Many people ask, sheepishly, how psychotherapy really works. The term “therapy” is mentioned constantly in the media as a short form of the word “psychotherapy.” It’s natural that people are curious about something that is seemingly ubiquitous, yet apparently defies easy explanation. There is nothing magical or new about psychotherapy. Like most medications, however, there are aspects of its intrinsic functioning that remain a mystery. The nebulous and fleeting words strewn about a psychotherapy session appear, mysteriously, to be less important than the conditions demanded by the therapeutic frame. The “frame” of psychotherapy refers to all aspects of the session divorced from the actual words used within the session: for example, cost, time, place, office policies, etcetera.
Whatever the psycho-therapeutic school of thought, there are set features that are standard across most styles and techniques. The most important element of effective psychotherapy is the promise of confidentiality. Without a solid confidential therapeutic base, psychotherapy is nothing more than a Socratic conversation for hire. One’s life may be blessed by many intimate trusted contacts, yet one cannot divulge literally everything to any one friend. There are always social consequences, and consciously or unconsciously, all of us must monitor and filter the content of our conversations. I do not believe that this encompassing social information management is strictly selfish. As often as not, the filtering of information is used to protect the feelings of others. Having intimate friends is certainly important to one’s mental health, yet even the closest of relationships may be of little use when one’s situation is altered by psychological suffering. For instance, most of my patients are very conscious of becoming a “burden” to others through ventilating their distress. Unless the intimate attachment is based upon this sort of negative ventilation, the voicing of complaints may alter the basis of the friendship. Existing social support may be lost. For this reason alone, close friends are often of little help when psychological distress becomes significant.
Confidentiality is the boiler plate of psychotherapy. Psychotherapy research of the last 50 years is convergent in revealing that the particular therapeutic technique employed is less important than confidentiality in achieving a favorable patient outcome. Part of these findings may be explained by the decreased social risk obtained by ventilating to a professional. Another aspect of these findings may be explained by the very nature of psychotherapy technique. Each school of psychotherapy tends to focus on particular features of the human experience, yet similarities do exist. Broadly, psychotherapy is dedicated to resolving problems that negatively affect one’s life. The relative importance of thoughts versus behaviors differs, yet nearly all seek to identify “maladaptive” thoughts or behaviors that lower a person’s psychosocial functioning. Many schools, such as Rogerian, eschew the whole notion of maladaptive, yet even the most positive and uplifting psychotherapy is seeking to alter one’s thoughts and/or behaviors. It is unlikely that anyone would pursue psychotherapy as a treatment if they perceived their thoughts and behaviors to be wonderful. Many schools of psychotherapy are better at appearing more positive and uplifting than others, but the mission is essentially the same. For example, a new form of psychotherapy is termed “coaching.” This form of psychotherapy/counseling even eschews the whole notion that it is a psychotherapy! As in Rogerian therapy, there is a strong accent on the therapist being positive and proactive. The word “coaching” is synonymous with “instructing.” It appears that some people would forgo the benefits of an intimate attachment to a therapist, in order to avoid being perceived as a “psych case.”
Schools of psychotherapy are targeted towards individuals, couples or families. While the number and relation of the individuals is different in various schools of thought, the mission to discover less than desirable thoughts and behaviors is the same. Many therapists and schools of thought voice a focus on “communication.” I am at a loss to know what else could be a focus of psychotherapy. All psychotherapy assumes communication as essential to the experience, since no therapeutic school pretends to work with comatose or catatonic individuals. Nonverbal behavior communicates a great deal to the therapist and others involved in the session. Verbal and nonverbal communication is the very stuff with which we work, such that the notion of “communication” being a special focus is a bit absurd. The greatest difference between psycho-therapeutic schools of thought are that each tend to emphasize particular features (subsets) of the therapeutic experience; thoughts versus behaviors and individuals versus groups.
If I may draw on the medication analogy again, the use of different forms of psychotherapy is similar to considering side effects in proscribing a particular medication. If we know that two medications will work equally well to cure a condition, which should be employed? The medication with side effects better tolerated by a particular individual would be the obvious choice. For example, the new class of antidepressants called SSRI’s are very good, yet most cause serious reversible symptoms of sexual impairment. If the patient is very sexually active, it might be better to use an older, though less effective, antidepressant without the unwanted sexual impairment. Similarly, group psychotherapy is the most obvious choice to reduce social anxiety, yet initially it may be the worst form of treatment. Exposed to the stimuli they fear the most, a group of people, the patient may experience recurrent trauma as a consequence of this treatment. For this person, it is better to lessen the initial anxiety with individual psychotherapy, and then save the finishing touches for group psychotherapy.
The basics of psychotherapy are centered about confidentiality, a solid frame, and the identification of unwanted thoughts and/or behaviors. The choice of which psychological technique to employ is similar to choosing amongst equally effective medications. The choice of interventions should be based upon the comfort level of the particular patient, in light of their unique situation and lifestyle.