Dr. Philip Bender is a practicing psychologist in Manhattan and Poughkeepsie, NY. Writing about modern life and mental health from an existential perspective

How the Therapy Sausage Gets Made

As therapists, we must have some idea about the why. Why do people get depressed or anxious? Why do we have a hard time understanding ourselves or connecting with others? Trouble is, the mental health fields haven’t agreed on one set of answers.

There are dozens of theories and models of the mind, generally sorted into three or four schools of thought. Each school and sub-school has its dogmatists and its detractors. And graduate programs tend to follow a particular school, bringing their students into the fold.

I earned my doctorate at Adelphi University, a psychodynamic (a.k.a. psychoanalytic) program, which means we learned the theoretical models that evolved from Freud’s original work. I’d done some psychodynamic therapy personally, and found it very helpful for understanding myself and casting off the burdens of my past.

I now have an integrative approach that is part existential, part psychodynamic, and part trauma-informed, adding various tools from cognitive-behavioral therapy (CBT) as needed, and I’m a big proponent of group therapy as well…...But if you don’t work in mental health, I’m guessing I lost you about two paragraphs ago. So what does all this mumbo-jumbo really mean?

No, We Don’t All Want to *#&$ Our Parents

I’ve found that when you bring up psychology among lay people, somebody generally mentions Freud right away, so they can feel erudite parroting the common criticisms of his “weird ideas about sex with our parents.” They’ve now dismissed his contributions entirely, making the whole foundation of clinical psychology taboo, and so the conversation is already over. How do you discuss evolutionary biology if Darwin is off the table?

Let’s tackle this head-on. No, we don’t all want to sleep with our parents. Yes, Freud got some things wrong. Like anyone, he was a product of his time. Victorian European society was extremely patriarchal and extremely repressive of human sexuality. This all influenced Freud’s ideas. But the “Oedipus complex” and his childhood sexuality concepts are small pieces of the puzzle.

Freud was the first scientist to focus on unconscious experience, meaning, we can have thoughts, feelings and urges that are beyond our conscious thought. Is that really so outlandish? Just look around you; it doesn’t take an astute observer of human behavior to know people do lots of things that make no fucking sense.

Messy behavior follows messy feelings. We want, we fear, we love, we rage, we lust, often in a single afternoon. But this remains controversial and threatening for some folks, which is why, when I tell people what I do for a living, some repressed baby boomer will often retort, “I’m not saying anything else, you’re probably analyzing me right now.” (Don’t flatter yourself, buddy. I don’t work for free.)

Freud’s other major insight was that memory includes little mental copies of all the important people in our lives. Our emotional attachments still exist, even when those people aren’t around. Again, not too complicated, right? If we love someone, we still love them when they’re outside the room.

Those little mental copies of people we love are really quite adaptive, because we can call on those feelings when we need them (imagine holding a close friend’s love in your heart while facing a painful loss). Trouble is, that same principle applies to the people we fear or loathe, and those feelings can come back even when we don’t want them, which eats away at us.

My job exists because our minds are terribly inefficient at cleaning up and reorganizing all this emotional clutter. Our feelings, attachments, passions, wounds, and losses accumulate over the course of a lifetime, and a lot of it just stays there. On the one hand, that’s growth and maturation; on the other, our demons don’t exorcise themselves.

So that’s, in short, what Freud got right: he created a model of the mind. He showed us how one person’s animal urges, transcendent yearnings and parental voices of conscience all share space in the same brain, leading to a mess of contradictory feelings and behavior.

Our Existential Situation

Eventually I grew disillusioned with the psychodynamic way of practicing. Sadly, there is plenty of truth in the stereotypes about psychoanalytic therapists; many live for highfalutin theorizing about their patients’ unconscious motivations, invoking concepts like the Oedipus complex, which I generally consider ridiculous, while the question of what to do to help our clients is too often neglected.

Don’t get me wrong—our families of origin have a huge impact on our lives, but that’s not how. They impact us because love and connection are basic human needs. When we were children, especially helpless infants, our caregivers kept us alive and gave us our first tastes of human warmth. That’s pretty damn important!

All of which brings us to our existential situation. We don’t choose our basic needs because we don’t choose what makes us human. We don’t choose the family we’re born into or the body we inhabit. We get the cards we’re dealt, simple as that. One human life, expiration date unknown, stability not guaranteed.

What we do with our lives is up to us...whether we want it to be or not. But no matter what we do, our lives will run their course and end. Death is inevitable. Conscious, reasoning creatures that we are, we can know all this, but we can’t change it. That’s a tough pill to swallow.

Our knowledge of death presents a problem that is insoluble to the child’s mind. Because the solution is emotional acceptance, which is a mammoth task. Irvin Yalom argues in Existential Psychotherapy that this, not the Oedipus complex, is the core human conflict that causes us to twist ourselves into unconscious emotional knots.

Talk therapy is premised on the notion of free will. (I mean this in practical psychological terms: we perceive that we have free will, therefore we do. I’m not touching the Philosophy 101 side of it.) Now, will is distinct from feeling, thought, and behavior, none of which we directly control. Consider: your heartbeat, your mood after a bad night’s sleep, and your thoughts right after I tell you not to think about elephants.

The best we can hope for is to shape our experience, which we have tremendous power to do, because every choice we make has an impact. Our free will is both our saving grace and our most crushing responsibility. This is the human dilemma, as Rollo May puts it.

This is why, no matter what tools I’m using as a therapist, it’s always existential. My task is to help everyone who comes to me to face these truths, however they apply to that person’s specific circumstances, and to find the inner strength to embrace their own will. Then, the change begins.

Attachment, Trauma, and Neuroscience

Many people start therapy feeling like crap, so my first step is usually helping clients build coping strategies to make life more manageable. This might include mindfulness and related skills, or even just reviewing the client’s existing habits and routines: are they sleeping and exercising enough? Drinking too much alcohol or caffeine? Absorbed in screens for too many hours?

These tools largely come from cognitive-behavioral therapy, or CBT (in short, changing thoughts and behavior), and they’re not to be underestimated. I really have had clients whose mood turned around after some changes to sleep and screen habits, and some effort at living more mindfully. But in most cases it’s only the first step, and the next is often to start learning about the client’s attachments.

We’re creatures of habit, so we develop patterns of behavior based on what has already worked to get us the connections we crave. Which means, whatever you instinctively learned to do to win your parents’ approval, those habits are going stick with you. They’re going to shape your future relationships and keep reinforcing themselves.

This is the psychodynamic part. I help people understand their attachments, and these learned patterns of behavior. When the patterns outlive their usefulness, a change process is needed. Knowing why we do what we do is the first step to changing it.

Group therapy is also particularly effective for this because whatever patterns the members bring, they’ll act on those behaviors in the group. We see it happen in real time, can help the member understand and face what they’re doing, and actively work on changing it.

Now, by coming to therapy, the client has a relationship with me too, so I experience those patterns firsthand. A client who’s been mistreated, and learned to distrust authority figures, will probably be suspicious of me. The jargon for this is “transference,” and it’s what makes psychodynamic therapy feel so intense and off-putting to some (like that boomer guy from before).

Working on these patterns often means confronting the past experiences that formed them, which brings us to trauma. Remembering emotional pain can cause us to relive that pain, which is particularly hard because our brains operate differently in traumatic situations. They enter emergency “fight or flight” mode, which can imprint the trauma on mind and body in disorganizing ways.

So this is the trauma-informed piece. Healing trauma in therapy is rarely as simple as talking about it. Survivors need emotional support to rebuild forgotten coping skills, and sometimes we use specialized techniques to approach the charged trauma memories in a safe way. Anyone who comes to me for help has already begun harnessing their will in the service of their recovery; we can’t rewrite the past, but we can heal its wounds and shape the client’s future.

I treat trauma with Eye Movement Desensitization and Reprocessing (EMDR), a confusingly named therapy that uses what we know about neuroanatomy to activate different brain regions so they can communicate with each other more effectively. Disorganized, fragmented trauma memories instead become integrated and can be digested. At its best, it is quite literally life-changing.

The Role of Neurodiversity

I’ve been speaking in general terms, but we all experience the world in vastly different ways based on our biological makeup. Psychodynamic work and trauma therapy are about healing and overcoming the wounds of the past. Freedom also often means meeting ourselves in the present and having compassion for who we are.

Our society is only built for certain kinds of people to thrive. People with ADHD, OCD, or autism, to name a few—who we now describe as neurodivergent—have differences of experience that can be quite interesting and beautiful, but can also cause those people pain and stress, particularly because our school and work environments operate with certain implicit expectations.

Neurodivergent folks are who they are; we can’t and shouldn’t expect to change them, and they can’t and shouldn’t expect that of themselves (though sadly, many already do). One of my jobs as a therapist is to help people understand whatever differences they experience and love themselves for it.

Part of self-compassion is making intentional decisions about how to care for ourselves and accommodate the challenges of the world. Where do we strive for flexibility and where do we accept difference? When to seek help, and when not to? These are all personal choices, and people must be allowed to decide from their own values.

I hope this helps demystify psychology and psychotherapy. Therapy is about helping people grow, heal wounds, and live fulfilling lives. It is an inherently humanistic practice, and that means it should be intelligible to humans too.

Notes:

Text and Photograph © 2025 Philip Bender

Subscribe at the bottom of the home page: https://write.as/philipbenderphd/ More about my practice: https://www.benderphd.com/