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In This Chapter:
What does Psychotherapy do?
What doesn't it do?
Why are there different "therapies"
How different therapies are the same
Chapter 2: Building One Framework for Many Therapies
Entrenched Dysfunctional Patterns of Reaction
Psychotherapy, the "talking cure," whether it is gestalt, cognitive-behavioral, psychodynamic or based on "motivational counseling," is aimed at changing dysfunctional behavior and feelings. People don't seek psychotherapy unless they are experiencing a significant degree of distress, usually repetitively. Furthermore, they have found themselves unable to make changes using ordinary social means such as conversation with friends or self-help books. The irrational, "stuck" behaviors and feelings that remain are the target of psychotherapy. Putting these characteristics together, a general formulation of what psychotherapy seeks to modify could be stated as: "entrenched dysfunctional patterns of reaction."
Of course, the variety of such patterns is infinite. They can be severe, and have the capacity to unbalance emotional equilibrium, and even brain chemistry. They can and do cause enormous suffering. One way of categorizing dysfunctional patterns is based on their likely origin: 1. Patterns around unhealed traumatic experiences. 2. Patterns originally aimed at coping with important others. 3. Patterns resulting from arrested development. 4. Patterns relating to unhealthy or contradictory internalized values or attitudes. 5. Patterns aimed at achieving unconsciously held, secret childhood goals. These are generally the subject matter of psychotherapy.
When psychotherapy is provided in the context of treatment for major mental illness, it may not be curative but can still focus on entrenched dysfunctional patterns of reaction. Emotional healing and growth can markedly improve the quality of life and even the course of the illness.
Emotional Activation, a Common Factor in All Structural Change
The two fundamental healing processes discussed here have one element in common. In both cases, catharsis and internalization, change requires the activation of emotions. This fact was part of Freud's original description of cathartic healing. It is also true of internalization. Recent work on the neurobiology of therapy has suggested that Donald Hebb's 1949 notion that "cells that fire together wire together" may explain how emotional activation is necessary for the modification of neural networks. A universal aspect of all therapies is that they activate emotions. Perhaps the main factor that distinguishes one from another is the method they use to do so.
Cooking is a good metaphor. Different therapies can be thought of as different cooking methods. There are many ways to heat food, microwaves, wood stoves, open fires, etc. They all work, but use different means to heat the ingredients to the temperature needed for the chemical reactions take place.
For example, behavioral therapies push patients to adopt new behaviors. Letting go of old behaviors and trying on new ones is a powerfully emotional experience. Thus, emotional activation is achieved through behavior change.
Psychoanalysis and other therapies based on free association activate emotions in a very different way. Helped by the inherent intensity of multiple sessions per week and very little structure, surprising thoughts and feelings slip into consciousness. As this happens, emotions are powerfully activated, setting the stage for the needed change processes to take place.
Cognitive therapy challenges the patient's most fundamental "core beliefs." These are so central to our being that simply bringing them into question raises emotions, not to mention the behavior changes that are the logical result of adopting modified beliefs.
Brief Psychodynamic Therapy activates emotions by tearing away defenses in an active and focused way. Interestingly, while this mode of therapy has the same theoretical base as psychoanalysis, the means of activating emotions is quite different.
Putting It All Together
Psychotherapy is a treatment for "entrenched dysfunctional patterns of reaction." Resolving or modifying such patterns will require structural change. The two final pathways of such change are catharsis and internalization. Our job as therapists is to understand what changes need to take place and how to create conditions that will allow change mechanisms to operate. The choices we make in doing this can be governed by what is most efficient and what will be most comfortable without losing effectiveness. In addition, we will need checks and balances to prevent harm from being done, and to avoid doing things now that will defeat the treatment in the future.
As this approach is outlined in greater detail, it will be apparent that some traditional distinctions are no longer relevant. The pejorative notion of "supportive" therapy will not appear. As we gain a more specific and precise understanding of the two change process, we will see that thoughtful support is a key ingredient in all kinds of therapy. Similarly, tension between empathy and insight will not be apparent because both have important and specific roles in healing.
On the cognitive-behavioral side, much of learning theory will not be apparent. Learning theory includes important and true observations, especially relevant to change in behavior patterns (see chapter on behavior and cognition), however, like insight, they are helpers rather than integral parts of the processes of structural change.
In the next chapter, we will start with the "classic session." This technique is psychodynamic, but is a good starting point because it represents the fastest and most efficient way to get therapy started. With practice, there is more potential for learning from a free-form interview than from any structured decision tree or rating scale.