Theory has long been the well-combed tail wagging the psychotherapy dog. This article presents a model that turns theory-based psychotherapy on its head.
During this first century of Western psychotherapy, arguments among and between the schools of psychotherapy have dominated discourse. The psychotherapy of the next century is likely to place theory and associated techniques in their appropriate, practical places in the psychotherapy outcome puzzle.
Behavior therapy, cognitive therapy and interpersonal therapy, for example, appear to be equally effective in the aggregate for the treatment of depression (Frank and colleagues).
The predominant influence of personality-based theorizing is multidetermined. Sigmund Freud can, of course, be blamed. Hoping to stay on the faculty of the University of Vienna, Freud worked in neuropathological research. Finding himself dismissed and married with a family, he had to find work. Viennese internist Josef Breuer, Freud's mentor, suggested hypnotism for patients with neurological disorders having no apparent neurophysiological basis. The ideas of his mentor proved viable. Freud's practice developed reasonably well, but he was more interested in developing a theory of mind than a model of therapy (Gay). His creative energies brought the world a compelling, complex and evolving system that captured the imagination of many. He became disenchanted with the therapy he had introduced (Freud), as did others who brought empathy (Rogers 1942 and 1951), interpersonal relationships (Sullivan), cognitions (Ellis, Beck), emotion (Perls), behavioral exposure (Wolpe) and systems thinking (e.g., Minuchin) to psychotherapeutic conceptualizing. They and their successors felt compelled, sometimes by textbook editors (e.g., Corsini and Wedding) to imitate Freud's system by describing their school's theory of personality, theory of psychopathology and theory of therapy. None had theories of psychopathology and personality as elaborate as Freud's, yet they struggled to match his complexity.
Of course, school-bound concepts have many benefits. They provide a rallying ground for believers who can form and maintain ideological organizations. Knowledge of personality and psychopathology theory allows therapists to conceive of themselves as experts and feel confident in what they do. But the reality of clinical practice requires different concepts generally unacknowledged by the general body of psychotherapeutic thinking-patient readiness to change, nature of the social network, symptom type and severity, and strength of the working alliance.
The pragmatic emphasis of managed care is loosening therapists' attachment to schools of therapy and forcing conceptual refinement of practice. Only theories and techniques that correlate with cost-effectiveness and quality are likely to survive in the managed-care environment (Cummings and Sayama). Other developments are also forcing the de-emphasis of schools of therapy. The movement to integrate the psychotherapies has been gathering momentum and support (Norcross and Goldfried). Compelling findings of reductions in caudate and prefrontal hypermetabolic activity associated with cognitive-behavioral treatment of obsessive-compulsive disorder direct therapists to consider how psychotherapy alters brain function (Schwartz and colleagues).
Goals of Psychotherapy
Psychotherapy can be defined by its goals, its process (stages), its tools and the principles for using those tools.
Future-oriented psychotherapy's intent is to help patients do something positive for themselves after they leave the office. The goals of most psychotherapy relationships fall into six categories:
Crisis stabilization. A person is distraught because his wife has suddenly left him for another man, for example.
Symptom reduction. A person has been depressed for several months, which is interfering with his work and social functioning.
Long-term pattern change. A woman repeatedly develops intimate relationships with abusive men.
Maintenance of change, stabilization, prevention of relapse. A woman with chronic medical disease, a disabled husband and recurrent depressive episodes requires continuing support to help maintain current functioning.
Self-exploration. A person with reasonably good social and work functioning wants to understand himself more fully.
Development of coping strategies to handle future problems. A person learns to handle emotions that increase the likelihood of wanting to drink alcohol excessively but wants to generalize this coping strategy to other situations.
Psychotherapy does not usually cure people of problems. Patients may return for a different set of problems or recurrence of the same ones. In this way therapists may act like primary care physicians.
Major Patient Variables
The practice of psychotherapy takes place in the real world, in the lives of patients functioning in their social networks. Several "functional inputs" play greater roles in influencing outcomes than do theory and technique:
Client readiness to change (Prochaska and DiClemente) and nature of social network (Marziali, Moos, Bankoff and Howard).
Symptom type, severity and chronicity
Strength of the working alliance (Horvath and Greenberg).
Number of sessions (Howard and colleagues, Mental health, Lambert 1996).
A critical next phase in psychotherapy research should relate these functional inputs with outcome findings to determine the degree of influence of each of these factors.
Patient strengths and limitations strongly influence outcome. Therapists do not "do it to them," but instead help patients find the means to change themselves. A study by Jones, Cumming and Horowitz supported the conventional wisdom that higher levels of client pretherapy adjustment correlated with successful outcome. In addition, perseverance, depth of affective experiencing, a specific problem versus a pervasive problem and acute difficulties versus chronic problems are well-established correlates of improvement (Robertson).
Courage (willingness to take risks, to face fears) may also be a crucial but difficult measure variable since change often requires trying the unknown or attempting new action without the certainty of the desired outcome.
Stages of Psychotherapy
Psychotherapists generally help patients solve problems. The dysfunctional pattern(s) need to be defined in a way that suggests solution. Then the patient has a set of guidelines for how to proceed. As the problem or problems are being defined, therapist and patient must be engaged in a working relationship that fosters collaboration. The therapist is responsible for managing their time together efficiently.
All relationships move through the same general stages. Stages guide interventions by providing subgoals for the process of change. These subgoals include engagement, pattern search, change and termination (Beitman 1987). Some patients may change by simply becoming involved in an empathic, understanding relationship (e.g., Rogers). Some may change when, together with their therapists, they clearly define a pattern or set of patterns to change. They may not need the therapist's change-inducing skills.
Change can be divided into three substages: relinquishing an old pattern, initiating a new pattern and maintaining the new pattern. Guided by the subgoals of the psychotherapy process and the substages of change, therapists confront choice points. At each of these choice points (silence, intense affect, report of homework, couple disagreement), therapists access an array of alternative intentions and response modes appropriate to the goals of each stage.
Psychotherapy takes place within patients' psychosocial context. In once-weekly therapy, there are 167 hours outside of the therapists' office. Family members, supportive friends, problem-specific books, cocounseling (Jackins), self-help groups, as well as homework, can all assist.
1. Bankoff EA, Howard KI. The social network of the psychotherapy patient and effective psychotherapeutic process. J Psychotherapy Integration. 1992;2(4):273-294.
2. Beck AT. Cognitive Therapy and the Emotional Disorders. New York: International Universities Press; 1976.
3. Beitman BD. The Structure of Individual Psychotherapy. New York: Guilford Press; 1987.
4. Beitman BD. Stop exploring! Start defining the principles of psychotherapy integration: call for a consensus conference. J Psychotherapy Integration. 1994;4(3):203-228.
5. Corsini RJ, Wedding D. Current Psychotherapies, 5th ed. Itasca, Ill.: Peacock Press; 1995.
6. Cummings N, Sayama M. Focused Psychotherapy: a Casebook of Brief, Intermittent Psychotherapy Throughout the Life Cycle. New York: Brunner/Mazel; 1995.
7. Deikman A. The Observing Self: Mysticism and Psychotherapy. Boston: Beacon Press; 1982.
8. Ellis A. Reason and Emotion in Psychotherapy. Secaucus, NJ: Carol Publishing Group, 1994.
9. Frank E, Karp JF, Rush AJ. Efficacy of treatments for major depression. Psychopharmacol Bull. 1993;29(4):457-475.
10. Frank JD, Frank JB. Persuasion and Healing: a Comparative Study of Psychotherapy. Baltimore: Johns Hopkins University Press; 1991.
11. Freud S. Analysis terminable and interminable. Standard Edition. 1937;23:209-253.
12. Gay P. Freud: a Life for Our Time. New York: W.W. Norton & Co.; 1988.
13. Goldfried MR, Wolfe BE. Psychotherapy practice and research: repairing a strained relationship. Am Psychol 1996;51(10):1007-1016.
14. Horvath AO, Greenberg LS, eds. The Working Alliance: Theory, Research and Practice. New York: Wiley Interscience; 1994.
15. Howard KI, Kopta SM, Krause MS, Orlinsky DE. The dose-effect relationship in psychotherapy. Am Psychol . 1986;41(2):159-164.
16. Howard KI, Orlinsky DE, Lueger RJ. The design of clinically relevant outcome research: some considerations and an example. In: Aveline M, Shapiro DA ., eds. Research Foundations for Psychotherapy Practice. New York: John Wiley & Sons, Inc.; 1994.
17. Jackins H. The Human Side of Human Beings: the Theory of Reevaluation Counseling. Seattle, Wash.: Rational Island Publishers; 1978 (1981 printing).
18. Jones EE, Cumming JD, Horowitz MJ. Another look at the nonspecific hypothesis of therapeutic effectiveness. J Consul Clin Psychol. 1988;56(1):48-55.
19. Karasu TB. The specificity versus nonspecificity dilemma; toward identifying therapeutic change agents. Am J Psychiatry. 1986;143(6):687-695.
20. Lambert MJ. Tracking patient progress on a session-by-session basis. Behav Healthcare Tomorrow. 1996;5(3):45,48,50.
21. Lambert MJ, Bergin AE. The effectiveness of psychotherapy. In: Bergin AE, Garfield SL ., eds. Handbook of Psychotherapy and Behavior Change. New York: John Wiley & Sons, Inc.; 1994.
22. Marziali EA. People in your life. Development of a social support measure for predicting psychotherapy outcome. J Nerv Ment Dis. 1992;175(6):327-338.
23. Mental health: does therapy work? Consumer Reports. 1995; 60(11):734-739.
24. Minuchin S. Families and Family Therapy. Cambridge: Harvard University Press; 1974.
25. Moos RH. Depressed outpatients' life contexts, amount of treatment and treatment outcome. J Nerv Ment Dis. 1990;178(2):105-112.
26. Norcross JC, Goldfried MR. Handbook of Psychotherapy Integration. New York: Basic Books; 1992.
27. Perls F. In: Stevens JO, ed. Gestalt Therapy Verbatim. Lafayette, Calif.: Real People Press; 1969.
28. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Am Psychol. 1992;47(9):1102-1114.
29. Prochaska JO, Prochaska JM. A transtheoretical model of change for addictive behaviors. In: Gossop M, et al., eds. Psychological Treatments for Addictive Behaviors. Barcelona, Spain: Cevron; 1994.
30. Robertson MH. Psychotherapy Education and Training: An Integrative Perspective. Madison, Conn.: International Universities Press; 1995.
31. Rogers CR. Client-centered Therapy . Boston: Houghton Mifflin; 1951.
32. Rogers CR. Counseling and Psychotherapy. Boston: Houghton Mifflin; 1942.
33. Schwartz JM, Martin KM, Baxter LR. Neuroimaging and cognitive-biobehavioral self-treatment for obsessive-compulsive disorder: practical and philosophical considerations. In: Hand I, et al., eds. Obsessive-Compulsive Disorders: New Research Results. Berlin: Springer Verlag; 1992.
34. Sullivan HS. The Psychiatric Interview. New York: W.W. Norton & Co.; 1954.
35. Wolpe J. The Practice of Behavior Therapy. New York: Pergamon Press; 1973.