How psychotherapy works

There are at least two basic approaches to psychotherapy. The most widely used branch is aimed at symptom reduction, which means essentially to reduce the subjective symptoms of anxiety and depression. The two most effective symptom-reduction psychotherapies are the cognitive-behavioral therapies and interpersonal therapy. People with depression or anxiety, whose lives are otherwise fairly satisfactory, are able to benefit fairly quickly from either of these approaches. The therapy is considered complete when the symptoms of anxiety or depression is reduced to a "normal" level.

The other basic approach to psychotherapy is aimed at less easily definable goals, such as "maturation" or some form of helping people to feel more comfortable about themselves and to reorganize their values and goals in a more suitable way. One famous definition of maturity is "the ability to love and to work". There are a number of different forms and labels for this branch of psychotherapy, from psychoanalysis or psychodynamic therapy or existential analysis to transactional analysis. I would like to offer some thoughts about this second general approach.

People sometimes come to see a psychotherapist because they feel that something is wrong with their life. Sometimes conventional symptom-reduction therapies haven't worked, or they have had too many marital or career failures, for instance, or have a general gnawing unhappiness that they can see no way to overcome through the usual distractions. Sometimes people have a sense that they are their own worst enemies, somehow, and that there is a pattern or at least a repetition of the mistakes they make. They may have symptoms of depression or anxiety, but that's not why they come. They are aware that their discomfort is a byproduct of something more pervasive, even though they may not be able to put a name or label to it.

It's very hard to measure outcomes for this kind of therapy. It's even very hard to determine if there is in fact an outcome to therapy. Where is the endpoint of maturation or self-confidence or selfhood? Therapies of this kind don't lend themselves easily to research projects or the kinds of publications that advance one in a faculty position at a University. Nevertheless, people keep searching out psychotherapists who work in this area, pay their money and keep their appointments regularly for years at a time, because there is something they want and need, even if it's hard to put a name to.

What happens in the therapist's office? Every therapist and every patient know that there are sessions that are clearly satisfying and effective, even if we can't spell out precisely what happened or how it changed things, if it did. Most of my life has been spent in attempting to make this happen more often and to find out how and what we do that makes it happen at all.

Helmuth Kaiser, in his book "Effective Psychotherapy" published now many years ago, proposed an idea that has haunted me ever since. He said "Therapy happens when two people are talking together and one of them says what he means and means what he says." He doesn't even specify to whom the therapy happens, and from later writings of his it is clear that he thinks it happens to either or both. There is something about this kind of truth telling that can change us. An interesting corollary is that not telling the truth in this way is predictably harmful in some difficult to define ways, and I will explore this idea in a later blog

In a "good" psychotherapy session I struggle with saying what I mean and meaning what I say, whether I'm the patient or the therapist. Not only do I attempt to say what I mean, I try to say ALL that I mean, and I try my best to mean ALL that I say. I have found that this is not a very easy task. It's so much easier to present oneself in a pleasant and favorable light; it's so much easier to use "tact" to avoid difficulties and confrontations. Many times when I am less than honest I am not trying to deceive or fool someone. I am just trying to make the next few minutes a little easier and more comfortable for both of us.

"Good" therapy sessions are not necessarily comfortable. They are more often disturbing and somewhat disorganizing; people (including the therapist) leave them thoughtful and anxious. People frequently have a sense that their entire lives are in the process of reorganization. Their internal maps are out of date, and they are uncertain about where they are going and why they are going there.

People in search of comfort tell well-meaning lies. They leave out the less favorable parts of what they say. They say things like "I really want to quit smoking", as if that were the entire truth. It certainly presents them in the light of a helpless victim struggling against a powerful enemy. If that were the entire truth, of course, they would have already stopped smoking. They might say they are "unhappy" or "depressed", when the real truth is that they are miserable in their marriage and fearful of divorce. They might say they "just keep screwing up and failing" when what they mean is that they are afraid of success. They might say they are isolated and lonely, when the truth is that they dislike intimacy.

It's quite common for patients to present themselves as good people struggling with bad thoughts or feelings, but this presentation falls far short of honesty. In fact the dishonest claim cited above helps the patient maintain his position as a good person who has a bad habit which he really hates but is helpless to fight. The reality is he smokes because he wants to more than he wants to stop, but he wants me to notice the struggle rather than the reality. Why should he not say "I really want to stop smoking, but I enjoy it far too much to quit. I don't want you to think badly of me, though. I can tell my wife that I talked the problem over with a therapist, and he couldn't help me stop either. But that shows you both my heart is in the right place, doesn't it?"

When I collaborate with someone's dishonesty I do it by pretending to understand what they meant when I know I did not. I listen to someone at a party telling me he is only interested in his wife while he stares at the bodies of the other women present. He tells me he "needs to lose some weight", with a regretful look. A patient tells me she impulsively spent too much money. I ask a patient to tell me what started the disagreement he had with his wife, and he replies, "I don't remember". When I don't question such statements, I collaborate with their dishonesty.

Sometimes that seems socially appropriate; people don't go to parties expecting to be confronted with dishonesty or "helped" to become more honest and thereby more mature. I would soon find myself in the center of an empty circle like a penicillin patch in a culture medium. Perhaps if everyone were compulsively honest growth would be a more routine matter, but personal comfort would certainly drop sharply. Probably that's why we restrict therapeutic transactions to special places and relationships. Comfort and personal growth seem to be mutually exclusive.