What is psychotherapy and how does it work?

Research as shown that five elements should be present for a psychotherapy to be effective (Weinberger, 1995):

  1. A positive therapeutic alliance (relationship between the client and the therapist)
  2. Helping the client confront what s/he has tried to avoid
  3. Revival of hope
  4. Increased sense of mastery and competence
  5. Attribution of success to one’s own efforts

This brief article will examine several modern psychotherapies in light of these elements.

A bit of history. There have always been people to whom we go to talk about our problems. In the modern world they are doctors, psychologists, social workers and other health practitioners.

Modern psychotherapy came out of the work of Sigmund Freud in the late 19th and early 20th centuries. His insights into human behavior helped him develop psychoanalysis. This form of psychotherapy is the first of the many modern forms of therapy that we know today.

Analysis involved his patients (he was a doctor and the medical approach was the only one around at that time) lying on a couch and talking about their problems. He called this type of talking ‘free association’ as the patient talked freely about anything that came into her mind. He maintained that the patient’s talking was in fact directed by unconscious conflicts that were causing the problems she came with. The therapist’s job was to offer interpretations at key moments that brought about changes in the patient’s insight and so led to changes in her life

By making the unconscious conscious, the “talking cure’ helped patients to gain insight into their problems and make changes in their lives.

Psychoanalysis gained a bad reputation for being long and expensive for little improvement. In an attempt to address this, short forms of what is now known as short-term ‘dynamic’ psychotherapy have been developed. ‘Dynamic’ means that the therapy acknowledges there are unconscious forces or dynamics at work in the person’s psyche that create conflicts within him and lead to the problems he presents with in therapy.

The short form that has the best evidence for being effective is Intensive Short-Term Dynamic Psychotherapy or ISTDP. This approach takes a more active stance to the person and does away with the couch in favour of two chairs as is usual in therapy today. Short-term therapy is regarded as less than 40 sessions.

ISTDP is an attachment-based therapy that recognizes that when we engage in relationships with others, old attachment feelings are awakened. We become defensive about the feelings and closeness to others and/or we become anxious and adopt unhealthy patterns of responding to our feelings and the people who come close to us. This causes depression, anxiety, distance in our relationships and problems being productive in work, lack enjoyment and often lack insight into ourselves.

ISTDP and other emotion -focused therapies see it as vital that the client experience emotions in the session in a safe and healing way. There is considerable evidence that the full-experience of emotions gives a more effective result and people have less medication, return to work and have more healthy relationships following such therapy.

Because emotions are physical (in our body) as well as psychological (in our mind) ISTDP focuses on the physical experiencing of feelings so the client can accurately identify and understand his own feelings and not remain depressed or anxious. There is growing interest in these approaches as the body of evidence for effectiveness grows.

ISTDP uses techniques including assisting the person to be aware of her own emotions in her body and mind, and to experience the emotions in the session, including the emotions that the person wants to avoid. This is an active therapy and involves a partnership between therapist and client to achieve the client’s goals.

Many approaches to helping people change through a “talking cure’ have been developed since Freud’s lifetime. The most common approach used today is Cognitive Behavioural Therapy (CBT). This has a solid evidence base but notably recent evidence is not as strong as for early studies.

This approach is based on the idea that most problems occur because of faulty/distorted thinking and habits of acting that no longer work in the person’s life. Examples include thinking styles such as ‘black and white thinking’ or ‘overly negative thinking’. This requires strategies of cognitive restructuring (helping the person to think in more reasonable and balanced ways), response scheduling (adopting regular and scheduled changes) and response prevention (stopping old patterns of behavior that no longer work) among others.

The CBT therapist identifies these thinking styles with the client and provides strategies and homework to reinforce insights and assist them to make the changes to the way they respond to the problem situations in their life.

Another common approach is Interpersonal Psychotherapy. This is most often used for treatment of depression. This approach understands the problems people have as caused by changes in social roles and the way these changes have affected interpersonal relationships. It is these changes in relationships that cause depression. This therapy has a ‘here and now’ focus. It is not focused on the past but on how the person is functioning in the present.

There are many new types of psychotherapy that are proving popular. These include Mindfulness-based therapy, Acceptance and Commitment Therapy (ACT), and some approaches based in the positive psychology movement.

Mindfulness is an ancient technique that is practiced by Buddhists and has become very well known in the west in the past 60 years. It involves being attentive to your current experience, remaining present to yourself, your activity or inactivity and your surroundings. By being attentive and noticing yourself you become aware of the truth of yourself, your desires, feelings and urges. This enables you to make choices that are more grounded in what is actually happening in your life rather than from your thoughts alone, which may or may not be a good indicator of what is good for you.

Meditation is the most common form of mindfulness and is taught by many practitioners today, some more reputable than others. Used as a technique within many types of psychotherapy it is an effective way to assist the client to be aware of her own internal experience, particularly of her own feelings.

Acceptance and Commitment Therapy (ACT) is also proving popular among therapists. The aim of ACT is to enable the client to accept what is out of her personal control, and commit to action that improves her life. This approach is focused and can be applied to many life problems including depression and anxiety.

ACT uses techniques common to many psychotherapies. These include assisting the client to be present and identify his experience, and of course mindfulness, with or without meditation.

So when you are choosing a therapy, ask yourself:

  • Does the therapy tick each of the above five points?
  • Is there evidence for it being effective for the problems you are experiencing?
  • Are there sources of evidence that are reliable, such as independent university studies?

Do your own research. This is a brief survey that should lead you to the Internet for more information and to ask others who have been to a therapist. Keep in mind though that their experience will not be your experience. The dynamic between therapist and client is always unique to each person. So your friend’s experience may not be yours. That said, if it ticks the five elements and you can answer the questions above, you should at least avoid harmful experiences at the hands of charlatans who may promise you that you will get better if they slap a couple of salmon together over you and chant ‘Om’.

Disclaimer: Bernie McCarthy practices ISTDP.

 

 

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