COMMON ELEMENTS IN ALL PSYCHOTHERAPIES
All good psychotherapeutic systems, irrespective of their theoretical underpinnings and while
they manifest some differences, employ these processes to a greater or lesser degree, whether
they involve conventional dyadic insight approaches, manipulations of the patient-therapist
relationship, or selected reinforcement of special aspects of behavior.
Interviewing Procedures
Communication is the channel of interchange between patient and therapist. Practitioners of
different methods are usually taught principles of interviewing consonant with their theoretical
systems. In the main, the practitioner must be able to subject the patient’s communications to
selective scrutiny, directing comments toward facilitating and constructively utilizing
verbalizations. This involves an ability to employ language that is understandable to the patient.
It includes an awareness of non-verbal behavior, an index of some of the most important
defensive operations. It entails knowledge of techniques of maintaining the flow of significant
verbalizations either toward free association or toward selective focusing on pertinent themes. It
embraces methods of understanding or inculcating insight by various techniques, including
interpretation. It encompasses an understanding of how to terminate the interview.
Stages of the counselling process:
Initial Disclosure- Relationship Building,
In-depth Exploration - Problem Assessment.
Commitment to action - Goal Setting.
Step 1: Relationship Building.
Step 2: Problem Assessment.
Step 3: Goal Setting.
Step 4: Counselling Intervention.
Step 5: Evaluation, Termination.
Consent for the Interview
Prior to the interview, the professionals should introduce her/him self and, depending on the
circumstances, may need to identify why they are speaking with the patient. Unless implicit (the
patient coming to the office), consent to proceed with the interview should be obtained and the
nature of the interaction and the approximate amount of time for the interview should be stated.
A crucial issue is whether the patient is, directly or indirectly, seeking the evaluation on a
voluntary basis or has been brought involuntarily for the assessment. This should be established
before the interview begins, as this information will guide the interviewer especially in the early
stages of the interview process.
Privacy and Confidentiality
Confidentiality is the most important component of the patient–therapist relationship. The
interviewer should make every attempt to ensure that the content of the interview cannot be
overheard by others. t. If the patient is sharing a room with others, an attempt should be made to
use a different room for the interview. If this is not feasible, the interviewer may need to avoid
certain topics or indicate that these issues can be discussed later when privacy can be assured.
Generally, at the beginning, the interviewer should indicate that the content of the session(s) will
remain confidential except for what needs to be shared with the referring physician or treatment
team.
Establishment of a Working Therapeutic Relationship
Unless a cooperative empathic contact is established with the patient, the therapeutic process
may come to naught. An effective system must maintain this as a prime objective during the first
part of therapy. The techniques of achieving a relationship are rarely formalized, but usually they
involve gaining the patient’s confidence, arousing expectations of help, accenting the conviction
that the therapist wishes to work with the patient and is able to do so, motivating the patient to
accept the conditions of therapy, and clarifying misconceptions. Without a working relationship,
in reconstructive therapy, there can be no movement into the exploratory and working through
phases of therapy; the patient will be unable to handle anxieties associated with the recognition
and facing of unconscious conflict. In supportive and reeducative therapy, a good relationship
expedites progress immeasurably.
The patient–physician relationship is the core of the practice of medicine. While the relationship
between any one patient and physician will vary depending on each of their personalities and
past experiences as well as the setting and purpose of the encounter, there are general principles
that, when followed, help to ensure that the relationship established is helpful. The patient comes
to the interview seeking help. This desire for help motivates the patient to share information and
feelings that are upsetting and often private. The patient is willing, to varying degrees, to do so
because of a belief that the professional has the expertise, by virtue of training and experience, to
be of help.
The sharing is reinforced by a nonjudgmental attitude and behaviour of the physician. Being able
to share thoughts and feelings with a nonjudgmental listener is generally a positive experience.
Carl Rogers’ unconditional positive regard epitomizes the nonjudgmental response of the
clinician. There are two additional essential ingredients in a helpful patient–physician
relationship. One is the demonstration by the physician that he or she understands what the
patient is stating and emoting. The other essential ingredient in a helpful patient–physician
relationship is the recognition by the patient that the physician cares. The patient–physician
relationship is reinforced by the genuineness of the physician.
Determination of the Sources and Dynamics of the Patient's Problem
Cognitive learning is present in all therapies. The different psychotherapies attempt to search for
and to explain the patient’s emotional difficulties in varying terms, such as discordant elements
in the environment that mobilize stress, distorted interpersonal relationships that prevent the
individual from self-fulfillment, conditionings that rigidly dragoon the patient to destructive
behavior, and unconscious conflicts that mobilize anxiety and interfere with a realistic
adjustment. All psychotherapies attempt such explorations within the framework of special
theories about human development and adaptation that include to a greater or lesser degree some
of Freud’s monumental discoveries and refinements of Pavlovian concepts.
It is generally considered essential in the resolution of a problem toward reconstructive change
for the individual to become aware of the fact that one is being victimized by repetitive patterns
that force one to actions opposed to a productive life. These patterns are rigid and compulsive;
they defy logic and common sense; they are both supported and opposed by ambivalent value
systems that have been incorporated within the self; they make for an undermining of security
and self-esteem, and for helpless expectations of injury that are registered in reactions of anxiety.
The physiologic and psychologic manifestations of anxiety, and the marshaling of defenses
against anxiety create various symptoms of neurosis.
Much of this dynamic turmoil goes on below the level of awareness, and its recognition is
opposed by the mechanisms of denial and repression that both safeguard the individual against
anxiety and help to retain the neurotic gains residual in their preservation. A variety of
resistances operate to maintain this denial-repression. The individual who is being treated under
the aegis of this dynamic model is, through a number of techniques, taught to recognize personal
offensive patterns and their consequences, the repudiated conflictual aspects of the psyche, and
the origins of difficulties in destructive past conditionings.
Awareness of stress sources and conflicts hopefully enables the individual better to challenge
current maladaptive patterns, to be liberated from old values, to rectify the disturbed life situation
with new modes of relating to people, and to develop a more wholesome and realistic conception
of the self. Supportive and reeducative therapies deal more with provocative reality factors in the
here and now, while attempting to correct faulty past learnings in line with goals of symptom
alleviation and problem solving.
Many contemporary psychotherapeutic systems utilize some of the fundamental principles of
Freud, though they affix to these their own labels. To a greater or lesser degree, concepts of the
unconscious, repression, transference, and resistance are acknowledged. The means by which the
patient is brought to an awareness of problems and the extent of exploration of the unconscious,
will depend on the type of theoretical orientation to which the therapist has been exposed. The
focused interview, free association, dream interpretation, analysis of the transference, exploration
of genetic material, and the buildup of a transference neurosis will thus be employed in varying
degrees.
Behavioral therapies, rooted in conditioning theories, do not put much credence on insight
acquisition; rather they focus more on tactics of relearning. But inherent in the techniques
employed is a relationship between therapist and patient and the inevitable derivation of some
insight as part of the corrective therapeutic experience.
Utilization of Insight and Understanding in the Direction of Change
Effective psychotherapies acknowledge that understanding is not enough, that conditioned
patterns of behavior do not allow themselves to be displaced so easily, and that various
techniques must be implemented to produce change. Techniques, therefore, are put into effect to
create incentives for change, to deal with forces that block action, to promote problem-solving
and reality testing, to help the patient to master anxieties investing normal life goals, to correct
remediable environmental distortions, to encourage adjustment to irremedial conditions, and to
accept personal limitations and handicaps while fulfilling creative potential to the highest degree.
Behavior therapies focus on this relearning dimension almost exclusively.
Resistance and the Readiness for Change
In all forms of therapy resistance will appear in stark or disguised forms and may block or
destroy therapeutic progress. Despite the fact that suffering is intense and symptoms disabling,
the patient may resist changing a preferred way of life. Toward this end the efforts of even
experienced therapists may be blocked. The bounties derived from pursuing a course that must
inevitably result in anxiety and turmoil may not be apparent on the surface. The patient seems
frozen into unreasonable bad habits that refuse to dissolve. And credit for failure may be ascribed
to the impotence of the therapist and the worthlessness of the latter’s methods. Resistance to
change can paralyze all forms of therapy, and the capacity to recognize their subtleties and to
deal with them constructively spell the difference in any psychotherapeutic endeavor between a
therapeutic triumph or a debacle.
What we seem to be dealing with in all of our patients is their readiness for change, which
apparently involves the degree to which they have spontaneously or with professional help
resolved their resistance to change. An individual with reasonable readiness to move forward
will seem to benefit from almost any situation or tactic that can be used constructively. For years
there may have been silent building either through spontaneous insights and propitiously
reinforcing life experiences or in formal therapy, with few apparent signs of improvement.
Should more psychotherapy later be sought, improvement or cure may then unjustifiably be
entirely credited to the second treatment experience, however brief or coincidental it may be, or
to some dramatic event in life that actually served as a convenience that was successfully
manipulated.
Multiple obstructions in the form of resistance are apt to present themselves at every phase of
treatment. They may oppose the establishing of a working relationship, the acceptance of
explanations of the therapist, the full cooperation with the therapist’s techniques, the search for
provocative conflicts, the probing into genetic material, the facing of reality, the abandoning of
the pleasure values and secondary gains of neurotic tendencies, the acceptance of maturity, and
the giving up of the treatment situation when termination is necessary. Obstructions appear in
various masquerades, as transference, as “acting out,” as forced “flight into health,” as self-
devaluation, and as innumerable other disguises. The skill of the therapist is revealed by
dexterity in recognizing and managing the resistive maneuvers of the patient.
Patient Variables
There are an endless number of variables that the patient brings into therapy that will augment or
negate the direction of psychotherapy. The expectations of the patient, the kinds of symptoms
possessed, the attitudes and reactions to the therapist as an authority as well as to the techniques
being employed, and the intensity and persistence of childish distortions are among the most
common factors that must be taken into account. Perhaps of greatest importance is whether or
not the patient will utilize the relationship with the therapist for objectives inimical to therapeutic
goals. Thus if residual dependency needs exist, the patient may overidealize the therapist and
project personal aspirations for magic onto the therapist. Basking in the sun of the therapist’s
celestial power, the patient will establish a satellite position insisting that the therapist cure him
or her even in the absence of any personal effort.
We are all victims of past conditionings and habit patterns, some of which interpose themselves
subtly on our present-day adaptations. If a person as a child has been able to maintain identity
only by resisting or fighting parental authority, there is no reason why we should not suspect that
the individual will attempt to treat the therapist with similar defensive tokens.
These may never interpose themselves in outright defiance; rather they may take the more subtle
form of an inability to respond to remedial promptings. An insidious pattern possessed by some
patients who seek to enhance their independence and emancipation is a detachment that separates
individuals from others and from themselves and accordingly tends to rob them of many of life’s
pleasures.
The presenting complaint may be depression and generalized anhedonia. We may find that a
meticulous application of techniques fails to register marks on the patient’s indifference. When
we realize that our patient has an investment in maintaining detachment, that it has always served
the patient as armor against being controlled and manipulated, that it dulls threatened anxiety and
a thousand imagined hurts, we can see that efforts toward its maintenance have greater
reinforcement value for the patient than the rewards we as therapists can proffer.
There may be nothing faulty in our techniques, but psychological obstructions act as
impenetrable barriers to our efforts. This is why a high level of motivation is so important in all
therapies.
Therapist Attitudes and Operant Conditioning
The proper therapist attitudes are therefore crucial for effective psychotherapy as they are
probably important for all kinds of learning. They constitute powerful reinforcers that strongly
influence the patient’s behavior. Attitudes of empathy, warmth, and understanding tend to
promote positive feelings in the patient; they relieve tension and lower the anxiety level. In such
an atmosphere learning is enhanced. Interviewing, focused by the therapist on anxiety-laden
content, may then prove rewarding. Thus, if dynamically oriented, the therapist will pursue and
encourage the patient to explore zones that are usually resisted or repressed. Approbative
responses, verbal and non-verbal, from the therapist reward the patient when repudiated material
is prosecuted. In addition to the temporary benefits of emotional catharsis, the patient learns that
this material can be tolerated, and when placed it in the context of the historical past, a
revaluation may occur. Schedules of selected reinforcement foster the extinction of anxiety-
provoking past experiences and their present-day associations.
In behavior therapy the patient is also exposed, in the medium of a rewarding emotional climate,
to reinforcers that help extinguish certain reactions that have been self-defeating and accentuate
others that have an adaptive potential. Symptom relief and the acquisition of constructive
behavior patterns occur without the formality of insight. Apart from specific reinforcing
maneuvers that are implemented in dynamic and behavioral approaches, the therapist-patient
relationship itself serves as a relearning experience from which the patient may generalize
constructive responses toward other relationships. This gratuity may occur in any helping or
therapeutic relationship.
Dynamic approaches have the advantage of working with transferential contaminants that can
effectively block this happening. Where interfering transference is not bypassed, but dealt with
firmly in terms of its genetic roots, and the patterns and defenses that it embraces are skillfully
analyzed, it will tend to undergo negative reinforcement and extinction. The therapist
relationship will then become a powerful corrective experience for the patient. This does not
mean that cure is automatically guaranteed, since in some cases psychic damage is so profound,
the secondary gain benefits so intense, the masochistic need so great, that inner rewards for the
perpetuation of transference exceed those the therapist can supply by approving-disapproving
tactics.
Nevertheless, in a considerable number of patients the developing and unravelment of
transference can be most facilitating of extensive personality alterations. Behavior therapies,
while remarkably effective in promoting symptomatic improvement and behavior change, cannot
approach the depth of reconstructive personality change possible in selected patients exposed to
dynamic therapy with trained psychotherapists whose personality structures contain the proper
ingredients of warmth and understanding, and who know how to deal with transference and
countertransference.
A question immediately poses itself. Is not the proposed climate for some types of
psychotherapy, for instance classical psychoanalysis, a neutral, detached one, and, if so, would
not the patient then respond in an antitherapeutic way to the traditional detached manner of the
therapist? The answer to this question lies in the simple fact that effective psychotherapists,
including psychoanalysts, are not really neutral and unconcerned. They communicate, in spite of
practiced non-interference and passivity, an understanding of and empathy toward their patients.
The patient quickly discerns from non-verbal cues the underlying true emotional feeling of the
therapist. Non-effective therapists (including psychoanalysts), on the other hand, who
personality-wise are detached, cold, uninvolved, or lacking in empathy will stimulate negative
therapeutic reactions in their patients. Extensive training and experience will not compensate for
the absence of positive personality qualities, without which no technique can truly be productive.
Psychotherapists generally practice preferred methods that over the years have yielded enough
triumphs to reinforce faith in their powers. What we do in therapy is tempered constantly by how
we do it. We have an affinity for some techniques and prejudices toward others. Not all
procedures make sense, nor will they work for all therapists. A highly discriminating process
generally takes place as therapists gain experience and find that certain theories and special
techniques seem effective in their hands. A problem that plagues our field, of course, is the
tendency to apply one’s personal experience to the world at large. The fact that a therapist finds a
particular approach of great value for her or him does not mean that other therapists will do
likewise.
Countertransference
An effective psychotherapeutic system recognizes negative damaging consequences of
countertransference. The prejudiced responses of the therapist to the patient, positive or negative,
may interfere with the latter’s getting well.
The nature of countertransferential projections onto the patient will depend upon the specific
problems of the therapist that are being activated by the patient at the lime. These may be unique
to a single case, or they may occur in different forms with various patients. Where a therapist is
victimized by feelings over which he or she has little control, such an individual may not be able
to apply techniques with a proper measure of disciplined objectivity. For instance, a therapist
repulsed by homosexuality is not the preferred resource for an individual pursuing a non-
heterosexual life style.
A therapist who is fearful of aggression may display anti-therapeutic behavior when verbally
attacked by a disgruntled soul. The passive, ingratiating, helpless patient may arouse
overprotective attitudes in the therapist who may act as a crippling shield, isolating the patient
from the realities of life. Such attitudes will interfere with the working relationship, the womb in
which personality change and other benefits are propagated.
In contrast, countertransference may be, if utilized correctly, an important indicator of non-
verbalized attitudes and feelings that are being projected onto the therapist and thus prove helpful
in understanding the patient’s conflicts and needs.
Termination of Therapy
The termination of all types of therapy is best handled in a planned way and not left to chance.
An analysis of any obstructive dependency elements in the therapist-patient relationship is part
of this process. The patient is generally induced to shoulder the bulk of probings into personal
problems and to take total responsibility for his or her plans and activities. Independence and
assertiveness are goals toward which the patient is encouraged. The patient is prepared for
possible relapses and reminded that should any symptoms return, the tool of self-understanding
acquired in therapy should help him or her regain equilibrium.
SUMMARY
Having delineated the important aspects of process, can we reasonably assume that these will
bring good results? In the main, yes; but, as has been indicated, there are important
qualifications. There are certain limitations to change in all people; there are certain potentialities
for change in all people. If the psychotherapist applies himself or herself to the task with
disciplined process, he or she will be best equipped to foster in patients a successful outcome.