Does my Therapist Really Understand Me?
Therapy is often thought of as a space created for understanding. However, this does not mean that understanding always comes easily. This is because therapy is not simply a conversation between two people, but rather a process that unfolds simultaneously on multiple levels. On one hand, there is what the person shares; on the other, how those shared experiences are actually felt. On one hand, there are the therapist’s interventions; on the other, how these interventions resonate with the person. These layers do not always align perfectly. Sometimes, small discrepancies arise between what is said and what is felt, or between what is understood and what is experienced.
These differences are often natural and inevitable. The person’s current emotional state, past experiences, expectations, and the relationship established with the therapist; the therapist’s points of focus, the language used, and the timing of interventions…All of these shape the process simultaneously. Therefore, while therapy may appear to progress linearly from an external perspective, internally it unfolds in a more fluid and multi-layered manner. Within this multi-layered structure, the therapeutic alliance and pacing plays a significant role which brings past relationships are also brought into that room in some way.
A significant portion of these dynamics is not always explicit. They often emerge indirectly; sometimes the person does not articulate them, and at other times the therapist may not fully recognize them.
At this point, approaches aimed at making the therapy process more transparent and jointly evaluable begin to gain importance. Feedback-Informed Treatment (FIT) is one example of this. FIT proposes regularly incorporating the person’s experience of the therapeutic process into the process itself and actively utilizing this information. In this way, these dynamics can be identified earlier, and the therapeutic process can be reshaped to better align with the person’s needs. In this therapy sketch, we will explore feedback informed treatment.
Therapeutic Alliance as a Form of Understanding
At this point, understanding the therapeutic alliance becomes crucial. The therapeutic alliance is the working relationship between the therapist and the person, and it has three key components: agreement on therapy goals, a shared understanding of how to achieve those goals, and the emotional bond formed between the two individuals. Research has shown that the stronger this relationship is, the better the therapeutic outcomes tend to be.
However, the mere existence of the alliance is not sufficient on its own. The person’s genuine sense of being understood lies at the heart of this relationship. This feeling is often linked to the therapist’s empathy, which is how accurately and deeply the therapist can grasp the person’s inner world. Additionally, the therapist’s level of sincerity and the extent to which they collaborate with the person are also decisive factors. The therapist’s ability to attune to the person’s emotions (how emotionally “in tune” they are during the session in a timely and fitted way) also directly influences this experience (Wampold & Flückiger, 2023).
Pacing as a Form of Understanding
In addition to the therapeutic alliance, another key factor that determines how the process unfolds is pacing. Here, pacing is not merely about the frequency of sessions; rather, it is about when and how the therapist uses interventions, how ready the client is for these interventions, and how change emerges.
The client’s readiness becomes the determining factor here. While some individuals are ready to delve deeper emotionally, such interventions can be challenging for others to regulate. Similarly, while some individuals benefit from more structured and directive work, this approach may feel overly restrictive for others. In this sense, pacing serves as an indicator of how well the therapy aligns with the person’s capacity.
If the therapist’s pace goes beyond the client’s pace, therapy can become too intense and overwhelming. If it lags behind, the process may remain superficial, and the sense of progress may be lost. In either case, the client may not feel fully understood or supported (Prochaska & DiClemente, 1983).
The therapist and the person receiving therapy do not have the same experience
The therapist and the person getting therapy may not experience the same session in the same way. While the therapist may think the process is going well, the person getting therapy may feel that they aren’t being understood enough. People getting therapy generally evaluate the therapy not so much based on how “correct” it is, but rather on how helpful it is, whether they feel they’re working together, and how responsive the therapist is. In other words, the issue is not always about making the correct analysis, but rather how the person experiences it.
For this reason, being understood in therapy is not solely about technical accuracy. It has more to do with how the therapist listens, how they respond, and the kind of relationship they build with the person. And it is precisely at this point that other dynamics come into play, dynamics that are difficult to discern within the process itself.
Transference & Countertransference
We specifically use the word “dynamic” here because therapy is not a static process. On the contrary, it is a relational process that is constantly changing, taking shape, and being reconstituted in the moment. At the same time, this process is not limited solely to what is happening “right now”; past relationships are also brought into that room in some way. We refer to this phenomenon in psychotherapy as transference and countertransference.
Transference involves the person directing emotions, expectations, and relationship patterns from past relationships toward the therapist. The person receiving therapy may experience the therapist as critical, distant, or abandoning. This often has more to do with the person’s past experiences than with what the therapist is actually doing in that moment (Praško et al., 2022).
Countertransference, on the other hand, encompasses the emotional and behavioral responses the therapist offers to the person receiving therapy. These responses are influenced by both the therapist’s own inner world and the relationship patterns the person brings to the session. These two processes work together and form an important part of the therapeutic relationship. In fact, alongside the therapeutic alliance, it is one of the fundamental relational layers that shape what happens in therapy. For this reason, therapy progresses not only through the content of what is discussed but also through these relational dynamics (Praško et al., 2022).
For this reason, therapy progresses not only through the content of what is said but also through these relational dynamics. However, a significant portion of these dynamics is not always explicit. They often emerge indirectly; sometimes they are not expressed by the person, and at other times they may not be fully recognized by the therapist.
This is precisely where a critical question arises: How accurately can the therapist understand the actual experience of the therapeutic process?
Feedback Informed Treatment
Research shows that therapists may not always accurately assess a persons progress or the areas where they are struggling. In particular, minor disruptions in the therapeutic alliance, mismatches in pacing, or the effects of transference and countertransference processes can go unnoticed if not explicitly addressed (De Jong et al., 2021; Delgadillo et al., 2018). This poses a risk in therapy: the process continues, but it may not be sufficiently clear how understood the person feels or how effective the therapy truly is.
It was precisely at this point that approaches began to emerge aimed at making the therapeutic process more transparent and jointly assessable. One of these is Feedback-Informed Treatment, or FIT for short.
FIT was developed in the early 2000s by Scott D. Miller and Barry Duncan. It was not created with the intention of introducing a new therapy model. In particular, the work of Michael Lambert and other researchers has shown that therapists often fail to notice when a person is deteriorating or when progress has stagnated. In other words, even well-intentioned, trained, and experienced therapists may not always be able to clearly see how the process is actually unfolding (Lambert et al., 2003; Hannan et al., 2005). Miller and Duncan took this as their starting point. If the therapist cannot always accurately assess how the process is going, why shouldn’t obtaining this information directly from the person be part of the process?
How does FIT work?
FIT is an approach that changes how the therapeutic process is monitored, rather than simply adding new techniques to therapy. Essentially, it proposes that the person’s experience of therapy (in terms of both progress and the therapeutic relationship) be regularly assessed, and that this information be actively utilized during the session (Miller et al., 2016).
A key aspect of this approach is that feedback is not merely collected but integrated into the therapeutic process itself. At the start of each session, the person assesses how they are feeling and how their life is going; at the end of the session, they express their thoughts on the therapeutic relationship and how beneficial the session was. The therapist does not simply record this information but discusses it with the person.
Thus, therapy transforms from a process based solely on the therapist’s observations into a more transparent and collaborative process actively guided by the person’s experience.
Take aways
- Therapeutic understanding does not occur automatically; it is a process that must be actively cultivated.
- These layers do not always move in sync; mismatches between them are a natural part of the process.
- Feedback-Informed Treatment (FIT) helps bring these layers into alignment by making the client’s experience visible and usable within the process.
References:
Wampold, B., & Flückiger, C. (2023). The alliance in mental health care: conceptualization, evidence and clinical applications. World Psychiatry, 22. https://doi.org/10.1002/wps.21035.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages of change model.
Praško, J., Ociskova, M., Vanek, J., Burkauskas, J., Šlepecký, M., Bite, I., Krone, I., Sollár, T., & Juskiene, A. (2022). Managing Transference and Countertransference in Cognitive Behavioral Supervision: Theoretical Framework and Clinical Application. Psychology Research and Behavior Management, 15, 2129 – 2155. https://doi.org/10.2147/prbm.s369294.
De Jong, K., Conijn, J. M., Gallagher, R. A., Reshetnyak, E., Heij, M., & Lutz, W. (2021). Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: A multilevel meta-analysis. Clinical Psychology Review, 85, 102002.
Delgadillo, J., Moreea, O., & Lutz, W. (2018). Different people respond differently to therapy: A demonstration using patient profiling and risk stratification. Behaviour Research and Therapy, 100, 1–10.
Lambert, M. J., Whipple, J. L., Hawkins, E. J., Vermeersch, D. A., Nielsen, S. L., & Smart, D. W. (2003). Is it time for clinicians to routinely track patient outcome? A meta-analysis. Clinical Psychology: Science and Practice, 10(3), 288–301.
Miller, S. D., Bargmann, S., Chow, D., Seidel, J., & Maeschalck, C. (2016). Feedback-informed treatment (FIT): Improving the outcome of psychotherapy one person at a time. In Quality improvement in behavioral health (pp. 247-262). Cham: Springer International Publishing.
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