The brain is a pattern-seeking organ that continually organizes the world into a more predictable experience. Our first predictions arise out of early childhood and are predicated on messaging from primary caregivers. These are deeply buried in implicit memory meaning that much of what we anticipate from interactions lies outside of our awareness. Over the course of a lifetime, these guiding assumptions working in the background are continuously modified in relationship. It is no coincidence that we are in many ways much like those with whom we choose to spend time, and that we gravitate towards those with whom we feel comfort in the familiar. Psychotherapy deliberately leverages how individuals develop in relationship to facilitate growth and change, foster self-reliance, and healthy interdependence. Psychotherapy offers a different relationship compared to friends and family in that it does not engage a typical conversational mutual exchange. This one-sidedness is deliberate in mining an individual’s expectations by creating space to explore experiences, feelings, and assumptions. These can then be held up in a non-threatening way for observation and evaluation. It is a unique relationship dedicated to understanding geared towards change, outside the comfort of the familiar.

Autonomy is favored in a depth perspective by exploring how an individual thinks about decisions, what feelings arise, or sometimes what feelings are deeply buried. A depth perspective goes beyond identifying and challenging distorted thinking in seeking to also understand where those notions originated, what they often protected, or how they served in navigating early circumstances. Sometimes discovery is an arduous emotional process, and this is the work of therapy. It is sometimes a first experience of not seeking answers or approval from outside sources but rather from within, and learning to trust one’s own instincts, thoughts, and feelings. A goal is to understand and sometimes ameliorate frustration, confusion, and suffering while nurturing a deeply felt ability to rely on self. This means clarifying, prizing, and trusting one’s own values, what one feels, and what one feels as priority.

Some pattern-producing experience in a relationship is marked by intense or even overwhelming emotion for which we do not retain any overt memory. Because a trauma response is generated in emotional overwhelm to varying degrees, this is an important marker for the work of therapy. Not all work in therapy is related to trauma though. And there need be no formal medical diagnosis such as post-traumatic stress disorder to generate meaningful work. Expected change as life unfolds referred to as phase of life transitions further refines a guiding framework for therapy. For example, becoming a parent for the first time with a radical change in identity, caring for aging parents, integrating into a first post-training job, facing retirement, facing mortality. Identifying the underlying contributions of expectation in facing challenges contributes to outcomes by providing understanding, insight, and capacity to choose differently.

Negatively valanced perception generally lies outside of awareness but is a frequent reason for seeking psychotherapy, ultimately an experiential modality. In its more powerful moments, therapy provides an emotional experience of recognizing imposed intergenerational rules which once seen now become mutable. Limiting, distorted, and painful beliefs based in past circumstances may crumble like a concrete wall revealing blue skies. For example, an implicit belief can be teased out of multiple statements which imply an underlying sense that “everyone is out to get me.” Recognition that this is not actually the case reveals access to new possibility. Calibrated with contemporary life transitions, insight changes one’s pathway into the future.

Similarly expectations such as things never go my way, I am always passed over, I am so unlucky, people do not like me, people will always disappoint, I have no control over things, I am an outsider, I have to do everything on my own, no one looks out for me, I have to do everything perfectly otherwise I will not be liked, or loved; these are some of the messages that influence our perceived place in the world, often driving some self-fulfilling elements in our own behaviors. If people are guaranteed to disappoint, be manipulative, or unreliable it seems easier to protect oneself by isolating or rigidly depending on no one. There is no opportunity for change if one is unaware of those assumptions as we so often are, never having had them held up for us to clearly see. The simple observation, it seems like you feel as if everyone is out to get you, that life singles you out for punishment, if it lands correctly born out of active listening, is accurate, empathetic, and not judgmental, can lead to powerful revelation. This is the potential for fundamental change that a depth perspective holds out in possibility.

Erik Erikson elaborated stages of growth further informing how individuals navigate psychosocial development. He described predictable challenges at distinct phases of life from infancy, through youth and the elder years, beginning with developing an ability to trust, and concluding with a vision of integrity versus despair in a final, end-of-life challenge. While mastering trust versus distrust depends on preverbal relational experiences, much not remembered, the last psychosocial stage depends on choices made over the course of a lifetime and through prior stages of change. Contributing factors include quality and connection in relationships, a sense of community and belonging, and the arc of meaning over the course of a lifetime of experience: gratifying, difficult, and sometimes tragic. A reflective practice can be protective in the gradual transformation from youth to elderhood, which threatens to catapult one into despair in the myriad ways we all face mortality.

Moving through the unfolding of a career asks that we be thoughtful about participation from early on. At first new in the field, focus involves so many questions, doubts, and anxieties, but also excitement if it is a long-sought-after profession. It asks that we retain and nurture our values, grace, and humanity, sometimes contributing to mentorship, training, education, leadership, or focusing on the day-to-day work itself. Erikson identified this challenge as generativity versus stagnation. A reflective practice, however, enables us to face our inevitable diminishing stamina over time as an active, generative participant. It allows us to see our prior cutting-edge skill set become obsolete while creating space to show up in our capacity, but also knowing when and how to step back with grace. And finally, self-reflection helps us to find our place, less in our work and more in who we are, in approaching the end of a career and finding new rootedness and belonging in the unfamiliar. It is what Erickson described, as finding integrity in our past accumulated successes, our more generous decisions, and also in our flaws and failures, finding meaning in who we have been and who we are, and not to despair. All this, a recapitulation of our final task, to find acceptance and meaning in a life that inevitably ends.

Maire Daugharty is an anesthesiologist who expanded her expertise by earning a master’s degree in clinical mental health counseling, merging her long-standing interest in mental health with her medical background. As a licensed professional counselor, licensed addiction counselor, and licensed marriage and family therapist, she brings a well-rounded perspective to her private practice, where she works with adult individuals and couples on a wide range of concerns. In addition to her counseling practice, she continues to work part-time as an anesthesiologist and has a deep understanding of the unique challenges faced by clinicians in today’s medical landscape. To learn more about her practice, visit Physician Vitality Services.