8 Core Components of Psychotherapy

1. Trust is a must. Patients begin with varying degrees of it. Trust is facilitated by the therapist’s interest in helping the patient, the capacity to ask intelligent questions, and knowledge about the patient’s diagnostic category. The obvious object of our listening is the patient’s narrative. We listen to what occurs between us during the session and, in the subsequent session, we listen to the patient’s thoughts that occurred between our meetings. We also listen to our own feelings, thoughts, and memories that arise during and after the session with our patient.

2. The therapist must provide a respectful psychological intimacy. Patient trust is undermined by poor intimacy skills, such as lack of evident interest, criticism, and failure to comprehend the narrative. A refined quality of listening is our basic tool. Refined listening rests on our pleasure in and appreciation of the patient’s narrative. We strive to comprehend what is being said, noting the style of the narrative and wondering about what is not being said. We seek to understand the emotional tone of the patient’s words by observing the postural and facial expressions that accompany the narrative. We listen in an effort to recognize the patient’s meanings, to create a bond with the patient, and to derive our separate meanings from the narrative.

3. Understanding what led to a predicament is a multistep process that is not complete after the first session. Over time, the history becomes multidimensional; both the therapist and the patient grasp the individuality and the complexity of the situation. The predicament must be understood in ordinary human terms rather than professional jargon.

4. The therapist should assume the patient will have many changing feelings about him or her and will be reticent to share most of them in therapy. The patient is always evaluating us. In early sessions, we are auditioning to be the patient’s therapist. Only if we "pass our audition" does the therapeutic alliance begin. Later in therapy, the patient’s new negative evaluation of us can lead to an abrupt cessation of our work together. Nonetheless, our refined listening creates a therapeutic alliance.

5. The attachment to the therapist should be perceived, acknowledged, and respected. It should also be discussed, in particular, when a separation or termination is approaching. Therapists are not readily interchangeable. Because of the psychoanalytic origin of the term, transference is often erroneously assumed to not exist in other forms of therapy. Transference is a human rather than an ideological experience. Transference originates in unconscious processes that mysteriously link us with the patient’s past through his or her thoughts, feelings, and perceptions of us. It sometimes surfaces during a session, but most of its manifestations arise between sessions. Transferences reside in the patient’s privacy and tend to be kept from the therapist.

6. The therapist should assume that the patient has told as much of the story as he was able to tell at this point in their relationship. The continuing conversation within the therapeutic alliance; the patient’s changing life circumstances; and the evolution of the therapist’s skills, knowledge, perspective, and style all contribute to the uniqueness of psychotherapy.

7. Patients can get better! Psychotherapy is a purposeful, professional, intimate, conversational process that focuses on the patient’s subjective, interpersonal, developmental, and biological life in order to benefit the patient. There is often an initial improvement that results from the new attachment to a therapist. Complete symptom disappearance usually requires a significant change in understanding, social circumstances, or maturation.

8. Psychotherapy is a conversation between two human beings! It is a rubric-an umbrella under which a vast array of differing interventions exist. Its diverse forms are supported by different ideologies and vocabularies. No one brand of psychotherapy is applicable to everything that ails humans. A professional’s preferred form of psychotherapy often generates passion, identity, and affiliation patterns.

For more on this topic, see On the Essence of Psychotherapy, on which this slideshow is based.