the "How-To" Therapy Handbook
HOW WE WORK
Contemporary Psychodynamic Therapy, Skills, and Clinical Pragmatism
PART TWO: Other Ways We May Understand the Same Experience
Therapy does not have to choose between understanding yourself deeply and learning practical ways to respond differently.
Our work is grounded in contemporary psychodynamic therapy.
This means that we are interested in more than symptoms alone.
We pay attention to emotions, internal narratives, recurring patterns, relationships, earlier experiences, avoidance, and what happens between us in therapy.
At the same time, contemporary psychodynamic therapy does not require us to ignore useful ideas simply because they originated in another school of therapy.
This is why at TheXponential, we use a pluralistic and pragmatic approach.
It’s not to have every intervention carry the same theoretical label.
The point is that different therapeutic models can illuminate different parts of the same experience, and techniques are chosen based on how they fit the person and the problem.
To put it simply: WE DO WHAT WORKs.
Interpersonal: What Happens Between People?
Many difficulties make more sense when we look at them in the context of relationships.
We may explore:
What do you expect from other people?
What happens when you need reassurance, closeness, independence, or space?
How do you respond to disappointment or conflict?
What does your response then evoke from the other person?
Does the interaction eventually produce exactly what you feared?
An interpersonal perspective helps us move from
“What is wrong with me?”
toward “What pattern is happening between us?”
Psychodynamic therapy adds questions about where the pattern came from, what emotions and expectations organize it, and why it may continue even when you consciously want something different.
Relational Psychodynamic: What Happens Between Us Here?
Relationships are not only something we talk about in therapy.
Therapy is itself a relationship.
That means familiar expectations can sometimes appear here too:
fears of disappointing the therapist,
being misunderstood,
needing to perform,
expecting criticism,
wanting approval,
pulling away when vulnerable,
or worrying that disagreement will damage the relationship.
Contemporary relational psychodynamic therapy treats these moments as useful information.
Rather than assuming the therapist is a neutral observer who always knows what is happening, we can examine the interaction together.
Sometimes the client’s old expectation is appearing.
Sometimes the therapist has genuinely misunderstood something.
Sometimes both people have contributed to what happened.
Understanding that process together creates an opportunity to experience a relationship differently rather than simply talking about relationships outside the room.
Emotion-Focused: What Is the Feeling Underneath the Reaction?
People often arrive knowing what they think about an experience long before they know what they feel.
We may slow the experience down.
You say:“I am angry.”
We may ask:
What kind of anger?
What happened immediately before it?
Was there hurt? Fear? Shame? Rejection? Helplessness?
Or perhaps anger really is the central feeling and needs to be recognized rather than explained away.
Emotion-focused approaches help us differentiate emotional experiences rather than treating every uncomfortable state as the same thing.
Psychodynamic work then becomes curious about the pattern surrounding the emotion:
Why is this feeling difficult to experience?
What happens when it appears?
What do you do to move away from it?
What have you learned that this emotion means about you or about relationships?
The goal is not simply to identify the “correct” emotion.
It is to become increasingly able to experience, understand, tolerate, and use emotional information.
DBT: Noticing, Regulating, and Choosing
DBT provides practical ways to slow the sequence down when emotion is intense.
Mindfulness / Observe and Describe can help us notice:
Here is the sensation.
Here is the emotion.
Here is the thought my mind produced.
Psychodynamically, this also strengthens the capacity to observe internal experience rather than simply enact it.
Check the Facts helps distinguish what is known from what is feared, assumed, or anticipated.
→Psychodynamic exploration can then ask why a particular feared interpretation carries so much emotional weight.
Opposite Action can help someone behave differently when an emotion is pushing toward an ineffective response.
→ Psychodynamic inquiry examines:
What makes the alternative response feel dangerous, unfamiliar, guilty, exposing, or somehow “not me”?
Distress-tolerance skills, including STOP or other ways of reducing immediate arousal, can make deeper exploration possible when an emotion is simply too intense to think about productively.
Interpersonal skills such as DEAR MAN, GIVE, and FAST can provide concrete ways to communicate needs, maintain relationships, and preserve self-respect.
Therapy can then examine what happens when you try:
Do you become afraid of being demanding?
Do you over-explain? Withdraw?
Become angry when the other person has a separate perspective?
The skill helps us create a different interaction.
The interaction gives us new information.
That new experience becomes part of the deeper work.
ACT: A Thought Can Be Present Without Running the Show
Sometimes the central problem is not whether a thought is factually correct.
It is how completely the thought takes over.
We isolate the internal narratives:
“I am disappointing everyone.”
“I cannot handle this feeling.”
“If I say no, I am selfish.”
ACT calls one way of working with this cognitive defusion: learning to notice a thought as a mental event rather than automatically treating it as an instruction or fact.
We may therefore distinguish:
This is what happened.
This is what my mind is telling me about it.
This is what I feel.
This is what I want to do.
This is what actually matters to me.
ACT also emphasizes acceptance, present-moment awareness, values, and committed action.
Psychodynamic exploration adds another dimension:
Why does this particular narrative have such power?
What feeling becomes more visible when we stop arguing with the thought?
What old expectation may be organizing it?
The goal is not necessarily to eliminate difficult thoughts and feelings before living differently.
Sometimes change means becoming able to hold them without letting them make every decision.
CBT: Examining the Thought
CBT gives us useful tools for identifying automatic thoughts, distinguishing interpretations from facts, examining evidence, generating alternative explanations, and testing predictions through behavioral experiments.
We might ask:
What actually happened?
What did your mind immediately conclude?
What evidence supports that conclusion?
What evidence does not?
What else could explain the situation?
What happens if you respond differently and see what occurs?
Psychodynamic work does not oppose those questions. It adds others.
Why did “they are upset with me” become the automatic interpretation rather than one of twenty other possibilities?
What emotion does that interpretation organize?
What are you expecting from the other person?
What do you then feel compelled to do?
Where else does this sequence occur?
The cognitive thought becomes one entry point into a larger pattern.
Existential: What Do You Want to Do With the Life You Actually Have?
Not every problem has a technique that makes it disappear.
People face uncertainty, loss, limitation, responsibility, loneliness, changing identities, difficult choices, and questions about meaning.
Existential thinking gives those questions a legitimate place in therapy.
We may ask:
What matters enough to you that discomfort is worth tolerating?
What are you choosing, and what are you avoiding choosing?
Which parts of this situation can you influence?
What cannot be changed?
What kind of person do you want to be in relation to what has happened?
What makes a life feel meaningful to you rather than merely successful?
Psychodynamic work contributes an important complication: we are not always completely free agents. History, relationships, unconscious expectations, fear, and defenses shape what feels possible.
Greater self-understanding can therefore create greater freedom to choose.
Family Systems: The Problem Does Not Exist in Isolation
Individual therapy still takes place in the context of families, relationships, communities, and larger systems.
A family-systems perspective asks us to notice roles and interaction patterns.
Who usually takes responsibility?
Who keeps the peace?
Who withdraws?
Who becomes the problem-solver?
Whose feelings determine what everyone else does?
What happens to the system when one person begins setting a boundary or behaving differently?
This can be particularly useful when someone understands intellectually that they are “allowed” to change but experiences enormous guilt, anxiety, or pressure when they actually try.
Psychodynamic work can explore why a particular role became psychologically important.
Systems thinking helps us see how other people may react when that role changes.
Both are relevant when building a different way of relating.
Multicultural and Culturally Responsive Work: Context Changes Meaning
Psychological experiences do not occur outside culture.
Family expectations, race, ethnicity, gender, sexuality, immigration, language, religion, socioeconomic position, community, disability, and other identities can affect what an emotion, behavior, relationship, or decision means.
A culturally responsive approach therefore requires curiosity rather than assumption.
We may ask:
What does this mean in your family or community?
Which expectations feel like your own and which feel inherited or imposed?
Where do culture and identity provide belonging or strength?
Where do they create conflict?
Are we interpreting something through different cultural assumptions?
This perspective also applies to the therapist.
Therapists bring their own identities, assumptions, and blind spots into the room.
Cultural humility means remaining willing to notice them, discuss them, and revise our understanding.
Pluralism is especially important here: the client should never have to fit a psychological theory that ignores the context in which their life actually occurs.
Trauma-Informed: Understanding Adaptation Before Calling It Pathology
Traumatic experiences can shape emotion, attention, relationships, the body, expectations of safety, and ways of coping.
A trauma-informed perspective asks not only:
“Why are you doing this?”
but also:
“What might this response have helped you survive, manage, or prevent?”
Hypervigilance may once have increased safety.
Emotional distance may have protected against overwhelming vulnerability.
Control may have created predictability.
Avoidance may have prevented unbearable emotional activation.
Understanding the adaptive function of a response does not mean that the response must remain unchanged.
It means change begins with understanding why the response exists.
Depending on the person and situation, work may involve
grounding,
emotion regulation,
restoring choice and agency,
developing safer relationships,
processing meaning,
recognizing triggers,
or gradually approaching experiences that have been avoided.
One Foundation, Multiple Ways of Working
These approaches do not need to compete with one another.
A difficult moment may involve a thought that CBT helps us examine, an emotion that emotion-focused work helps us experience,
an ACT skill that helps us make room for it,
a DBT skill that helps us regulate it,
a relational pattern that psychodynamic therapy helps us understand,
a family system that reinforces it,
a cultural context that changes its meaning,
and
an existential question about what we want to do next.
Clinical pragmatism means we can use those perspectives without pretending they are interchangeable.
We ask what each perspective helps us see.
We try interventions intentionally.
We pay attention to your response.
And we continue revising our understanding together.
Theory gives us ways of seeing.
The therapeutic process tells us what actually helps.
Understanding the adaptive function of a response does not mean that the response must remain unchanged.
It means change begins with understanding why the response exists.
Depending on the person and situation, work may involve
grounding,
emotion regulation,
restoring choice and agency,
developing safer relationships,
processing meaning,
recognizing triggers,
or gradually approaching experiences that have been avoided.
Contemporary psychodynamic therapy recognizes that insight alone does not automatically change every pattern.
Sometimes we understand exactly why we do something and still keep doing it.
Change may also require practicing another response, tolerating a feeling we usually avoid, approaching something we fear, communicating differently, or discovering through experience that an old expectation no longer fits the present.
This is where behavioral experiments, exposure, problem solving, emotion-regulation skills, or interpersonal skills can become useful.
But we remain interested in what happens inside you while you try them.
Difficulty using a skill is not automatically a failure to “do therapy correctly.”
It may itself tell us something important.
Why does setting a boundary produce guilt?
Why does accepting reassurance feel unsafe?
Why does asking directly for what you need feel humiliating?
Why does calming down sometimes feel like surrendering?
Why is a familiar painful response easier to tolerate than an unfamiliar healthy one?
These are psychodynamic questions.
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