychological processes encountered in psychotherapy, where people can find themselves navigating remarkably similar emotional storms without understanding what keeps drawing them back into the same waters.
What interests me about this metaphor is that the therapist's task isn't simply to help the person survive another storm. It is to help them understand something about the course they have been following, and perhaps discover the possibility of steering in a different direction.
When Someone's Own Will Becomes the Problem
Another area that has captured my attention concerns what happens to a person's will. We sometimes encounter people who appear to know what they want, whether that involves changing careers, developing a relationship, pursuing an interest, asserting themselves, or beginning to make different choices.
Yet something continually gets in the way, and the person may struggle to understand why. They procrastinate, distract themselves, abandon their plans, or convince themselves there is no point, often becoming increasingly frustrated or critical of themselves for failing to act.
It can be tempting to approach this as a problem of motivation, confidence, or practical organisation, and sometimes these are important considerations. But ISTDP has encouraged me to consider another possibility, particularly when someone repeatedly finds themselves unable to pursue something they genuinely appear to want.
What happens psychologically at the precise moment someone begins to want something for themselves? Does the wish immediately generate anxiety, or does a critical internal voice dismiss it before the person has even considered acting upon it?
Does the person anticipate rejection, failure, or disapproval, perhaps losing contact with their own desire before they've had the opportunity to explore it? These questions have become increasingly interesting to me because they shift the focus from what someone isn't doing to what happens internally when they begin to consider doing it.
This is an area where the attachment-based perspective seems particularly valuable. For some people, developing an independent will may have become associated with the possibility of losing love, approval, or emotional security.
The conflict is no longer simply about whether they can make a decision. It concerns what it means emotionally to have a separate wish, and what they anticipate might happen if they were to act upon it.
I've been reflecting on how often psychotherapy can become focused on helping someone develop the confidence or motivation to do something, without adequately examining the psychological processes that interfere with their capacity to pursue it. Sometimes encouragement may even become part of the difficulty, particularly if the person already experiences themselves as someone who continually fails to meet expectations.
I'm increasingly interested in helping people recognise what happens to their own will before another layer of pressure, expectation, or self-criticism is added. The aim isn't for me to become the person who knows what they should do, or to substitute my wishes for their own.
Rather, it's to help them develop the capacity to recognise and act upon what matters to them, without automatically surrendering their autonomy to fear, anxiety, or an internalised critical authority. I think this represents an important shift in how I understand some forms of psychological stuckness, particularly when the difficulty appears to persist despite considerable motivation and insight.
Becoming More Aware of My Own Anxiety
Reflecting on all of this would be incomplete without considering what has been happening within me. Training in ISTDP has made me increasingly aware of my own anxiety as a therapist, particularly in relation to the demands of maintaining a more active and focused therapeutic stance.
There is a considerable amount to attend to during a session. Feelings, anxiety, defences, the therapeutic alliance, transference, emotional capacity, and the consequences of each intervention all require attention, sometimes within a relatively short period.
At times, I can become so preoccupied with trying to understand what is happening, or considering what I ought to do next, that some of my attention shifts away from the person sitting in front of me. This is something I've become increasingly interested in recognising because the quality of my attention is central to the kind of therapeutic work I'm trying to develop.
I've also become more aware of the temptation to retreat into familiar therapeutic habits when the work feels uncertain. Sometimes this means offering another interpretation, asking another exploratory question, or allowing the narrative to continue when I suspect something important has just been avoided.
These responses can look entirely reasonable from the outside, and sometimes they are clinically appropriate. But I'm learning to question whether they always arise from an assessment of what the client needs, or whether they occasionally reflect my own wish to avoid the uncertainty associated with intervening more directly.
This has been a particularly interesting recognition because it introduces another level of psychological observation into the work. The client may be avoiding something emotionally difficult, while I may be experiencing some anxiety about addressing that avoidance.
If neither of us recognises what is happening, we can potentially continue having a perfectly thoughtful conversation without approaching the central difficulty. The therapeutic relationship may remain comfortable and collaborative, yet something important may continue to be avoided by both participants.
I think this is one of the more uncomfortable aspects of developing as a therapist. It requires a willingness to recognise that our own psychological processes can become involved in maintaining the very situations we're trying to help someone overcome.
This doesn't mean constantly scrutinising myself or attempting to eliminate all anxiety from my clinical work. Some uncertainty is inevitable, and I suspect the capacity to tolerate it is an important part of becoming a more effective therapist.
What I'm increasingly interested in developing is the ability to recognise my own responses without allowing them to determine the direction of the session. I want to become better at remaining emotionally available and clinically attentive, even when I'm uncertain about precisely what might be happening or how best to intervene.
One of the things I admire in experienced ISTDP clinicians is their ability to maintain a calm, sustained therapeutic focus. They don't appear to be anxiously searching for the next intervention, nor do they seem preoccupied with demonstrating their knowledge or understanding.
Instead, they observe, intervene, assess the response, and continue from there, adapting their approach according to what emerges. It is a deceptively simple process, and one I'm working towards developing through continued training, supervision, and reflection.
Perhaps one of my most useful realisations has been that I don't need to know everything that's happening, but I do need to become increasingly accurate about what I can actually observe. I also need to become more thoughtful about what I do next, recognising that an intervention is only as useful as its relevance to the psychological process unfolding in front of me.
Recognising the Limits of What I Already Know
There is something interesting about undertaking this kind of training after several years of clinical practice. When you're relatively inexperienced, there is an expectation that you have an enormous amount to learn, and much of your development involves discovering how to work effectively with people.
But after accumulating considerable clinical experience, something different begins to happen. You develop confidence in your clinical judgement, recognise familiar patterns, and establish ways of working that become increasingly natural.
Experience can be enormously valuable, but it can also make certain habits more difficult to recognise. I've begun to appreciate that clinical experience and clinical development aren't necessarily the same thing, particularly when we become accustomed to working in ways that feel familiar and effective.
We can accumulate thousands of hours of psychotherapy while continuing to practise in ways that have become established, especially if we aren't regularly examining the consequences of our interventions. Experience provides opportunities for learning, but the extent to which we use those opportunities may depend upon our willingness to scrutinise what we actually do.
This is one of the reasons I've found the emphasis on video-based learning and supervision within ISTDP particularly valuable. It introduces a level of clinical scrutiny that is difficult to achieve through memory and reflection alone.
We can remember what we intended to do in a session, but video allows us to examine what we actually did. We can observe the client's response, notice moments we overlooked, and begin considering whether an alternative intervention might have been more useful.
I find this both exciting and exposing because it challenges the comfortable assumption that good intentions, professional experience, and a sound theoretical understanding are necessarily sufficient to produce the best therapeutic outcomes. These qualities are important, of course, but they don't remove the need to continually examine our work.
In some respects, I think this year has involved becoming more comfortable with not knowing, while simultaneously developing a greater determination to understand. There is a particular kind of humility involved in watching some very experienced clinicians demonstrate skills that appear effortless, then recognising how much practice will be required to develop anything approaching that level of competence.
But there is also something reassuring about the process because it suggests that therapeutic effectiveness isn't simply a mysterious quality possessed by particularly gifted clinicians. There are observable processes, teachable skills, and opportunities to improve through careful study, supervision, and repeated clinical experience.
Becoming a More Effective Therapist Without Losing Myself
One concern I've occasionally considered is whether developing a more active therapeutic stance might somehow mean becoming a different kind of person within the consulting room. There are aspects of my existing therapeutic identity that I value considerably, and I want to remain warm, approachable, emotionally available, and interested in the person beyond their psychological difficulties.
I don't want to become preoccupied with technique at the expense of human connection, or so determined to identify defensive processes that I lose sight of the person who developed them. Yet increasingly, I'm beginning to think this may be a false distinction.
The choice isn't between being a warm, relational therapist and becoming a precise, active one. The challenge is learning to bring these qualities together in a way that allows genuine therapeutic engagement to coexist with greater clinical focus.
Perhaps the therapeutic relationship can become more meaningful when we are willing to address difficult processes directly, rather than repeatedly accommodating them out of concern that doing otherwise might threaten the relationship. Perhaps compassion sometimes involves helping someone recognise how painfully they treat themselves, rather than simply reassuring them that they deserve better.
And perhaps therapeutic care occasionally requires a willingness to tolerate discomfort, including our own, when something important needs to be understood. This doesn't diminish the importance of emotional safety, but suggests that safety and psychological growth may sometimes require different forms of therapeutic engagement.
This is where I find myself increasingly appreciating the influence of Josette's work and the clinical teaching I've received through ISTDP North. The aim isn't to become harder, more confrontational, or less emotionally responsive, but to become more precise about where compassion, therapeutic focus, and psychological change meet.
I'm beginning to understand that being a more effective therapist doesn't necessarily mean abandoning the therapist I've been. However, it will involve becoming more deliberate about how I use the qualities I've already developed, while recognising when those qualities need to be accompanied by greater activity, clarity, or therapeutic challenge.
There is something reassuring about recognising that professional growth doesn't require the wholesale rejection of our previous experience. Instead, it can involve building upon what has served us well while becoming increasingly willing to question the habits and assumptions that may now limit our development.
Looking Ahead
As I look towards beginning three years of ISTDP Core Training, I'm conscious that this is still very much the beginning. There is a substantial difference between recognising these processes in a training video and being able to work with them consistently within my own clinical practice.
I have no illusions about the amount of learning ahead, and I'm increasingly aware that developing competence in this approach will require considerable patience, practice, and a willingness to examine my own limitations. But I also feel that something important has begun to change in the way I understand the purpose and possibilities of psychotherapy.
I'm becoming less interested in how much material we explore within a session, how sophisticated an interpretation might be, or how many connections we can make between someone's past and present experiences. Instead, I'm becoming more interested in whether the work is helping someone recognise, experience, and change the psychological processes that maintain their suffering.
Sometimes that might involve a powerful emotional experience, but sometimes it might be something much quieter. A person recognising how automatically they dismiss their own wishes, becoming aware of anxiety before it overwhelms them, or discovering that they can express a feeling towards another person without losing the relationship can all represent meaningful developments.
These changes can be extraordinarily important, even when they don't look particularly dramatic from the outside. I'm increasingly appreciating that psychotherapy doesn't necessarily need to produce dramatic emotional experiences to be effective, but it does need to remain attentive to what is changing and what continues to maintain the person's difficulties.
I'm also becoming more conscious that psychotherapy isn't simply about uncovering the past. It's about helping someone become less governed by it, particularly when earlier emotional experiences continue to influence how they perceive themselves, relate to others, and respond to situations in the present.
The past matters because of the ways in which it continues to organise present experience, but the possibility for change exists in the present. In what someone feels, what they avoid, how they relate to themselves and others, and what becomes possible when they begin to recognise these patterns and respond differently.
Learning to Listen Differently
If I were to identify the most important thing I've taken from this year, it would probably be a developing appreciation of clinical attention. The ability to listen to someone's story while remaining attentive to what is happening psychologically as they tell it, hearing the narrative without becoming lost in it.
It involves recognising the emergence of emotion, the mobilisation of anxiety, and the operation of defensive processes. It also means noticing how earlier attachment experiences may be influencing the present therapeutic relationship, while developing the judgement to know when to intervene, when to regulate, when to clarify, and when simply to remain present.
I'm discovering that effective psychotherapy can sometimes involve doing considerably less, but with much greater precision. Not less care, emotional involvement, or attention, but less unnecessary activity, less rushing towards understanding, and less becoming caught in the latest difficulty.
Instead, it involves a greater willingness to remain with the psychological process that is actually unfolding, even when that requires tolerating uncertainty or resisting the temptation to retreat into familiar ways of working. I'm beginning to recognise that this kind of sustained attention is a clinical skill in its own right, one that requires considerable practice and a willingness to continually examine our own responses.
And perhaps this is where the most personal aspect of my reflection lies. For several years, I've been developing my capacity to understand people and help them understand themselves, learning to value patience, therapeutic consistency, emotional safety, and the importance of allowing people to discover things at their own pace.
I still value all of these things, but increasingly, I'm recognising that I also need the confidence and clinical competence to intervene when understanding alone isn't enough. I need to recognise when the therapeutic process itself has become organised around avoidance, and when something important is being repeatedly discussed without necessarily being experienced or changed.
This requires something from me as well as from the person I'm working with. A willingness to tolerate uncertainty, recognise my own anxiety, question familiar habits, and remain open to the possibility that a different therapeutic response might be needed.
I began this year wanting to become more effective at helping people with the problems they bring into therapy. As the year has progressed, that ambition has begun to change, becoming less about responding to individual difficulties and more about understanding the psychological processes that continue to generate them.
I want to become more effective at helping people understand and overcome what keeps them trapped in those problems in the first place. I want to develop the capacity to recognise when someone's emotional life is being governed by old conflicts, defensive processes, or a harsh internal authority, and to help them discover that something different is possible.
And I want to do this without losing the warmth, humanity, and genuine curiosity that brought me into psychotherapy in the first place. These qualities remain central to how I understand the therapeutic relationship, but I'm increasingly interested in developing the clinical precision necessary to make the fullest possible use of them.
Perhaps becoming a better therapist isn't about acquiring an entirely new therapeutic identity, but developing the courage to examine the one we already have. It involves recognising what has served us well, what may have become too familiar, and what we might need to relinquish in order to continue growing.
Ultimately, I don't think the purpose of psychotherapy is simply to help someone survive another difficult week. It's to help them develop a greater capacity to live their own life, with more emotional freedom, more autonomy, and perhaps most importantly, a little less fear of being themselves.
And if this year's training has taught me anything, it's that developing the capacity to help people achieve this is a lifelong undertaking. One that requires just as much curiosity about ourselves as it does about the people who come to us for help, and a willingness to keep learning long after we might reasonably have assumed we knew what we were doing.
Rick Cox is a BACP Accredited Psychodynamic Psychotherapist practising online across the UK. During 2026, he has been studying ISTDP Pre-Core training with ISTDP North, led by Dr Javier Malda Castillo, ahead of beginning three-year Core Training.
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media depth anxiety emotion betterhelp reflections quizzesWritten by Rick Cox, MBACP (Accred)
Psychodynamic Psychotherapist, UK & Online
