Psychotherapy 101

“The harvest of psychotherapy is not cure—surely, in our field that is an illusion—but instead change or growth.” (Irving Yalom, 1931--)

While on faculty at Washington University School of Medicine, I developed and taught a two-year introductory course on Child and Family Psychotherapy. My students were residents and fellows, M.D.’s and D.O.’s in their 4^th and 5^th years of post-graduate psychiatry training.  Coming into this course, these students were well trained in biological psychiatry, psychiatry as a medical specialty. Now, it was their time to be introduced to a wide range of behavioral and psychological theories and techniques.  This blog is about day-one of that course, the basics. On that first day five questions were asked and explored.

1) What is psychotherapy?  Perhaps it would be more accurate to ask, “What are psychotherapies?”, for there are many models and theories of psychotherapy.  However, with the input of my students, we arrived at the following definition that captures the common and quintessential nature of most, if not all, of the psychological and behavioral therapies.  “Psychotherapy is a process of guiding change in a patient or client, undertaken within a theoretic framework, by a therapist trained in the application and implementation of that theory.”

2) What are the goals of psychotherapy?  There are as many goals as there are theories of psychotherapy:  making the unconscious conscious, strengthening the ego, working through problems, expressing feelings, clarifying goals and beliefs, reducing symptoms, resolving conflicts, improving self-esteem, empowering, growing, finding meaning, improving relationships, self-actualizing, extinguishing negative behaviors, reinforcing positive behaviors, correcting distorted cognitive schema, etc., etc., etc.  Yet, however otherwise stated, the common purpose and goal of psychotherapy is constructive change; behavioral, psychological, cognitive, and/or emotional change.

3) How does change occur?  In medicine, change occurs either by altering structure (anatomy) through surgery, or by altering function (physiology) through the use of medication.  In psychotherapy, change occurs when someone’s way of thinking, or someone’s way of behaving, are modified through use of one or more techniques associated with psychological and behavioral therapies.

4) What skills and characteristics are found in a good therapist?  A good therapist is well-trained and well-informed. A good therapist is genuine and warm.  A good therapist is a good communicator.  A good therapist is cognitively flexible, able to tolerate uncertainty, ambiguity, and subjectivity.  A good therapist is ethical, adhering strictly to professional boundaries and standards.  A good therapist possesses a sense of humility, understanding the limits of psychotherapy or what has been called by some ‘the impossible profession’.

5) What determines good outcome in therapy?  Outcome in therapy may be less determined by the specific type of therapy and more determined by the experience, quality, and personality of the therapist.  Theory is important, but relationship is even more so.  Outcome also depends upon the attitude of the patient coming into therapy. Good things happen when a patient comes to therapy ready to learn and to change.

It reminds me of an old joke.  How many therapists does it take to change a lightbulb?  Just one, but the lightbulb has to really want to change.