What happens when a psychotherapist revisits something familiar and discovers what they've been overlooking? A reflection on emotional experience, clinical attention, and the continuing process of learning to listen with your eyes!
Vilhelm Hammershøi, Interior, Young Woman Seen from Behind (1903–1904). A quiet study of presence and absence, reminding us that what remains unexpressed can be as revealing as what is spoken.
Attachment Based ISTDP Workshop, November 14th 2026, ISTDP North
Reflections on psychotherapy, emotional experience, and the things we sometimes fail to notice.
There's a particular kind of humility that comes with discovering how much you still have to learn about something you've been doing for years. I've experienced quite a lot of that recently, particularly through my ongoing training in Intensive Short-Term Dynamic Psychotherapy (ISTDP). Having worked with hundreds of people over thousands of clinical hours, I might reasonably have expected to feel increasingly confident in my understanding of psychotherapy. In some respects, I do. In others, the more into this I go, the more I become aware of things I hadn't previously considered.
I was reminded of this during a psychotherapy training workshop recently. We were revisiting clinical material I'd encountered before, and I found myself noticing aspects of the therapeutic process that had previously escaped my attention. Nothing about the material had changed. I was simply seeing it differently, which left me thinking about something deceptively simple: How much of psychotherapy involves paying attention not only to what someone is saying, but also to what isn't happening as they say it.
When we think about listening, we usually imagine attending carefully to someone's words, trying to understand their meaning and recognising the emotions behind them. This is certainly an important part of psychotherapy. People arrive carrying experiences they may never have spoken about openly, sometimes struggling to find language for things they've lived with for years. Being able to tell their story to someone who is genuinely interested can be profoundly meaningful.
But there's another dimension to listening that I'm becoming increasingly interested in. It involves noticing what happens within the person as they speak.
Someone might describe an experience that appears deeply significant, perhaps something involving loss, disappointment, rejection or an important relationship, yet seem surprisingly detached from what they're describing. They might understand the circumstances perfectly well, explain why something happened and even recognise how it continues to affect their life, while remaining relatively disconnected from the emotional experience itself.
Of course, there are many reasons why someone might not visibly express emotion. People differ enormously in how they experience and communicate their feelings. A composed appearance doesn't necessarily indicate emotional avoidance, and outward expression is never a reliable measure of how deeply someone feels something. These distinctions matter, particularly in psychotherapy, where assumptions can easily become obstacles to understanding. Nevertheless, there are occasions when the apparent absence of feeling becomes something worth exploring.
Perhaps someone has learned that expressing sadness makes other people uncomfortable, or that anger threatens relationships they cannot afford to lose. Perhaps they grew up in an environment where emotional needs were dismissed, criticised or simply overlooked. Over time, they may have become remarkably skilled at explaining their experiences without allowing themselves much contact with the feelings associated with them.
Such adaptations often make sense when considered in the context in which they developed. What once helped someone navigate a difficult relationship or environment can become so familiar that they no longer recognise themselves doing it.
This is one of the things I find most compelling about psychodynamic psychotherapy. We aren't simply interested in what has happened to someone, but in how their experiences have shaped the ways they relate to themselves and others. Sometimes the very strategies that helped a person manage difficult feelings in the past become the things that prevent them from experiencing greater freedom in the present.
There's also an important difference between understanding something intellectually and experiencing it emotionally. A person might know that their childhood involved criticism, recognise that they continue to expect criticism from others and understand why they find it difficult to express themselves. Yet that understanding doesn't necessarily change what happens when they encounter a situation that brings those old expectations to life.
They may still become anxious, withdraw, criticise themselves or automatically place someone else's needs above their own. This isn't because they lack insight or haven't thought carefully enough about their difficulties because sometimes the understanding is already there, but the emotional experience has yet to catch up.
Part of the therapeutic work involves helping people become more aware of these processes as they happen, rather than only recognising them afterwards. It may mean noticing how anxiety appears when a particular feeling begins to emerge, or how quickly someone dismisses their own experience when something emotionally important comes into view.
What interests me increasingly is the precision this requires from the therapist. It's tempting to imagine that good psychotherapy depends upon finding the right interpretation, asking a particularly insightful question or saying something that produces a dramatic moment of recognition. Yet much of the work appears to depend on something quieter: maintaining enough attention to notice the small changes that occur throughout a conversation.
A slight hesitation, a change in tone, a sudden movement away from something emotionally significant, or a moment when the person's words and apparent emotional experience seem strangely disconnected. None of these observations tells us what is happening on its own, but each may offer an opportunity to become curious, and this level of curiosity, I think, is essential. Not the sort that demands an answer, but the kind that leaves room for another person's experience to surprise us.
This brings me back to my recent training and the rather humbling experience of noticing something in familiar material that I hadn't properly appreciated before. It would be easy to interpret that as evidence of something I'd previously missed or failed to understand. Perhaps it was. But I'm beginning to think that developing as a therapist involves becoming increasingly comfortable with the knowledge that our understanding is always incomplete.
Experience is valuable, but it can also make familiar ways of listening feel deceptively comprehensive. We begin to recognise patterns, anticipate where conversations might lead and develop ways of responding that have served us well. The danger is that familiarity can narrow our attention as readily as it sharpens it.
Learning something new can disturb that familiarity. It asks us to reconsider what we think we're observing, examine our assumptions and become willing to recognise things that have been present all along.
I'm finding this both challenging and quietly rewarding. There are moments during training when I feel considerably less experienced than I did before I started, which is a peculiar feeling after so many years of clinical work. Yet perhaps the willingness to experience that uncertainty is part of what allows professional development to continue.
I don't think becoming a better therapist necessarily means accumulating an ever-growing collection of techniques or increasingly sophisticated explanations. There is certainly a place for both, but I'm beginning to appreciate how much rests upon the quality of attention we bring to another person's experience.
Sometimes that means listening closely to what someone is trying to tell us. Sometimes it means recognising the effort involved in saying it. And sometimes it means noticing that something emotionally important appears to be missing, without assuming we already know why.
The workshop reminded me that there is always more to discover, even in something we've encountered before. Perhaps especially then.
After all, the material hadn't changed. What had changed was my ability to notice it.
Rick Cox is a BACP Accredited Psychodynamic Psychotherapist and IEDTA Student practising online across the UK. During 2026, he has been studying ISTDP with ISTDP North, led by Dr Javier Malda Castillo, in preparation for beginning three-year Core Training in 2027.
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media depth anxiety emotion betterhelp reflections quizzesWritten by Rick Cox, MBACP (Accred)
Psychodynamic Psychotherapist, UK & Online
