In the real world of clinical practice, based not on theory but on the unspoken power narrative embedded in the therapeutic relationship, there are only three kinds of therapy (Table 2): supportive, directive and relational. Our patient began her odyssey in the directive column, where most contemporary psychiatric treatment starts, first with the CBT, then DBT. When she came back, it was to the supportive column, albeit to a therapist who had not yet learned its language. If all goes well, she will finish in the relational column, probably availing herself again of directive techniques along the way.
The underlying premises of each kind of therapy establish a power structure within doctor-patient relationships -- a structure that doctors may not have thought through in advance and that they might not endorse if they had. With deliberate exaggeration, therefore, let me explicitly voice the power narrative of each of these three forms of therapy to show the differences between them.
When I speak of power, I refer to the therapist's power to define the nature of reality. Thus, in directive therapies, the unspoken narrative is, "I, the therapist, am powerful and know what is or isn't dangerous [in anxiety disorders], is or isn't negativistic [depression], is or isn't real [psychosis]. I know the diagnosis and causes of your illness, and I direct you to change your thoughts/feelings in the following way," and so on.
Such a narrative reiterates the existing social status quo and asks the patient to adjust to it. This is often a good and necessary thing, as with a potentially violent paranoid man in the emergency department, or a widowed woman whose grief has extended into major depression. But because many damaged patients are unable to let themselves be helped by a benign authority -- unable, in D.W. Winnicott's words, to "use the object" -- directive therapies don't work as often as their academic proponents would like to think.
While the supportive therapies are centered on the person rather than the symptoms, their power narrative has a remarkable underlying similarity to that of their directive cousins. "I, the therapist, am powerful-powerful enough to keep the world at bay. I will create the environment and give you the nurturance that you need. Let yourself unfold under my protection, bask in my empathy," and so on.
Instead of actively reinforcing the social status quo, this narrative provides the patient a temporary respite from it. Once again, this is often a good and necessary ("indicated") thing, as in the resident's case presented earlier. I want to stress, though, that it is a technical approach in that it purports to know what is wrong -- environmental stresses, developmental deficits from childhood -- and to be able to ameliorate or correct it through consciously (even if intuitively) modulated enactments on the part of the therapist. In comparison to directive therapy, the harsh diagnostic language is muffled and there is some implicit faith in an intrinsic healing process, which supportive therapy tries, indeed, to support. But the power arrangement in which a knowing therapist administers techniques to a malfunctioning patient remains the same. I maintain that this is even true of Kohutian self-psychology, which has developed a rich and beautiful theoretical language to describe its own version of supportive therapy. Such language does not change the fact that the therapist largely defines the nature of reality -- an arrangement much more obvious and above-board in the less humanistically couched directive therapies. Of course, what the experienced practitioners from any well-established school of psychotherapy actually do is likely to span all three of the types of therapy in this classification scheme at some time or another; it is only either very new, or very partisan, practitioners who refuse to adapt their behavior to the needs of a reasonable range of patients.
Relational therapy remains to be described, and it is as important not to idealize it as it is not to devalue the other two forms. It does not fit all or even most patients' needs, and its irresponsible application can be not only "contraindicated," but cruel. However, it is the only form of therapy whose power narrative allows both doctor and patient to be subjects engaged in an unpredictable process, rather than an Expert and the object of their technique. "I, the therapist, possess an institutionally sanctioned role, as well as education and experience. But my power and knowledge are limited. I offer no more nor less than an honest professional relationship whose primary purpose is to address your problem(s), but through which I fully expect to question myself, learn and grow as well."
The language of Martin Buber's "I-Thou" dialogue, Jurgen Habermas' "communicative action" or Winnicott's ingenuous term "object use" (which is really about subjects), all aptly describe such a relationship. Therapy takes the form of questions and statements about one's experience of self and other, and its power lies chiefly in the immediate interaction regardless of how much importance the therapist attributes to constructs such as transference, the unconscious, developmental issues, the Gestalt cycle of experience and so on. We all have our favorite constructs, our own ways of skinning a cat.
Because honest reciprocal dialogue fosters autonomy, independent thinking and acceptance of one's own emotional reality, it is subversive to the social status quo and its usual power arrangement of Expert and object. While patients retain, even improve upon, their ability to get help (including medical care) through relational therapy, its premise encourages them to become the ultimate Experts and Authorities on their own mental and interpersonal lives.
Before I conclude, two important corollaries to this triune scheme deserve mention. First is the place of the powerful modality of group psychotherapy. The various approaches to it fall into the same categories: supportive (peer and professional support groups), relational (process-oriented groups) and directive (psychoeducational and skills groups). As in individual therapy, actual practice favors hybrids rather than pure forms. Family therapies, with which I am less familiar, probably follow analogous patterns.
The other corollary involves the role of medication. It may be directive (as with antipsychotics in acute delusional mania, which aim to change mental content) or supportive (as with temporizing anxiolytics or antidepressants when used to prolong a patient's survival in an intolerable home situation: here the effort is to dull mental content). But medications can never be relational, much as patients sometimes attempt to have relationships with us through them, symbolically mediated by "side effects," paradoxical responses and refractoriness to treatment. This is one reason why longer visits and individual attention lead to more successful pharmacotherapy.
Giving psychiatric trainees an overview of these three kinds of psychotherapy demystifies the field and helps them to find their place in it. They can then move beyond the procedural "see one, do one, teach one" mentality of medical school. Instead of learning to "do some therapy on 'em" in only standardized ways, trainees will begin to look at their own natural aptitudes, as well as their intrinsic limitations, and how possibly to stretch them. Otherwise we consign them to the learning of an ever-narrowing, mechanistic approach to human problems.