One of the most common assumptions about psychotherapy is that if the treatment is progressing well, the patient and the psychotherapist will naturally understand one another. Many people imagine that therapy is a process in which the patient speaks, the therapist listens, offers helpful observations, and both gradually move towards greater understanding. While this can certainly happen, it is only part of the picture.

In reality, disagreement is an entirely normal part of psychotherapy. In some cases it is brief and easily resolved. In others, it can become one of the central features of the therapeutic work. Patients may become frustrated, irritated or even angry with their psychotherapist. They may leave a session feeling misunderstood, convinced that the therapist has completely missed the point. Equally, the psychotherapist may recognise that something important is taking place, even though it appears on the surface to be a disagreement about what has been said.

From a psychodynamic perspective, disagreements are rarely only about the words being exchanged in the consulting room. Very often they are expressions of something much deeper. They tell us something about the patient’s internal world, about the ways they relate to other people, about their fears, their defences, and sometimes about emotional experiences that have never previously been recognised or understood.

For this reason, disagreements should never simply be viewed as obstacles to therapy. They often become valuable clinical material. If approached thoughtfully and without retaliation, they can strengthen rather than weaken the therapeutic relationship.

During many years of clinical practice I have noticed that these disagreements tend to emerge in recognisable patterns. Although every patient is unique, there are certain themes that appear repeatedly. Understanding these patterns helps both the psychotherapist and the patient make sense of what is happening rather than becoming trapped in arguments that lead nowhere.

The first pattern is probably the one heard most often.

“My therapist doesn’t get it.”

This is perhaps the single most frequent complaint heard in psychotherapy.

Patients may say that the psychotherapist is not listening properly, is focusing on the wrong subject, is misunderstanding the real problem, or is simply failing to appreciate what they are trying to communicate.

Sometimes this is entirely accurate. Psychotherapists are human beings. They can misunderstand, they can miss important aspects of what a patient is describing, and they occasionally pursue an interpretation too early or in a direction that ultimately proves to be mistaken. Good psychotherapy requires enough humility for the therapist to recognise when this has happened.

However, there is another situation which, in my experience, occurs remarkably often.

The patient genuinely believes that the therapist has misunderstood them, yet at the same time the therapist has actually begun approaching the very issue that is most emotionally significant.

The disagreement itself becomes evidence that the therapy is moving closer to something psychologically important.

This is one of the paradoxes frequently encountered in psychodynamic psychotherapy.

Patients often speak fluently about many aspects of their lives. They may describe events in great detail, provide lengthy histories, discuss practical problems, explain what happened yesterday or last week, analyse other people’s behaviour, and appear to be addressing the issue that brought them into therapy.

Yet despite all of this talking, the central emotional conflict remains untouched.

The patient is speaking.

The therapist is listening.

But both are, in different ways, circling around the real issue.

This does not necessarily happen consciously.

In fact, it is usually quite the opposite.

The patient is often completely unaware that they are avoiding the area causing them the greatest psychological pain.

Instead, they approach it indirectly.

They speak through displacement.

They move sideways.

They walk around the problem rather than towards it.

Consequently, when the psychotherapist begins to move closer to the emotional centre of the patient’s difficulties, resistance frequently emerges.

One of the clearest examples of this occurs in discussions about intimate relationships.

Many patients enter therapy because of repeated difficulties with partners. They may describe endless arguments, disappointment, feelings of rejection or recurring relationship breakdowns.

At first glance, the discussion appears to concern the partner.

The partner is controlling.

The partner is emotionally unavailable.

The partner is selfish.

The partner does not communicate properly.

The partner does not understand.

The partner has all the problems.

Large parts of therapy can become devoted to describing what the other person is doing wrong.

Sometimes there is also considerable attention paid to the physical aspects of the relationship, including intimacy and sexual difficulties.

While these subjects are undoubtedly important, they do not always represent the core psychological issue.

Very often, the more emotionally significant questions remain largely untouched.

What does emotional closeness actually feel like for this patient?

What happens when another person genuinely cares for them?

What does dependency mean to them?

How comfortable are they receiving affection?

How do they experience love?

What happens when somebody becomes emotionally important?

These questions often provoke far greater anxiety than discussing the partner’s behaviour.

Consequently, they become much more difficult to think about.

Instead of exploring these emotional experiences directly, the patient may continue returning to practical complaints, everyday frustrations or descriptions of what the partner has done.

From the patient’s perspective, they believe they are talking about the real issue.

From the therapist’s perspective, something deeper remains consistently avoided.

When the psychotherapist gently attempts to explore this deeper level, resistance frequently becomes much more visible.

The patient may suddenly insist that the therapist has completely misunderstood them.

They may argue that the therapist is ignoring what they have actually said.

They may become irritated that the conversation has moved away from practical matters towards emotional ones.

They may accuse the therapist of making assumptions.

Or they may simply state, “You’re not listening.”

What is particularly important is that the psychotherapist does not respond defensively.

It can be very tempting to explain, justify or persuade the patient that the interpretation is correct.

Doing so usually leads nowhere.

Once therapy becomes an argument about who is right, the opportunity for understanding begins to disappear.

Instead, the disagreement itself becomes the material for psychotherapy.

Rather than retaliating, the therapist keeps the experience in mind.

It becomes a mental note.

Not as evidence that the patient is being difficult.

Not as proof that the therapist is correct.

But as another observation that may later help make sense of the patient’s way of relating both inside and outside therapy.

Often, the same pattern gradually appears elsewhere in the therapeutic relationship.

The patient begins moving away from emotionally significant areas during sessions just as they move away from them in their everyday relationships.

They begin talking around the issue rather than through it.

They introduce new topics just as an important feeling begins to emerge.

They become preoccupied with secondary details.

Or they argue that the therapist is focusing on the wrong subject precisely when the conversation has begun approaching something emotionally meaningful.

Over time these patterns become much easier to recognise.

Importantly, they should not be interpreted immediately or forcefully.

Instead, they are observed repeatedly until sufficient evidence accumulates.

Eventually the psychotherapist may say something like:

“I wonder whether we’re finding ourselves doing something here that you’ve also described happening elsewhere. Just as we begin approaching something emotionally important, it seems to become much harder to stay with it, and we find ourselves moving away from it together.”

At that point the disagreement itself is no longer simply a disagreement.

It has become part of the therapeutic process.

Rather than asking who is right and who is wrong, both patient and psychotherapist begin asking a much more useful question:

Why is this happening between us right now?

This shift is often one of the most important moments in psychotherapy.

The disagreement stops being something that threatens the therapeutic relationship.

Instead, it becomes something that deepens it.

Patients experiencing this pattern can sometimes become quite angry. They may feel exposed, frustrated or convinced that the therapist is missing the point altogether. Yet, when these moments are approached with patience, consistency and genuine curiosity rather than confrontation, they frequently become turning points in treatment.

The aim is never to win an argument.

The aim is to understand what the argument is protecting.

Very often, what initially appears to be conflict is actually the patient’s best attempt to avoid emotional experiences that have felt too painful, frightening or overwhelming to face directly.

When the psychotherapist can tolerate that uncertainty without retaliating, without becoming defensive and without abandoning thoughtful exploration, the disagreement itself gradually becomes one of the foundations upon which a stronger therapeutic alliance can develop.

The second group of patients who frequently experience disagreements with their psychotherapist are those who genuinely feel that the therapist is not listening to them properly. Unlike the first group, where the disagreement often develops because emotionally significant material is being avoided, here the patient’s complaint usually centres on something very different. They experience the therapist as overlooking details that, to them, carry enormous psychological significance.

This is something that can often be encountered when working with patients who have elements of neurodivergence. Their way of processing information may differ considerably from what most therapists are accustomed to hearing. A conversation that another person might summarise in three or four sentences may instead be described through dozens of separate observations, each of which carries equal importance in the patient’s mind.

For example, a patient may begin describing an event that took place in a restaurant.

Rather than immediately describing the conversation or the emotional impact of the encounter, they may first tell the therapist about the colour of the cup that was on the table. They may remember the precise pattern printed on the cup, the colour of the walls, the restaurant sign outside, the type of pavement leading towards the entrance, the colour of a parked car, the position of the chairs or even the arrangement of objects on the table.

To another person these details may appear completely incidental.

To the patient they are anything but incidental.

Those details form part of how they experienced the situation. Removing them feels as though an essential part of the memory has been removed altogether.

If the therapist simply dismisses these details as irrelevant, the patient may very quickly begin feeling misunderstood.

They may conclude that the therapist is not really listening.

They may feel that something important has been ignored.

In reality, the therapist may have listened very carefully. However, because the therapist has naturally tried to organise the material into what appears psychologically central, the patient experiences the omission of those details almost as though parts of their experience have been erased.

This can become a genuine source of disagreement.

It is therefore extremely important for the psychotherapist to remain curious about why certain details carry such importance.

The question is not whether the colour of the cup objectively matters.

The question is why it mattered so much to this particular patient.

Very often those details become part of the patient’s emotional organisation of the experience.

They may provide safety.

They may provide predictability.

They may serve as landmarks that help structure overwhelming situations.

Sometimes they become inseparable from the emotional memory itself.

Once this is understood, the therapist is no longer trying to separate important details from unimportant ones.

Instead, the therapist begins understanding how this particular patient’s mind organises experience.

This changes the therapeutic relationship considerably.

Many of these patients also communicate in a way that can be extremely demanding for both themselves and the therapist.

They often speak rapidly.

Several different situations may become intertwined within the same narrative.

Different people, different conversations and different time periods may become linked together before the therapist has fully understood the first situation.

The amount of information arriving within a short period of time can be enormous.

It can become genuinely difficult for any therapist to process every single element while simultaneously thinking about the emotional meaning behind what is being described.

From the patient’s perspective, however, there is no difficulty.

Everything they are describing belongs together.

Everything feels connected.

Everything has significance.

Consequently, when the therapist cannot immediately retain every single detail, the patient may experience this as further evidence that they are not being listened to properly.

This is rarely because the therapist lacks interest.

More often it reflects the sheer complexity and volume of information being communicated.

At times the therapist may even feel temporarily overwhelmed by the amount of material entering the session.

One thought has barely been considered before another arrives.

One description merges into the next.

Associations develop so rapidly that the therapist is left trying to establish links between numerous different strands simultaneously.

In psychodynamic thinking this can sometimes resemble what has been described as an attack on linking or an attack on thinking.

The therapist’s capacity to think becomes challenged by the pace and quantity of incoming material.

This observation should never be used critically.

It should instead help the therapist understand what may also be happening inside the patient’s own mind.

If organising thoughts becomes difficult within the therapeutic relationship, it is worth wondering whether similar experiences occur throughout the patient’s daily life.

Does the patient also struggle to organise experience internally?

Do they feel that other people repeatedly fail to understand them?

Have they spent years feeling unheard despite trying extremely hard to explain themselves?

These questions become much more useful than debating whether the therapist remembered the colour of the cup correctly.

Again, retaliation achieves nothing.

If the therapist responds defensively by insisting that those details are unimportant, the disagreement simply becomes reinforced.

The patient feels even less understood.

Instead, the therapist acknowledges the importance of those details within the patient’s own psychological world.

That acknowledgement does not necessarily mean that every individual fact must always be remembered perfectly.

Rather, it communicates something much more valuable.

It tells the patient:

“I understand that these details matter to you, and I want to understand why they matter.”

That response alone often changes the emotional atmosphere within the room.

The disagreement gradually transforms into curiosity.

The therapist is no longer defending themselves.

The patient is no longer trying to convince the therapist to listen.

Instead, both become interested in understanding the function these details serve within the patient’s emotional life.

As therapy progresses, these patterns can once again be explored in the here and now.

The therapist may notice that the patient becomes particularly distressed whenever they feel that something has been overlooked.

Perhaps this mirrors earlier experiences in which important parts of themselves were ignored by parents, teachers or significant figures throughout childhood.

Perhaps they have repeatedly felt that nobody has ever understood the way their mind works.

Perhaps they have spent years adapting themselves to fit other people’s expectations while feeling that their own way of experiencing the world has rarely been recognised.

Once these possibilities begin emerging within the therapeutic relationship, the disagreement itself becomes clinically valuable.

It is no longer simply about whether the therapist remembered every detail correctly.

It becomes an opportunity to understand how the patient experiences being known, recognised and understood by another human being.

Handled with patience and genuine interest, these moments often strengthen rather than weaken the therapeutic alliance.

Instead of becoming evidence that therapy is failing, they become evidence that something psychologically important has finally entered the room.

The third group of patients who may sometimes find themselves disagreeing with their psychotherapist are those who become very preoccupied with their appearance and with the ageing process. Many people naturally think about getting older from time to time, but for some individuals these concerns become much more central to the way they see themselves and the way they relate to other people.

If such a patient begins psychotherapy with someone who is considerably older, the therapist’s age itself may gradually become the focus of attention. It is not unusual for comments to emerge that appear, at first sight, to be observations about the therapist. However, when explored more carefully, they often tell us much more about what the patient is struggling with psychologically than they do about the therapist.

For example, a patient may begin questioning whether the therapist is hearing everything properly. They may wonder whether the therapist’s memory is as good as it once was. They may suggest that the therapist is no longer fully in touch with modern life or current ways of thinking. Sometimes attention becomes focused on the therapist’s mobility, the speed with which they respond, or even whether they appear tired during the session. Occasionally patients may even wonder whether the therapist has momentarily fallen asleep or is no longer following the conversation as closely as they should.

When comments like these arise repeatedly, it is important not to dismiss them or become defensive. Equally, it is important not to assume that they are simply accurate observations about the therapist. Instead, they should encourage curiosity. Why has the therapist’s age suddenly become so important? Why are these concerns appearing now? Why has this become the focus of attention within the therapeutic relationship?

Very often, these comments are not really about the therapist at all. They may reflect the patient’s own concerns about growing older, about losing their appearance, about the passing of time, or about changes that inevitably occur throughout life. These can be uncomfortable subjects to think about directly, and it is often much easier to notice them in somebody else than to recognise them in oneself.

The therapist should therefore avoid arguing, defending themselves or trying to prove that the patient’s observations are incorrect. Once therapy becomes an argument about whether the therapist’s hearing, memory or mobility is good enough, attention is drawn away from the issue that really deserves exploration.

Instead, these moments become opportunities to understand the patient’s emotional world.

Sometimes it gradually becomes apparent that the patient’s preoccupation with appearance has made it difficult for them to develop relationships based upon qualities that last much longer than physical attractiveness. Healthy long-term relationships depend upon trust, emotional closeness, affection, care, reliability and the ability to depend upon another person. These qualities become increasingly important throughout life, regardless of age.

When someone becomes almost entirely preoccupied with appearance, they may find it much harder to build relationships based upon these deeper emotional foundations. The therapeutic relationship therefore provides an opportunity to think together about these concerns rather than simply arguing about them.

Once again, the disagreement itself becomes valuable. It is no longer simply a disagreement about the therapist. It becomes another way of understanding how the patient experiences themselves, other people and relationships more generally.

The fourth group of patients express their difficulties rather differently. Rather than telling the therapist directly that they feel frustrated, disappointed or unsettled, they communicate these feelings through their behaviour.

Instead of putting difficult feelings into words, they begin expressing them through actions that gradually interfere with the therapy itself.

For example, they may repeatedly arrive late for sessions. They may frequently ask to reschedule appointments. They may arrive during the final few minutes of a session but still expect the therapist to continue beyond the agreed finishing time. Some patients repeatedly delay payments, withdraw payments after making them, or create ongoing financial difficulties that become part of the therapeutic relationship.

For patients whose therapy is funded through insurance companies or public health services, the same pattern may appear in different ways. Sessions are repeatedly missed. Attendance becomes irregular. Administrative difficulties become frequent. The therapist is placed in a position where these issues have to be addressed because they directly affect the continuation of treatment.

It is understandable that these situations can become frustrating for both patient and therapist. However, retaliation rarely helps. Equally, ignoring the behaviour is unlikely to help either.

The therapeutic framework exists for a reason.

The agreed appointment time, the duration of the session, regular attendance, privacy, confidentiality and, where appropriate, payment all provide the stability that allows psychotherapy to take place. Without that structure, meaningful therapeutic work becomes increasingly difficult.

When these boundaries are repeatedly challenged, it is worth asking what the behaviour may be communicating.

Very often, these actions are saying something that the patient has not yet been able to express in words.

They may be struggling with trust.

They may find it difficult to depend upon another person.

They may become uncomfortable as the therapeutic relationship becomes more meaningful.

They may fear emotional closeness without fully recognising that they do.

Rather than talking about these difficulties directly, they begin disrupting the very relationship that is beginning to matter.

This is why it becomes so important for the therapist to bring these patterns into the here and now of the therapeutic relationship.

Instead of discussing lateness, cancellations or payment difficulties simply as practical problems, they gradually become part of the psychological work itself.

The therapist may gently wonder whether the same pattern appears elsewhere in the patient’s life.

Do similar difficulties emerge in friendships?

In intimate relationships?

At work?

With members of the family?

Does the patient repeatedly find themselves pulling away whenever relationships become more important?

These questions often prove far more valuable than focusing only on the behaviour itself.

Across all of the situations described throughout this article, one central theme remains remarkably consistent.

The disagreement itself is rarely the real problem.

Whether the patient feels misunderstood, unheard, becomes preoccupied with the therapist’s age, or repeatedly disrupts the therapeutic framework, the disagreement usually points towards something much deeper.

When approached thoughtfully, with patience, curiosity and without retaliation, these moments become some of the most valuable opportunities for understanding that psychotherapy has to offer.

Ultimately, psychotherapy is not about deciding who is right and who is wrong.

It is about understanding why particular patterns emerge within relationships, what they are trying to communicate, and how recognising them can help the patient build healthier, more stable and more satisfying relationships both inside and outside the consulting room.

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