Manifest content, venting, and what you’re really trying to say in psychotherapy.

Or how psychoanalytically trained therapists listen…

A friend of mine used to tell me how useless therapy was for him, because “all I would do was vent.” He would complain mostly about his spouse, his children, and the unfairness of everything. Perceived snubs, office drama, boring weekends – all of it- would be spooled out in fifty-minute diatribes that he hoped would alleviate… something, somehow.

The therapists would offer unworkable solutions… (“let’s bring your wife in and tell her how you’re feeling” …!!!) or ask “well, how does that make you feel?”

Lousy, obviously…

It takes years of training to not get “caught” in the manifest content of our patients. So, what is manifest content, anyway?

It’s the stories that bring people into treatment. These stories are important, and also not important. They are complaints about daily life in the present or past. They are important because they are real life – and yes, that is important. They are also not important because they are not the real problem. They just feel problematic.

How to discern what the real problem is?

This is where listening gets interesting. Yes, of course, we pay attention to the manifest content. More important however, is the affect accompanying the story, and the feeling it provokes in us, the listener.

Here is a simple list for listening, in a dynamic way.

1. How is the story being told? Is the person engaged with the story, or is it flat? Where is her energy – is she animated, angry, absent?

2. Who is this story for? Of course, it’s ostensibly for the therapist, but the therapist is a stranger. Who – in the patient’s imagination – should hear this story, or could be listening? This lets us know, a bit, how a patient sees us in his internal world. Are we a rival? Someone who needs convincing? Someone they are charming? Does it feel like a childlike lament?

3. How does it feel to listen? Are we annoyed, interested, upset, sad, engaged, bored, confused? This will also give us clues as to how the story is being used to tell us about the real problem (or problems).

Once we’ve spent a few minutes listening, it becomes easier to hear.

The real problem is often hidden in the manifest content. It can involve a lot of tangled threads, most likely more than one thing, that people use to distract or soothe themselves from things that are hard to admit.

The following are often themes hidden inside the manifest content.

1. Oftentimes perceived slights mean that someone is vigilant about maintaining a “narcissistic equilibrium.” Put more simply – they are trying to soothe a sense of wounded self-esteem.

2. Sometimes the content is about a desire for caretaking, and dependency. Wanting the therapist to give specific advice and answers would fall under this category. Should you divorce your wife? Leave your job? Change countries? Or - sometimes people will talk of their physical aches and pains. We all need soothing, but to focus on it too much obscures the issues at hand.

3. Sometimes it’s about grief – especially the grief that the dreams that had once seemed possible when you’re very young (becoming famous, wealthy, whatever…) may no longer be realistic. Underlying the low self-esteem could be grief about opportunities that are no longer realistically achievable.

How I listen.

When I listen, I also follow the chain of associations. This is simply how we think – one thing slides into another – but why did the discourse take this particular direction? Is it the direction of feeling guilty or finding fault? The direction of worry, or sadness, or regret? This will give me an idea of where there is internal psychological pressure, and what it’s hoping to relieve.

Self-esteem and healthy narcissism.

Yes, narcissism can be healthy and it’s important – it helps us to care for ourselves.

People who have been through complicated life stories tend to be hyper-aware of how they think others see them, and quick to interpret things critically (either for themselves or others).

Most of us spend time, unconsciously, regulating our self-esteem. We do this by trying to be “good” – and this is not a bad thing. We try to be good to others – sometimes to the point of neglecting ourselves. The real problem is being unsure of one’s worth, or value, if others aren’t around to give a flattering mirror-image. The trap can be that you will never serve others enough to fill up a sense of unworthiness or wondering why you’re on the planet if you aren’t “useful.”

Guilt and Aggression

People can find themselves fine-tuning their life around a sense of guilt. These will be stories about how much they have tried to care for and about someone or something, to no avail. They find themselves with partners who take them for granted, so they try harder. Why do they feel like they must try harder than anyone else?

Sometimes this is because of unconscious aggression. Of course they are angry at their partner, their coworkers, whomever… but they are not supposed to feel this way. They are supposed to be nice. If you ask about anger, this is taken as an offense. Of course, they never get angry! Being mistreated is a way of punishing one’s self for feeling angry, which mitigates their guilt.

How can you learn to listen beyond your story?

Where there is strong affect (anger, grief, shame, etc.) there is always more to the story than the superficial content. It’s not about being cold; it’s not about snubs. In psychoanalytic therapy, we try to tie the affect to the real story, which often means you need and want change.

If your self-esteem is low, is it because you’ve crushed your dreams? Did you feel undeserving or incapable of following them? What could be a realistic path forward which allows you to become more yourself? Maybe it’s not realistic to go to medical school at age 45 or become an Olympic athlete or Nobel prize winner… but that doesn’t mean you can’t move forward in things that matter. What keeps you back?

Any story I hear carries something of those themes – a frustration and a desire to move forward towards something that matters, and then (the hard part) getting out of your own way to create that path – imperfectly and slowly, but in a way that feels authentic and uniquely your own.

Thanks for reading It’s Always Something!