How Psychotherapy Works

What actually occurs when psychotherapy helps alleviate a patient’s emotional distress? We explore this with the help of the PRC Psychotherapy Manual, an educational tool for clinicians, researchers, psychotherapy students and interested nonprofessionals characterizing various aspects of the psychotherapy process, across “brands” of psychotherapy (Ablon & Jones, 1998; Ablon et al., 2006). We also explore this via annotated, confidentialized transcripts from the recording of several sessions of an actual psychoanalysis.

The role of the healer is said to be the second oldest profession. Any psychotherapy relies on the culturally-mediated attributes of the healer’s role. In the study of cultures across the globe called Persuasion and Healing, Jerome Frank (1973) identified two crucial elements of this healing role: a socially sanctioned position in society; and knowledge of techniques believed to produce benefit in that society. In Frank’s study, the variety of techniques across cultures was enormous. Over the course of history, healers have used different methods to heal the suffering.

Beginning in the early 20th century, psychoanalysis brought a fresh method and set of ideas for understanding relationships between the surface manifestations of symptoms and the underlying meaning of these in personality and motivations. Freud, who greatly valued ideas and intellectual understanding, was naturally inclined to the belief that the patient understanding such hidden connections (developing insight) would lead directly to therapeutic benefit.

Seeking explanations, i.e. developing insight, was Freud’s own particular favorite method of mastery, of dealing with a world that sometimes feels out of control. But insight does not turn out to represent the full panoply of powerful interpersonal factors activated when an individual seeks the help of a healer. This is reflected in the title of John Norcross’ excellent edited book: Psychotherapy Relationships that Work (2011). Patient and healer implicitly and explicitly adjust in the way they relate to one another. This affects the roles that they take on with one another, and these changes may also help alleviate suffering.

Psychotherapy is a procedure in which various mental or emotional difficulties or disorders of personality are treated by some sort of communication between a psychotherapist and at least one patient. The nature of the difficulties, the specific setting for the procedure, and the particular sort of communication between the participants can vary quite a bit depending on the type of psychotherapy and how it was conceived (e.g. group psychotherapy, marital psychotherapy, play psychotherapy with children, cognitive-behavioral therapy, or psychoanalysis). Different kinds of experiences in therapy can help different patients with distinct emotional difficulties. However, despite all the individual variability in that, there seem to be a few common factors associated with being helpful. Some of these factors are specific to the psychotherapist, some are specific to the patient, and some have to do with how patient and psychotherapist relate to one another. Through our clinical research, we feel we can help determine how best to listen and respond to another person in a particular way feels helpful to patients with various kinds of emotional difficulties. By focusing on the process by which patient and therapist develop a productive conversation, we can understand how psychotherapy heals.

 

PRC Psychotherapy Manual

In this site, we are interested in what is actually helpful in alleviating a patient’s emotional distress. We have written the PRC Manual, as an educational tool for clinicians, researchers, and psychotherapy students to help characterize various aspects of the psychotherapy process. This manual provides many important clinical illustrations of different components of the psychotherapy process. We hope this helps you understand various elements of psychotherapy that are common to most types of therapy and different theoretical orientations.

 

This website will continue in the pages that follow, by describing the process via which a helpful conversation unfolds between patient and therapist. Click here or continue to scroll down to read about early considerations in introducing a patient to psychotherapy.

 

Introduction to Treatment

Patients seek help from a psychotherapist because they experience difficulties in life, relationships, work, and how they feel about themselves. They may feel stuck in some way that they may not yet be able to identify, or they may have readily identifiable psychological symptoms. It may be helpful for them to have someone listen to their story without judgment and accept them as they are. It may also be helpful if someone offers hope for change, clinical judgment, and a procedure to achieve relief from their emotional suffering. Part of our goal as psychotherapists also involves helping the patient become curious enough to establish flexible and adaptive meanings for experiences that may seem to the patient meaningless, confusing, or overwhelmingly painful.

When a suffering individual seeks psychotherapeutic help, there is an immediate benefit which has been described as the restoration of hope or of morale, activated in most people simply from seeking help. In fact three phases have been described as typical of a psychotherapeutic encounter (Howard et al., 1993; Howard et al., 1996):

  • Improvement of subjective well-being (occurring within a session to a few sessions).
  • Reduction in symptomatology (requiring a few to many weeks).
  • Enhancement of life functioning and character or personality change (requiring a longer time).

The first of these three tend to occur due to the power of nonspecific factors in the psychotherapeutic situation. Hence the finding of similar, early results in studies of different “brands” (see Ablon et al., 2006) of short term treatment at or soon after the completion of treatment.  However, these short term benefits tend to disappear with time, unless changes are accomplished in the preconditions for the development of a symptomatic illness in the patient’s emotional life.

Meanwhile, a psychotherapist attempts from the outset to make a particular kind of connection, in order to engage in a conversation about these difficulties. The therapist thereby determines the nature and severity of the patient’s problem, patterns of how the patient relates to others and how the patient sees him/herself, a formulation of the patient’s maladaptive personality traits and baseline psychological strengths, and a rudimentary plan for how best to alleviate the patient’s suffering. Depending on the psychotherapist, this assessment may involve use of a specific diagnosis, or it may involve the formulation of a more flexible and less defined narrative to describe the patient’s emotional difficulties. Of course, eventually, this narrative and associated plan include considering some aspects of how the patient relates to the therapist him/herself. Click here for an example of one patient and psychoanalyst’s initial meeting, and the analyst’s efforts to engage an anxious, inexperienced patient about why she presented for treatment.

Early considerations in introducing a patient to psychotherapy involve creating a productive engagement between therapist and patient, and agreeing more or less on a plan for the future. Click here or continue to scroll down to read about general considerations in how to engage patients seeking psychotherapy.

How to Engage the Patient

Psychotherapy may rightfully be defined as the art of developing a particular type of conversation with a patient for therapeutic purposes. Each of the topics below describe early and fundamental aspects of therapeutic activity which generally can contribute to the developing of the therapeutic alliance, a crucial component of effective therapy. As the therapist listens and encourages elaboration, he/she will also alternate between an overall acceptance of the patient’s point of view on the one hand, and challenging the patient to elaborate and potentially revise or amend their description of themselves. Through the highly-individualized process of immersing him/herself in a patient’s emotional experience and inquiring more about points of salience therein, the therapist fosters in the patient curiosity and further reflection. In turn, often patients respond with greater trust in the therapist’s understanding and empathic connection in the task of exploring their potentially difficult emotional territory, as well as greater confidence in exploring new connections unearthed during the conversation. In short, the mind of the patient can expand to accommodate new meanings and new ways of relating.

 

Listening Attentively

Listening attentively is experienced by most patients as comforting, especially with careful attention to what feelings the therapist may discern with which the patient is struggling (and may not be aware of, or may be too embarrassed to reveal). The therapist is there for the patient, listening and witnessing aspects of the patient’s emotional life that may rarely be disclosed to anyone else, and offering him/herself this way often evokes strong feelings in the patient. Leo Stone wrote a slim book that describes some of the early origins of the feelings evoked, called The Psychoanalytic Situation (1973). In an influential paper titled “Primary Maternal Preoccupation,” Donald Winnicott also discussed how early experiences with a parent holding her infant child in mind (often the mother) affect the child’s ability to manage his/her emotions and understand the world. In particular, he highlighted the degree and many ways a parent attends to their child, and how this goes askew. Since then, many psychoanalysts have theorized about similarities between these early experiences and a patient’s conversation with a psychotherapist. Simply by focusing our neutral curiosity and attention on the patient, and on understanding the various ways we listen to our patients, we can help our patients manage their difficulties.

It is equally important to monitor whatever feelings the therapist is having as he/she is listening, because so much of our capacities to be aware of others occur outside of our conscious awareness. The metaphor used by an influential writer about how we respond in life situations (Jonathan Haidt, in The Righteous Mind, 2013) is that our conscious mind is like the rider atop an elephant. We are fond of the illusion that we determine where the elephant goes!

 

Encouraging Elaboration

Encouraging elaboration is the first tool described and illustrated in our PRC Psychotherapy Manual [see here] in the beginning and throughout therapy. It is a simple means to add to what one knows of the patient’s thoughts and feelings, and, if done tactfully, it can provide a safe, unobtrusive environment for the patient to reflect on him/herself and others.  We encourage elaboration based upon what we discern as described in the previous paragraph, particularly when the patient seems to pause or veer away from a deeper elaboration of a topic (see Paniagua, 1991).

Closely related to encouraging elaboration is allowing silences to occur in the conversation, when the therapist has the impression that the patient may very well continue on their own. It is interesting how often patients will only have a dream come to mind in just such a silence [for example, click here to see this unfolding in an early session of the patient we call Annie].

In the first few meetings, patient and psychotherapist typically discuss how or why the patient’s emotional life has led them to consult a psychotherapist at this particular time. Ideally, patient and psychotherapist become collaborators in describing the nature of the patient’s problems and how best to recover from them. Moreover, patient and psychotherapist can revise or clarify any misunderstandings in how they each view these difficulties.

As a therapist listens to the patient’s emotional troubles, it stands to reason that the patient will struggle with how to conceive of his/her difficulties. In these moments, the therapist can tactfully highlight the particular manner by which the patient is thinking about his/her own feelings. Here are relevant examples from the PRC manual of clinical situations that occur early on in establishing a therapeutic conversation between therapist and patient:

  1. Sometimes, a patient has not yet identified the emotional problem.
  2. At times, a patient finds it difficult to think about how his/her feelings relate to his/her difficulties.

When patient and psychotherapist more or less agree on how to understand the problem and how to treat it, psychotherapy has the best outcome. Click here or continue to scroll down to read more about the development of this therapeutic alliance.

The Therapeutic Alliance

The therapeutic alliance has been described as a good personal match between the personalities of patient and psychotherapist, or a specific type of helpful relationship between therapist and patient. How therapist and patient relate to one another, and how this relation affects and is affected by the patient’s emotional difficulties effectively shapes how the duo understands the patient’s difficulties, and how each participant discusses or addresses managing these difficulties. Attention by the therapist to the therapeutic alliance is now considered of paramount importance in what happens in psychotherapy.

Some factors that affect the therapeutic alliance predate the patient meeting the psychotherapist. Both therapist and patient have, after all, different temperaments, they may have lived in distinct cultures, and they have each developed somewhat-distinct ways of thinking or styles of relating to others. Recently, studies have demonstrated that the degree to which these personality factors converge or complement one another in therapist and patient affect how they converse with one another, and whether the conversation becomes therapeutically productive (Lingiardi et al., 2017; Werbart et al., 2018). The therapist should be mindful of these various attachment and personality factors, and he/she should engage in conversation about this with the patient as it affects their relationship, in order for patient and therapist to achieve enough common ground to work together. 

Essentially, therapists soon become involved in a subtle process in which they alternate between sharing in the patient’s emotional experiences and separate themselves enough from them to examine them in a different light. The tactful oscillation between empathic resonance on the one hand, and novel reflection and change on the other has been described in a number of different ways across types of psychotherapy. By attending to this process carefully, we hope to forge a relationship in which patient and therapist sufficiently agree on the nature of the patient’s difficulties, develop a working collaboration on specific goals and how to achieve them, and think together about how the therapist fits into the patient’s mental life. 

Listening attentively and encouraging elaboration on particular aspects of the patient’s conversation are early and general strategies for creating and maintaining a collaborative relationship with the patient. Below are a few more examples from the PRC Manual, relevant to the task of forging and maintaining the therapeutic alliance. Of course, the entire manual could be thought of as providing examples of such clinical moments, ripe for further collaboration and therapeutic progress.

 
Of course, there are many other kinds of interventions that therapists employ as healers, to develop a collaborative and productive conversation. Click here or continue to scroll down to read about other specific interventions used by therapists in working with their patients.

What Psychotherapists Say

The therapist expressing her/his own point of view

Literally hundreds of studies have shown the importance of the therapeutic alliance to outcome. If psychotherapy is modeled on having a conversation – an activity which is ubiquitous among humans – then what may be the elements from the point of view of the therapist which will contribute to a developing trust on the part of the patient? First is listening and encouraging elaboration just described. But how to handle the patient’s efforts to engage the therapist, directly or indirectly?  Psychoanalytic theory of technique decades back emphasized the importance of leaving a blank screen, so to say, for the patient to write on, and to project their innermost fantasies, fears and desires. The reason that was given for this recommendation was that the therapist should not be pulled into revealing much about her/himself, because this would obscure the patient’s own point of view. Many writers in the past forty years have challenged this technical recommendation (see Renik: The Perils of Neutrality, 1996; Hoffman: The Patient as Interpreter of the Analyst’s Experience, 1983). Recent research by the Analytic Process Scales Group, most of whom are also Directors of the Psychoanalytic Research Consortium, has shown that when the analyst expresses his or her subjectivity, the patient actually makes a better, freer contribution to the therapeutic work in the next session (click on our 2017 article included at the bottom of the home page). Sometimes, this means that a therapist confronts the patient more directly or urgently with his/her particular intervention. It can also involve the therapist presenting him/herself in a straightforward way, or expressing him/herself in a way that acknowledges his/her subjective point of view. It stands to reason that the patient will feel more comfortable and secure if (s)he experiences the therapist as someone whom (s)he can relate to, and whose point of view feels compatible. [Click here to see examples of the analyst expressing his own point of view early in the analysis of Annie]

 

Clarification

Patients know what their upsetting feelings are when they come for help generally, but they don’t generally understand the full origins of their feelings. Feelings of shame and guilt are painful, and people want to avoid experiencing such feelings, so they may have difficulty keeping aspects of their situations in mind. Consequently, the therapist’s effort to understand elements contributing to their unhappiness by clarifying what the patient appears to be experiencing may often be the patient’s first experience of the therapist’s ability to understand them. This can often also help the patient develop trust that the therapist understands them and has something important to add. [Click here for a definition and example of clarification. Click here for illustrations in Annie’s case.]

 

Interpretation

Clarification and interpretation differ in the degree to which the patient is presumably already aware of the relationship between the elements described by the therapist. [click here for further definition and description]. Clarification and interpretation can contribute to the patient’s sense of being understood and helped, or if the point made is too unwelcome, may lead to a negative reaction. If indeed the patient is initially unaware of the interpreted connection, the therapist’s tact and timing may help in avoiding overly strong negative reactions. One aspect to be considered by the therapist is the state of the therapeutic alliance at that time. The state of the alliance clearly affects whether the patient is likely to examine constructively the proffered interpretation.

Interestingly, one immediate response to an interpretation by the patient that has proved to be an indicator that the interpretation is, in fact, correct is the response, “I never thought of that.”

 [Click here for examples of Annie’s reactions to her therapist’s interpretations]. 

The single most under-emphasized aspect of understanding a patient is the importance of understanding the patient’s feelings, including those that the patient may not be aware of (see Elliott, 2018?; Greenberg ????). Inquiring about or acknowledging the patient’s feelings will often open up the conversation in directions the patient may find relieving, or distressing. If in doubt about the patient’s feelings, better to express an inquiry or offer a tentative thought, rather than being definitive. In fact, for most patients a more respectful style is to be preferred anyway. A tentative interpretation (even in the form of a question) of a feeling about which the patient is unaware can develop trust that the therapist understands aspects of themselves that they had not fully appreciated, and can provide a stimulus for patients to think more about their feelings generally and how they relate to one another..

An important issue is what is interpreted from the patient’s current life outside of the therapy, from the past, or from reactions within the therapy situation. No general principle can be claimed for the choice, although there are fine studies dating back decades showing that linking those three situations often is therapeutically effective (see Malan, 1976, for example).

 

Support

Patients who come to see us are suffering. Most also feel a sense of failure and being unable successfully to deal with their problems.  Accompanying feelings include guilt and shame. Consequently the first priority may not be clarifying or interpreting, but rather supportive remarks to ease the patient’s distress. Such remarks can only be based upon the therapist’s own empathic response. Being open to your own feelings in response to the patient can make offerings of support feel more timely and appropriate. [Click here for our definition and description of support, and click herehere, and here for examples from the case of Annie].

 

Addressing defenses

The problems patients experience, which bring them to a clinician for help, very frequently involve painful feelings, such as anxiety or depression. Eventually, a clinician comes to appreciate patterns in how a patient manages these painful feelings in the context of his/her life and protects him/herself from them, sometimes at some emotional cost. Thus, typically they also complain of aspects of their lives that are not going well, as a result of how, on some level, they feel they must protect themselves from these painful feelings. This often entails intimate relationships, or work difficulties or failures to achieve career goals. Harder to identify are inherent character problems that lead to the more apparent difficulties of which they complain. To address these difficulties requires tact and good timing. Yet often, if timed correctly, the patient can also experience relief from such interventions. By better understanding how one protects him/herself from painful feelings, one can sometimes become more curious about and make freer choices related to such feelings. The PRC manual example (click here) is from later in a treatment, while Annie’s therapist addresses defenses beneficially quite early in their work together (click here) {the instance when she insists that she must show respect to her parents, and the doctor points out how she does not want to criticize them, which then puts her more at ease, and causes her to elaborate further on her critical feelings toward them.}

 

Addressing transference

Decades ago, therapists were cautioned not to attempt to make remarks early addressing the patient’s reaction to the therapist. Then along came  Per Høglend and colleagues, who studied talking with more troubled patients about difficulties they were having in the therapy itself. They found that conversing about difficulties in the relationship with the therapist (for example, in patients distrusting the analyst), illuminated patients’ difficulties in their lives, and thereby led to more successful treatments (2008). The conclusion is that making an interpretation that includes the patient’s reaction to the analyst (a transference interpretation, since it involves feelings presumed to be transferred from earlier relationships in the patient’s life, onto the therapist) may be beneficial even early in treatment. [Click here for description and example from our manual. Click here for example by Annie’s analyst]. In addition, careful attention by the therapist to his/her own feelings as he/she listens to the patient can also help guide tactful and timely interpretations of patients’ feelings towards the therapist.