top of page
Post: Blog2_Post

ISTDP's Patricia Coughlin Is A Master Therapist. Here's The 15 Things She Taught Me (Part 1).

Updated: May 5, 2023

Back in January I attended an ISTDP Sex Therapy training with Patricia Coughlin.


Talk about one of the greats.

I'm in a bit of an Emotion Focused Therapy (EFT) bubble where everyone believes very deeply in the power of compassion, comfort, and empathy. They don't challenge, and the general sense is if you can offer someone enough support and comfort, they will eventually change. To see Patricia hold patients' feet to the fire and have "head-on collisions" with their defenses was refreshing. To see her do so while also holding deep compassion was masterful.

Honestly, this is the only time I can remember watching therapy videos and it not being boring.

So I've decided to share what I've learned from her in a two part blog post. Here are the first 7 things I learned from her.


Hello friends :) If you want to join me and other readers in exploring the world of counseling sign up for my newsletter.


1. "If you look at the effectiveness of CBT over 50 years, it has gone down."

Coughlin states he founders of CBT, such as Aaron Beck, were trained first as psychodynamic therapists and therefore had an understanding of the unconscious. Nowadays, we focus much more on teaching students techniques and don't talk about the unconscious, and therefore CBT outcomes are declining.

I don't know if CBT really is declining, but I do know we neglect the unconscious in therapy training, and, because of this, we're missing out on a huge reservoir of what we need to know to be effective therapists.

Part of unconscious training is seeing current behavior as metaphor for underlying issues.

For instance Patricia showed a tape of a client saying "fuck you" several times. They went on to process his violent rape fantasies. She was reading his statement as a metaphorical message from the unconscious.

Every therapist knows some things clients do are metaphors for their underling problem. The problem is its easy to take this idea too far. Everything is not a metaphor for something else.

Sometimes clients say "fuck you" just because they are angry.

Knowing the difference between when something is a metaphor and when it's not is a marker of mastery, and I know of no one who can train it.

2. What are the symptoms? Listen for those, not the diagnosis. When does the diagnosis happen?

One of the things I saw her do in her assessment was to listen for the symptoms. One patient had intense feelings of anxiety at work and had been diagnosed with social anxiety before seeing Coughlin. Coughlin made the point that he wasn't suffering from social anxiety, but rather workplace anxiety.

As Coughlin explored, the client revealed he was struggling at work because he was used to being the top performer, and as he aged it was harder and harder to stay on top.

With all the information it seems obvious he was struggling with workplace anxiety, but it would have been easy to miss if you were first focused on the presenting diagnosis.

3. "Now are you aware that you smile as you talk about this?"

One of the things Patricia did often was point out what the client does to defend against feeling their emotions. For example, the patient would smile when talking about difficult issues. Patricia pointed this out and asked, "now are you aware that you smile as you talk about this?" calling his attention to it and then asking him if he wanted to work against this defense and actually feel his feelings.

It was striking.

Most of my EFT training has been focused on noticing emotion and pain and attending to it. By contrast, Coughlin starts off by noticing the protective response.

It's a different way to do a similar thing. The benefit of Coughlin's method is if you can get the client to recognize it, they can turn against it. They then become an ally in fighting against their defenses.

Otherwise, if you go to the pain, the person might work against you.

4. "He'd rather have a conflict with me than deal with the internal conflict."

At one point, the patient mentioned he'd often go on business trips and pick up women, despite being married. Patricia said, "so you've had affairs." The patient then got defensive and started to explain how they weren't affairs.

I would have immediately assumed I'd created an alliance rupture and tried to repair. Coughlin does the opposite.

Instead of backing off, or assuming she's caused a rupture in the therapeutic alliance, or that maybe he should be in an open relationship, she just sees and comments on what's actually happening. Her logic is, "he told me he was sleeping with other women. I said he's having an affair. Now he wants to fight. There's probably an internal conflict for him about his behavior."

5. “It’s all about the response to intervention.”

The greatest diagnostic tool you have is how your client responds to your intervention.

For instance, at one point Coughlin began challenging a patient, and I thought it was an alliance rupture, but she pointed out a signal from his unconscious - he'd begun to roll up his sleeves like he's ready to get to work!

His response to the intervention says he's ready to get to work. I've never heard a school of therapy talk about this.

The Ericksonian hypnotists hint at it. The idea that response to intervention is the assessment is implied when you learn their concept of utilization. But they don't talk succinctly or openly about it.

It was refreshing to hear words to an idea I'd felt but hadn't been able to articulate.

6. Speaking in metaphors.

If she had a hunch or intuition about a client she might speak in metaphors.

For instance, another patient threw up his hands in helplessness and then fell limp. She responded with something like, "so is this what happens, your anger gets all aroused, and then you go limp?" Alluding to his inability to get an erection.


7. When you’re no longer getting reinforced for your defenses, they are no longer available for you, and you are finally open for change.

One of Coughlin's big ideas is we use "defenses" to prevent ourselves from feeling. These defenses are particularly strong when we get reinforced for them.

A perfect example is Coughlin's client who was sleeping around despite being married. He was an older male coming into therapy for anxiety and depression. As they talked he revealed he'd had one-night stands basically every time he went on a business trip. That is until a few years ago, right around the same time his anxiety and depression started.

Coughlin's thinking was:

  • his sleeping around was a defense against feeling his emotions...

  • this defense was deeply entrenched because every time he was successful he was getting reinforced for it...

  • as he got older it was harder for him to pick up women, so he wasn't able to get reinforced for his defenses...

  • now all his unresolved feelings were coming to the surface,

... and that's why he was coming into to see Coughlin.

For me this was a huge "aha" moment. There have been a few studies of people who've had sudden dramatic moments of growth and it's almost always during some major transition. It always puzzled me why transitions were the time when these big dramatic changes happened.

Now I think I get it. It's because transitions are when our old defenses no longer work to protect us. When that happens some of us have inner resources which propel us to growth and someone of us develop mental health issues.

Or as Stephen Gilligan says, we either have a breakdown or a breakthrough.

Patricia Coughlin is important because ...

I sometimes feel that to be a better therapist I have to become sort of this "cosmic mother" eternally nurturing and empathic.

The people who know me know that's not my natural bent. I'm certainly more empathic than I was, but I'm never going to be the therapists who oozes endless empathy.

Seeing Coughlin work was reassuring because she reminds me that there is room to explore and grow in the various models, but also be yourself. If you're truly dedicated to excellence, that's a hard path to walk. The idea of models is if you do therapy according to the model you'll at best get better outcomes, and at worse won't harm people.

Coughlin reminds us of something else, that on the far end of mastery, when you've mastered the fundamentals, that's when you reintegrate your personal style and skills. And when you do that, that's where the real mastery comes.

Coughlin is important because she shows that the path to mastery entails a mix of mastering your model, while mingling in what makes you unique.

And that's a reminder I need.


Jordan (the Counselor)

-You Finished! Congrats! Thanks for reading! 10 points!-


If you liked this post, consider reading this next. I think you'll like it ;) It's more about what makes therapist exceptional.


416 views2 comments


Apr 18, 2023

10 points! Whoop!

Apr 27, 2023
Replying to

Lol. Love it!

bottom of page