Therapy’s Goal: Finding Pathology or Accepting Complexity?

Double exposure of person wearing hat with calm face and eyes closed, turbulent seaLabeling pathology in another person is easy. One teacher of mine said it’s like “shooting fish in a barrel.” Think of any person you know and, unless you’ve totally idealized them, I bet you can find some psychological diagnostic label to pin on them. “So neurotic!” “So hysterical!” “So narcissistic!” We all have the ability to spot apparent pathology. But we all, therapists included, sometimes have a much more difficult time recognizing health—the healthy strivings of others and of ourselves.

So why is so much mental health education, from graduate programs to popular blog posts, focused on helping people identify and label (aka diagnose) pathology? What problematic dynamics are evoked when the therapist and others function only as pathology detectors? How can we reorient ourselves toward detecting human complexity, the complex intertwining of “health” and “pathology” within ourselves and each other?

Why Is It Useful to Be Sensitive to Pathology?

Imagine if you went to your car mechanic because something is wrong—your car would not accelerate past 25 mph. Imagine the mechanic takes a thorough look at your car and says, “Well, I can’t see anything wrong. I think your car is fine.” You might be more than a little concerned about your difference of opinion with the mechanic, and you’d probably look for a second opinion.

The same is true with therapists. Some emotional problems show up in big, visible ways—a depression that makes it hard to get out of bed, for example, or panic attacks. However, some mental health conditions and—more importantly—the underlying emotional processes that contribute to them are quite subtle and difficult to detect. Without thorough and nuanced training in detecting the manifestations and drivers of people’s issues, therapists are at risk of looking a suffering person in the eye and saying, “You seem fine to me.” For this reason, we need a refined understanding of all the parts in the engine of the human mind, and we need to know how a person looks when some part of that engine is malfunctioning.

As important as it is to be able to see and understand a person’s issues, the therapeutic relationship is deeply compromised when the person’s issues are all we can see.

When All We See Is “Resistance”

Realistically, some people come to therapy in a near-total state of resistance:

“I didn’t want to come today.”

“I’m only here because my partner said I need to be here.”

“Does therapy even work?”

It can be hard to imagine how progress can be made in the face of attitudes like these. It seems like “pathologies” like defiance, passive compliance and hopelessness have totally taken over the people quoted above. It’s hard to find any overtly “healthy” dimension of their comments.

As a therapist, I encounter statements like these with great regularity, and I’ve seen plenty of instances of “resistance” and “pathology” that are even more bold and provocative. It is incredibly easy to hear these comments and become hopeless—if all we see is resistance, we may begin to doubt whether a healing-oriented part of the person even exists for us to build an alliance with.

In moments like this, we forget that, though the person’s words are defiant, passive, hopeless, or whatever else, they still arrived for their session. Not only are they present for the session despite this resistance, they are making an effort to be honest about how they feel. When we relate only to a person’s resistance and “pathology,” we forget that their sharing of their resistance and sharing of their “pathology” is a vulnerable attempt at forming an alliance with us. When we relate only to the resistance described by their words and not to their efforts to reach out through sharing, we miss an important opportunity to connect with the healing-oriented forces buried under the surface behaviors. When all we see is “resistance” and “pathology,” we miss out on the full complexity of the person we are trying to get to know.

Consequences of Seeing Only Pathology

When we fail to recognize and acknowledge the “resistant” person’s profound efforts to reach out to us by sharing their resistance openly, certain problems can plague the therapy alliance.

The person will not feel heard. Generally speaking, we can sense when someone is “pigeonholing” us or seeing us in a one-dimensional way, and we tend not to like that. Conversely, we tend to appreciate it when people have a complex understanding of us, with honesty about our inner “bad” and “good” and “mixed”-ness.

This ability to see and embrace our complexity is perhaps one of the great challenges of growth in therapy and elsewhere. Every day and every therapy session reveals new truths about us, presenting anew the challenge, “Can I accept this part of me?”

When we as therapists relate only to the “pathology” and “resistance” people show us, rather than convey our appreciation for the fact they are showing up to willfully tell us about it, they may feel, and rightfully so, only one part of them is being heard. When we fail to acknowledge the healthy efforts that emerge alongside or are veiled by their “resistance,” we relate only to their “badness,” which can have a severely negative impact on our alliance and lead people to feel more hopeless. Sadly, in cases like these, people often blame themselves for their therapist’s error: “It’s my fault the therapy didn’t succeed. I’m just too resistant!”

The person sitting across from us is already good at criticizing themselves. An expert ability to see and criticize our own foibles is part of what brings many of us to therapy in the first place. I have noticed when therapists relate only to a person’s pathology, one common response is for the person in therapy to join in with the therapist, criticizing their thoughts, feelings, and behaviors. This may look like helping a person “turn against their defenses” or helping them to “see their resistance,” but so often it is the establishment of an alliance built around change via criticism, which never seems to yield the desired therapeutic result.

The person may try to change, but not to please themselves. People in therapy tend to respond to the therapist’s tendency to notice only their pathology by trying to change. In these instances, they tend not to be changing for themselves or changing in directions they desire for their own well-being; instead, they tend to change in the direction they believe their therapists would prefer with the hope of no longer being criticized or related to as “bad.” This can be a reenactment of problematic attachments from the person’s past.

The Therapist’s “Pathology”

Your therapist’s difficulty seeing your complexity, the ways your healthy efforts coexist and intertwine with your struggles, is a reflection of their difficulties seeing and accepting their own complexity. Remember, we tend to treat others the way we treat ourselves, and to see others through the lenses we see ourselves through; as a result, the tendency of a therapist to pigeonhole a person as “pathological” suggests the therapist may tend to devalue themselves that same way.

I can only accept the complexity of the people I help to the degree I can accept my own complexity. As therapists, and as people in general, whenever we meet a new person or a new part of ourselves we are called upon to face deeper and deeper levels of the complexity that is humanity. In that moment when we meet a new person, a new truth, will we accept it in all its complexity or will we reduce it to “pathology”?

Can We Accept the Complex Beings We Are?

So how can we see each other as complex people? How can we manage to hold both our health and our destructiveness in mind simultaneously so we have the most complete information about ourselves to work with? How can we gain an appreciation for the complex intertwining of our efforts to communicate and our efforts to wall off, such that our moment of greatest “resistance” may actually be our most profound effort to reach out? Can we accept our “resistance” as simply the most health we can muster at the moment?

This ability to see and embrace our complexity is perhaps one of the great challenges of growth in therapy and elsewhere. Every day and every therapy session reveals new truths about us, presenting anew the challenge, “Can I accept this part of me?” So often in therapy, when we discover something previously unknown about ourselves, we are tempted to reject and pathologize it. It is even tempting to pathologize and reject our tendencies to pathologize and reject ourselves! The human mind is incredibly adept at making an enemy of itself.

So can we accept that? Can we accept the conflictedness about self-acceptance that is part of our humanity at this moment? Can we initiate the journey of acceptance by loving and embracing the pathologizer and rejecter inside right now? That tendency must have been important to learn; otherwise, we would not have learned it. What if the goal in psychotherapy is not about finding health or finding pathology, but about attempting to embrace all of ourselves?

© Copyright 2017 GoodTherapy.org. All rights reserved. Permission to publish granted by Maury Joseph, PsyD, therapist in Washington, District of Columbia

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • Todd

    March 30th, 2017 at 6:41 AM

    I see it as being so much healthier to embrace all the different parts of yourself, not seeing it as something wrong, but rather just another different part of who you are. Not that you don’t have things to work on, of course we all do, but it doesn’t have to be viewed as a sickness.

  • Gina

    March 30th, 2017 at 12:41 PM

    Todd I do agree with you to a certain extent; however I don’t want someone to come away thinking that pathology is a path to normalcy. It isn’t/. Okay so it might be your normal and I understand that but to think that nothing can be done to improve or change it would, in my belief, be wrong. You don’t want to ignore something just because it is part of who you are. Of course if there is any way to own it and embrace it then I can fully accept that. But not if it could possibly harm you or maybe even others. I think that there are some things that you have to acknowledge need to be addressed and dealt with, and this is going to not only be for your own good but it will likely improve the lives of others around you to know that you are taking care of yourself in a positive way.

  • benji

    March 31st, 2017 at 6:37 AM

    Like I need one more thing that is wrong with me to focus on. Nah I will say not pathology.

  • Juzzy

    April 1st, 2017 at 4:24 AM

    “What if the goal in psychotherapy is not about finding health or finding pathology, but about attempting to embrace all of ourselves?”. So basically this whole statement is renaming the imperative towards health as embracing of the ‘self’, which self? How can you consider knowing the manifestations of conflicts, obsessions, existential questions and so on without a structural understanding of the terrain in which you are working? I read this uncritical meandering series of empty questions as one of repressing disturbance, sexual trauma and conflict in the name of blanket acceptance and harmony between client and therapist. As evidenced by the side stepping of the question of the resistance of the therapist, with a positivistic rejection of pathology that correlates with a desire to be loved by the client.

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