by Mia Semelman, Psy.D.

​​It is wrong to set a patient tasks, such as collecting his memories or thinking over some particular period of his life. On the contrary he has to learn above all—what never comes easily to anyone—that mental activities such as thinking something over or concentrating the attention, solve none of the riddles of a neurosis; that can only be done by patiently obeying the psycho-analytic rule, which enjoins the exclusion of all criticism of the unconscious or of its derivatives. (Freud 1912/1958)

Freud’s view that “tasks” get in a treatment’s way runs contrary to CBT’s directionality. This quote reminded me of a major challenge I currently face as a therapist: I haven’t decided how directive to be, in part because “different things work for different people.”

When I started graduate training, I requested placement at The Wright Institute’s CBT Clinic—funny, because I’d benefitted from a five-year psychodynamic therapy with the therapist who inspired me to become a psychologist.

I’m not sure what the CBT-pull was about. Maybe it was the flashy “evidence-based” label. Regardless, I felt I had great success as a first-year-therapist-in-training. My Expo-markered whiteboard provided an agenda that shouted certainty, and, therefore, relief. According to the measures I fastidiously administered, my clients all “got better.” We had a roadmap to success (or, at least, pretended we did).

So, too, did Dr. Hanna Levenson’s Time-Limited Dynamic Psychotherapy, the training I received in my second-year placement. I appreciated TLDP’s structure (though I couldn’t get on board with Freud’s psychosexual stages or object relations just yet). Again, I saw my clients benefit, and I personally benefited from seeing that “benefitting” looked different for different people.

But across practica, internship, and postdoc applications, I was told to market myself with a coherent narrative. I was to summarize years of experience, reading, supervision, and my own therapy to formulate “my approach.” When I became licensed in 2024, I was finally supervision-free. Now was the time to finalize my approach!

I reverted to the certainty of CBT. But what I discovered wasn’t that surprising: Different things work for different people.

Some clients claimed they wanted CBT, but their actions reflected otherwise. I couldn’t interrupt or redirect. Despite agreeing week after week, clients didn’t complete their homework. Many even became frustrated for not continuing with CBT after I’d accepted we weren’t doing it and needed something else. They’d ask, “Where are we in the curriculum?” I was confused. Should I stay the course, gently insisting on clients’ compliance before firing them when it was “clear” we weren’t “the right fit?” Or should I adapt and listen for what was underneath, “enjoined” not to exclude any manifestations of the unconscious and its derivatives?

My confusion leaves me wondering. Supposedly, I decide on my approach, knowing full well that different things work for different people.

Which leads me back to psychoanalytic thinking, possibly in the naïve hope that I’ll finally find some clarity.