What It Means to 'Do the Work' in (and Out of) Therapy

When I started transference-focused psychotherapy (TFP) in 2005 with Dr. Lev, a psychiatrist who specialized in treating people with borderline personality disorder (BPD), I had only a vague idea of what the phrase “do the work,” meant in regards to therapy. I’d talk for 50 minutes, go home, go about the business of my life, and return to therapy a week later and start all over again.

This approach was not working for me. I was chronically suicidal, self-harming, periodically starving myself down to unhealthy weights. I felt empty, a shell of a person whose worth was determined by the number on the scale each morning. I kept a stash of things I self-harmed with in my dresser drawer, so if the urge struck, I wouldn’t have far to go. By the time I started TFP with Dr. Lev, I’d endured 14 inpatient psychiatric admissions, including a 10-month stay on a long-term unit specializing in treating patients diagnosed with BPD utilizing dialectical behavior therapy (DBT).

Through my work with Dr. Lev, I finally discovered what “doing the work” in psychotherapy meant. It meant more than showing up, it meant more than cursory participation. For me, when Dr. L.ev asked, “What comes to mind?” (her favorite question), it meant digging down deep and talking about what I was most afraid to hear myself say. Thoughts and feelings I’d never shared with anyone before, words I was afraid would cause her to reject me or abandon me — the absolute fear for many people with BPD.

Speaking extemporaneously without taking pause to censor myself, as I had learned to do so well in childhood, meant taking a risk, that something may slip out untampered. It was often the conversations that started with those unthinking remarks that proved to be the richest for the work needing to move the therapy forward.

Self-reflection didn’t end when I walked out of Dr. Lev’s office. Feelings, thoughts, especially actions became fodder for the next week. I jotted notes down for upcoming sessions and while I may have started off with something that happened at work during the past week, one question from Dr. Lev, “What comes to mind?” and we’d be off down a totally different track than I intended, but still very much relevant.

Think of railroad tracks, not entirely parallel to each other, that go off in their own direction, but periodically intersect. That was our therapy. Everything is relevant to everything else at some point, but worthy of investigation unto itself. No wonder Dr. Lev and I worked together for 11 years. Miles and miles of tracks, miles and miles of broken psyche to unravel.

Somehow, we got all of my broken brain laid out, analyzed, calmed down, and put back where it belonged, much improved. Integrated, I believe they call it. All the pieces acting in harmony with each other instead of constantly fighting in a never-ending state of chaos.

There were times I was on my own, seemingly unable to tolerate my thoughts and feelings, on those railroad tracks alone, praying for a train to come. The work Dr. Lev and I did in therapy together resulted at times in incredible pain. The level of pain was necessary I realize now, and if I had acknowledged my anger at Dr. Lev in the moment, I most likely could have lessened the intensity of my feelings. But anger was not an emotion permitted in my childhood home, so I held onto all my rage, seething and turned that one emotion inward. Dr. Lev was well aware of where I was at every step of the way and tried to guide me, but I was blind and resistant, an almost deadly combination, and I did at one point attempt to take my life.

After that attempt, Dr. Lev noted the intensity of our work together amplified. I realized if I wanted any semblance of a life outside of the therapeutic office, I needed to ramp up and use every minute of the time I was in session with Dr. Lev and as much time as I could outside our sessions. I worked hard at being spontaneous, at following the flow of an unleashed psyche, like a dog let loose in the park on the first nice day of spring — just watch her go! And I let my mind follow the same course. No more worrying about if my thoughts connected in a logical manner, I just went with the flow and the results were astounding.

Without the pain I endured, I would never would have realized the joy and contentment of where I am today. I credit the work I did with Dr. Lev with saving my life and giving me a life worth living. Putting in the work of therapy during and outside of sessions is worth the effort.