How Psychotherapy Works

Introduction

 

Using the PRC Website

In this section, we describe central components of psychotherapy.  Throughout we provide many links to descriptions and illustrations in  the PRC Manual, and to illustrative moments in the recorded sessions of Annie, the first case provided here.

The PRC manual provides precise definitions and descriptions of central features of the psychotherapy process, with brief clinical illustrations. We link back and forth between our descriptions of these elements and our case material, with explanatory comments.  We hope this provides an understanding of various elements of psychotherapy that are common to most types of therapy and theoretical orientations.

To further enrich the experience and learning, a recorded and transcribed case is provided of the first four sessions of a highly successful case of psychoanalysis, with accompanying audio re-creation by actors (The Case of “Annie”). We recommend reading and listening to the entire first four sessions early on to have a sense of context when later following links to specific instances within the clinical example.

Brief History

Throughout history healers have used different methods to heal suffering, depending on their culture’s explanations of illness. 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.

Sigmund Freud, in the early 20th century, 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 motivation. His method of analyzing, understanding and treating patients is called psychoanalysis.  A psychodynamic (“talk therapy”) form of psychotherapy, it is the basis of much of the psychotherapy used today.

In recent decades a wide variety of psychotherapies in addition to psychoanalysis have been developed. Common elements are shared by these “brands” of psychotherapy (Ablon & Jones, 1998; Ablon et al., 2006).  At the same time, Freud’s psychodynamic therapeutic principles have been refined by decades of further development of clinical theories of therapy.

A crucial question the PRC research group addresses is whether the elements emphasized by psychodynamic theories demonstrably help patients over and above the benefit of elements common to all therapies. The evidence we and others have developed (Waldron et al. 2018; Høglend et al. 2011) support their importance.

Often these psychodynamic techniques are used by therapists with only partial or no awareness of the origin of these techniques (Waldron & Helm, 2004).

It is helpful to make a distinction between understanding how people’s minds and feelings work, which was greatly advanced by Freud’s discoveries, the specific recommendations Freud originally made for psychoanalytic treatment, and their subsequent elaboration through the decades. This elaboration eventuated in most places in a rather stilted form: by the 1950s, a model of psychoanalytic treatment was taught which discouraged suggestion, giving advice, expressing a personal opinion or point of view, showing feeling or revealing anything about the self, or even advising patients what they might do in life to feel better. Psychoanalytic treatment was supposed ideally to occur through interpretation alone. These teachings were not based upon sound empirical explorations of what in fact helped different patients under different circumstances. They were counter-intuitive, so many analysts ignored them often, and responded to the actual needs of their patients. Meanwhile many other clinicians rebelled against these strictures, leading to the sprouting of many schools of therapy espousing other ways to help patients change.

There are perhaps two main reasons why American psychoanalysis developed these limiting recommendations:  first, there was a wish among analysts to be as scientific as possible in their work, that is to maintain a degree of objectivity, that would do honor to the profession (Bettelheim, 1982). Human susceptibility to ideology took its toll. Second, there are indeed pitfalls for the young clinician in giving socially sanctioned advice too freely. Patients with difficulties have ordinarily already heard too much of advice they are unable to follow.

 

The Beginning of Treatment

Patients respond to an initial offer: “How can I help you?” This direct approach gets right to the point of the therapeutic encounter. An open ended question  like this can allow the patient directly to address what is top of mind.

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 phase tends to occur due to the power of nonspecific factors (“common elements”) in the psychotherapeutic situation. 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.

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, for long standing and complex personality problems, these short term benefits tend to disappear with time, unless changes are accomplished in the underlying personality issues which contributed to the development of a clinical illness (Shea et al., 1992).

A psychodynamic psychotherapist attempts from the outset to engage in a specific type of conversation about the patient’s presenting difficulties, thereby determining the nature and severity of the patient’s problems, personality traits, and patterns in how the patient relates to others, and how the patient sees him/herself.

A clinical diagnosis is not nearly as useful as the formulation of a flexible and workable description of the patient’s emotional difficulties, because formal diagnosis itself tells so little of the nature of the person.  Assessing both strengths and weaknesses, the therapist can form a plan for how best to alleviate the patient’s suffering.

Early considerations in introducing a patient to psychotherapy involve creating a productive engagement between therapist and patient. Click here [Annie’s first session] for an example of one patient and psychoanalyst’s initial meeting, and the analyst’s efforts to engage an anxious, inexperienced patient in an exploration of her difficulties.

 

Developing a Relationship

How therapist and patient relate to one another is of central importance. The therapeutic alliance is the widely used term in recent decades, because, as measured, it correlates  often with therapeutic benefit. But it seems more accurate to describe thie general catagory as addressing aspects of the relationship (see Norcross’ edited book, 2011, Psychotherapy Relationships that Work.)

In a way, defining the influence of the therapeutic alliance as capturing the essence of the impact of the relationship may beg the question of what aspects of the relationship are important in outcome for each therapeutic pair. For instance, there are occasions when confronting the patient in a challenging way may mark a positive turning point in a treatment, even though in general a confrontative approach to patients has been shown to have negative results (Norcross 2011, p. 427).

It can also be helpful to be aware of cultural differences (Lingiardi et al., 2017;  Werbart et al.).

Feelings the therapist has while listening can give important clues to the patient’s experiences and concerns, sometimes not available to the therapist consciously. Through the highly-individualized process of immersion in a patient’s emotional experience and inquiring more about it, the therapist has the opportunity to foster curiosity and further reflection in the patient. In favorable cases, patients respond with greater trust in the therapist’s understanding, empathic connection, challenges, and confrontations.

Therapists tend to alternate between sharing in the patient’s emotional experiences and separating themselves enough from them to examine them in a different light, a potentially tactful oscillation between empathic resonance on the one hand, and expressing different vantage points that can stimulate novel reflections.

Listening attentively is experienced by most patients as comforting, especially with careful attention to the patient’s feelings, of which they may not initially have been aware. 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.

This availability 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).

 

Specific Components of Ongoing Therapeutic Work

(Summarized from the PRC  Manual)

We have found it useful over decades of research on recorded analyses to characterize multiple dimensions of the therapist’s contribution (Waldron et al. 2004a, 2004b, 2013). It turns out that there are two major aspects of the work we have studied, discovered by factor analysis (Gazzillo et al. 2018), which we describe as 1) psychodynamic (technical) aspects, and 2) relational aspects. These components will be the basis of most of the different sections below. We tested the usefulness of these categories by classifying all the therapist comments in the four introductory sessions of “Annie”, which you are invited to read and listen to here [link to Recorded Cases]. The therapist had 752 turns of speech during these 4 sessions, many of which were not ratable using our dimensions, but we did find 523 opportunities to classify some of these comments, often qualifying in multiple categories. We present below components which were found in these four sessions, with a description and definition for each. We have added to these two more components from our examination of other tabulations of types of therapist interventions.

For this website, we wanted to include activities not part of the typical psychodynamic toolbox as well, so we studied three instruments which were specifically developed to tap the full range of therapist actions in psychotherapy (Jones & Pulos, 1993; Hilsenroth et al. 2005; McCarthy & Barber 2009). McCarthy and Barber’s “MULTI” scale, being the most recent and comprehensive, serves as a good introduction to the variety of psychotherapeutic interventions. We have altered their classifications of 60 types of therapist comments because, in our view, many of the items listed belong in the category of psychodynamic technique as actually practiced by many contemporary psychodynamic practitioners. Many of these can also be described as “common factors,” relevant to most types of psychotherapy.  

The result of this re-classification classifies 42 of the 60 types of comments as within the psychodynamic umbrella. We divide the remaining 18 types of interventions which we divide into three categories:  6 are suggestions in regard to therapy (“suggestions for therapy”), and 12 are suggestions to patients for what they might do to improve their life outside the therapy room (’suggestions for life”). Additionally there are two suggestions that apply both to therapy and to life outside the consulting room, and finally two which don’t fit into our classification system.

You may inspect the full list, with the authors’ original classification and our modification, by clicking here.There is an interesting mix of suggestions, which is no doubt added to each time a clinician invents or discovers a new type of suggestion, and then sometimes immediately adds to the literally thousands of newly named therapies, so that the clinician new to psychotherapy feels quite overwhelmed, and the experienced clinician throws up his/her hands!

We believe that most therapists would benefit from a careful consideration of the nature and results of therapist comments that they are not so familiar with. There is no doubt that the field needs much more extensive examination of what works for whom, and what the long term benefits are across the wide range of patients seeking therapeutic help. The role of suggestions of various kinds appears to be an important dimension for further study.

Encouraging Elaboration

Encouraging elaboration is the first tool described and illustrated in our PRC Psychotherapy Manual [see here]. It comprises much of the conversation in the beginning and throughout therapy. It is a straightforward means to add to the knowledge of the patient’s thoughts and feelings, and, if done tactfully, can provide a safe, unobtrusive environment for the patient to explore new emotional territory or further reflect on him/herself and others.  It is useful to encourage elaboration based upon what the therapist discerns, 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. 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 called Annie]. In the first few meetings, patient and psychotherapist typically discuss how or why the patient’s emotional life has led to a consultation at this particular time. Ideally, patient and psychotherapist become collaborators in describing the nature of the patient’s problems. Moreover, in the elaboration of this conversation, patient and psychotherapist can revise or clarify any disagreements in how they each view these difficulties.

Clarification

Patients generally know what their upsetting feelings are when they come for help, but often they don’t understand the full origins or implications of their feelings. Feelings of shame and guilt are painful, and people want to avoid experiencing such feelings, so they may have difficulty keeping many aspects of their situation in mind. The therapist’s effort to clarify elements contributing to their unhappiness or the nature of what the patient is 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 curiosity and trust that the therapist understands them adequately enough that he/she may have something meaningful 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 of interpretation]. Both clarification and interpretation can contribute to the patient’s sense of being understood and helped, provided sufficiently tactfully presented.

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.” In favorable circumstances, this leads to increasing curiosity and expanding opportunities for exploration and reflection.

[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 is flexible enough to understand 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 whether the focus of an interpretation concerns the patient’s current life outside of the therapy, the patient’s past, or 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).

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, when it came to feelings that seem alien or feel out-of-control. But insight does not 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).  The implicitly and explicitly changing relationship between patient and healer is surely the vehicle for change. More recent research examines the balance between various components of the therapeutic process that contribute to emotional benefit.

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 can include anxiety, guilt, grief, and shame. Consequently the first priority may not be clarifying or interpreting, but rather supportive remarks to ease the patient’s distress. Relief from distress can empower the patient to be more curious and think further about him/herself. Supportive statements can include straightforward guidance, statements of reassurance, or explicit acknowledgment and validation of the patient’s perspective. There is often a supportive element intertwined with interpretations, clarifications, and confrontations. Being open to one’s own feelings in response to the patient can make the therapist’s support feel more timely and appropriate. [Click here for our definition and description of support, and click here; here and here for examples from the case of Annie]

Further components in preparation.