Psychotherapy 101
All orientations to therapy are designed to lessen suffering, reduce symptoms, and increase a client's ability to cope with the stressors of life. In the process of successful therapy, we learn to experience, understand, and regulate emotion. Finally, each form of therapy teaches some new ways of thinking about the self, others, and the world. In this part of the learning process, a new story of the self is formed through the interactions of client and therapist.
At its most basic level, psychotherapy is an interpersonal learning environment similar in many ways to proper parenting. In both, we tend to learn best when supported by a nurturing relationship with an empathic other, while being encouraged to confront life's challenges. We learn best in a moderate state of arousal; too little puts us to sleep and too much triggers a fight-flight state that makes positive learning impossible.
Each form of psychotherapy strives to create a personal experience designed to:
Examine assumptions and beliefs
Expand awareness
Increase reality testing
Aid in confronting anxiety-provoking experiences
Modify negative self-talk
Develop a new and more adaptive life-narrative
Therapy explores and examines behaviors, emotions, sensations, and cognitions with the goal of expanded awareness and increased integration of these realms of human experience. In most cases, the primary focus of psychotherapy is the integration of affect and cognition (thoughts and feelings). Through the alternating activation of emotional and cognitive processes, the brain is able to interconnect neural networks responsible for these two functions. The various schools of therapy differ primarily in the emphasis they place on each of the human functions and the techniques they employ to regulate and integrate them. Depending on your theoretical orientation, the result of this process is called, ego-strength, affect regulation, differentiation, or symptom reduction.
What to Say / What to Do
The question about what to say and do comes in many forms:
What should I ask?
How do I know what to focus on?
How active should I be?
What techniques should I use?
When do I speak and when do I keep quiet?
When should I make an interpretation?
What intervention should I use?
The specific answers to these questions depend on your theoretical orientation and your conceptualization of the client with whom you are working. In general, it will be your theoretical knowledge that will help you to know how to understand what you are experiencing, to develop hypotheses about diagnosis and treatment, and to generate ideas about what to do next.
Consider Greg, a young man who comes to you suffering with moderate depression and social isolation. Depending on your theoretical orientation, this one symptom could activate many differing ideas, strategies, and tactics. A psychodynamic therapist might first think of early shame experiences that led to a negative self-image and low self-esteem; a cognitive-behavioral therapist would focus on negative self-statements that trigger and perpetuate Greg's depression; a family systems therapist may see the client's depression as an aspect of family homeostasis and scapegoating; an existential therapist might look to an absence of meaning in Greg's life. These very different theoretical starting points will lead to different understandings of mental illness, mental health, how to use the therapeutic relationship, and which strategies and interventions to employ.
Factors common to all forms of therapy required for positive outcomes include:
The therapist's care, compassion, or empathic attunement
A balance of nurturance and challenge
A balance of comfort and stress
A balance of affect and cognition
A goal of increased affect regulation
The co-creation of new narratives or developing a new story about the self
Keeping these concepts in mind when working with Greg, I would first strive to develop a connection with him that communicates my caring for him as a person and my emotional attunement to his sadness and isolation. I would then try to balance this support with challenges to his negative self-concept, encourage him to share difficult personal material, or structure anxiety-provoking situations to confront some of his social fears. In our discussions, I would alternate challenge and support, all the while encouraging both the experience and articulation of emotion to help him increase his ability to tolerate higher levels of stress (with less distress).
All forms of treatment recognize the need for stress, from the subtle disruption of defenses created by the compassion of Carl Rogers, to facing the existential reality of death, to the exposure to fear-provoking stimuli of cognitive-behavioral therapy for phobias. Learning the right balance of nurturance and stress for each client is a key challenge for therapists across orientations. Within this balance, the evocation of emotion coupled with the client's ability to put feelings into words is most likely to result in emotional growth, insight, and symptom reduction. This is one of Freud's essential insights that remains at the heart of psychotherapy regardless of theoretical orientation.
In psychotherapy, "understanding is the booby prize." It is a hollow victory to end up with a detailed psychological explanation for problems that remain unchanged. On the other hand, the expression of emotion without conscious thought does not result in positive change either. Regardless of orientation, clients overwhelmed with their feelings will be encouraged to think their way to solutions, while those who are emotionally cut-off will be helped to experience and express their feelings.
During this process, Greg and I would be developing a shared language that could come to serve as a new way for him to think about himself and his world. This "co-constructed" narrative should serve as a blueprint for future experience and behavior. How all of this plays out and the type of narrative Greg takes away from therapy will be highly dependent on my theoretical orientation.
Besides your theoretical orientation, the three primary theoretical tools that will guide you through therapy are your 1) case conceptualization, 2) treatment plan, and 3) case notes. These will ground you in your understanding of the process of therapy, how your theory applies to your client, and what to focus on from session to session. Supervision should provide you with these skills. The specifics will differ depending on your setting and supervisor, so stay flexible about the form and specific language. What is most important is to learn and understand the general principles you can apply throughout your career in a variety of situations.
This is an excerpt from Dr. Cozolino’s book The Making of a Therapist.