Patients change during psychotherapy for a number of reasons, some of which have little to do with therapeutic technique. A multitude of studies both pharmacological and psychotherapeutic demonstrate a "time effect," namely, that patients improve simply by the passage of time and being part of a study. Factors contributing to the time effect fall under the broadly defined categories of spontaneous remission and placebo response. The first refers to factors outside of the therapeutic relationship and the second to expectancy factors within the relationship.
In other words, patients sometimes improve because of events in their environments and sometimes because they believe the treatment program will be effective (Lambert and Bergin).
Outlined below are the primary tools of psychotherapists:
Relationship skills. These include the constructive use of empathic understanding; careful management of the therapeutic contract; demonstration of expertise, warmth and nonjudgmental acceptance. A strong working alliance is closely correlated with outcome (Horvath and Greenberg).
Activation of the patient's observing self. Most psychotherapists activate their patients' capacity to self-observe (Deikman). Disciplined self-observation fosters the opportunity for insight. Using empathic reflections, cognitive homework, affective exercises, behavioral instructions, interpretations and other methods, therapists encourage patients to look within themselves in order to find the data to delineate dysfunctional patterns.
Knowledge of basic patterns of psychological difficulties. Experienced therapists possess a broad array of generic patterns that characterize the common problems confronting their patients. The themes of these patterns contain cognitive components and generally concern interpersonal relationships. Patients struggle with lack of awareness or excessive anxiety about their own emotions, particularly anger; have poorly constructed and misconstrued interpersonal schemas; and struggle with unresolved tragic, disheartening and/or frightening memories including unresolved grief and traumatic events. Many have used maladaptive, repetitive responses to distressing events, retreating into substance abuse, depression, anxiety and eating disorders. Many patients reflect problems inherent in the thematic crosscurrents of the culture.
The schools of psychotherapy have elaborated on these themes in remarkable and stultifying detail. Commonly used change strategies extracted from the schools are contained in the Table.
The 21st century is likely to witness the realization of Freud's vision when he attempted the "Project for a Scientific Psychology." We will better understand the mind by better understanding the brain. We will continue to witness changes in the brain associated with changes in mind as suggested by research in obsessive-compulsive disorder (Schwartz and colleagues). Theorizing will increasingly be tethered to the organs of the brain (Beitman 1994).
Inductive reasoning. Such reasoning requires therapists to generalize from bits of information presented by the patient to explicit patterns of dysfunction.
Information can be gathered in a number of ways including: questions, confrontations, clarifications, homework assignments, reports from significant others, observation of the patient in the office and therapist reactions to the patient.
Persuasion. Therapists encourage patients to increase emotional awareness, modify cognitions and/or regulate behavior (Frank 1961; Karasu) and/or to refine their self-definitions in relationship to others. The strategies which guide these efforts include encouraging patients to face their fears, helping them to alter the way in which they anticipate the future and offering ways to redesign their role-relationship schemata and scripts.General Principles
Effective therapists seem to possess both a solid grounding in the basics of psychotherapy and disciplined flexibility. Disciplined flexibility requires structured ways to adjust psychotherapeutic ideas to the therapist's personality as well as to the individualized needs of patients and to move easily, but prudently, among various strategies for change.
Theory and technique are molded to the individual personality of each therapist. No matter how leaders of schools might attempt to create therapists who strongly resemble each other, most practitioners seem to adjust their selections of school-bound ideas to their own interpersonal styles and world views.
Theory and technique are shaped by the cultural context in which it is being practiced. Psychotherapy is strongly influenced by its sociopolitical context and may sometimes influence the culture in which it grows.
Therapists adjust to influences patients bring to the psychotherapy relationship. Generally, therapists strive to match client characteristics and problems with the most potentially effective interventions rather than attempting to force patients into therapist-imposed restrictive formats.
Effective therapists learn to move easily among the commonly accepted change strategies. Three meta-strategies guide the application of change strategies:
Key-change strategy: Sometimes the available evidence suggests that one strategy offers the quickest, most efficient avenue to change.
Shifting-change strategy: Therapy begins with the most easily used change strategy. If not effective, switch to another strategy.
Maximum-impact strategy: With some complex cases, therapists must work simultaneously on several patterns. Instead of hoping for a sequential effect, therapists may need to work for a synergistic effect as multiple changes mass together to bring about a desired state. The use of these strategies relies on the principle of using the least amount of energy to produce the greatest output (Prochaska and Prochaska).
Effective therapists reflect on and analyze their own thinking: Effective therapists seem to reflect upon their own responses to patients to differentiate their own neurotic responses from patient-induced ones. They attempt to utilize this understanding to help patients and also to help themselves grow as individuals and as therapists.
Overall, the guiding strategy of psychotherapists is an ethical one: everything therapists do is intended to help their patients.Knowledge Sources
The pressure of cost containment is painfully squeezing out the inefficiencies in the helping professions. One such inefficiency is how new knowledge enters the mainstream of clinical practice. Because psychotherapy is not a profession, little formal obligation exists for continuing education in psychotherapy. Because busy clinicians are often caught up in economic and personal concerns, their expansion of psychotherapy knowledge is likely to be haphazard and idiosyncratically built upon their own clinical biases. The primary sources of new knowledge for psychotherapists are theory, clinical experience of both their own and of other clinicians and research. Therapists may also acquire new ideas from the media and from their own personal experiences. For the practice of psychotherapy to become coherent, a new organization for the screening of new ideas may be required. There are numerous psychotherapy journals and newsletters. None seems dedicated to defining only that which therapists need to know in order to improve practice. A publication disseminated through the Internet as a public service to psychotherapists could be created to fill the continuing education need for this constantly evolving process. The organization behind this publication would need to filter information from the four primary sources: theory, clinical practice, controlled research and naturalistic outcome research.
Particularly useful will be feedback from well-constructed data sets based upon outcome and process data from actual clinical practices. Such data bases are currently being formed by managed behavioral health organizations. Simple but profound questions looking, for example, at the relationship between working alliance, stages of change and clinical outcomes could inform clinical practice.Toward the Future
Psychotherapy is not a profession. It is an activity of many different professions. It has no organization to set and uphold professional standards and ethics. In 1996, the American Psychiatric Association established the Commission on Psychotherapy to address the erosion of psychotherapeutic practice. For the long-standing survival and flourishing of psychotherapy, psychotherapists may need to create a multidisciplinary group dedicated to the growth and survival of psychotherapy.