What Is Real Psychotherapy?

When someone goes for “therapy” today, what are they really getting?
The field of psychotherapy has evolved (or devolved, depending on your point of view) drastically since the heyday of psychoanalysis a century ago. The person seeking therapy back in 1918, for example, would most likely see some disciple of Freud or Jung. Sessions would be scheduled for several (in some cases, perhaps as many as 5-6) days per week, and the patient would probably be expected to lie on a comfortable couch with the analyst or alienist (see my prior post) seated behind him or her, out of sight, listening intently, taking notes, and offering occasional interpretations of the unconscious significance of what was being said. Those interpretations would depend on the particular therapist’s theoretical understanding of the patient, which, in 1918, would have been primarily Freudian, though Jung, by then, had broken with Freud and the Freudians, starting to attract followers of his own Analytical Psychology. (See my prior post.)

Psychoanalysis was the first systematic form of psychotherapy, which was fundamentally a psychological approach to neurosis and psychosis. A “depth psychology.” It was predicated upon the concept of the “unconscious,” which Freud defined as that which we don’t know and don’t want to know about ourselves: our unacceptable and, therefore, repressed feelings, thoughts, memories, motivations and impulses. The therapy process consisted of plumbing the depths of the unconscious, and making the unconscious more conscious.

Central to psychotherapy in those days was the interpretation of dreams, viewed by Freud as the via regia or regal road, or royal highway to the unconscious, the idea being that understanding our dreams–which, for Freud, are encoded manifestations of unconscious  conflicts and wishes, and for Jung, valuable messages from the unconscious regarding how to become more whole and balanced–is the key to becoming more conscious, and thereby, less neurotic and symptomatic. In other words, both Freud and Jung saw excessive unconsciousness as the primary source of neurosis and psychosis. This sort of psychotherapy demanded (and still requires) serious commitment and investment–both emotional and financial–from the patient to the process, and tended to go on for protracted periods of time.  But did it work?

This is exactly the same question we ask about psychotherapy today. Based on what we know now regarding the efficacy of psychotherapy in general, the answer is probably “yes.” Psychotherapy in 1918 was likely more or less as effective as any psychotherapy available today. Indeed, according to a 1995 Consumer Reports survey conducted by positive psychologist Martin Seligman, more than 80% of contemporary psychotherapy patients reported beneficial results in general, and no single form of psychotherapy seemed, for the most part, to be more effective than another. Given the fact that psychoanalysis remained the predominant form of psychotherapy sought out by people well into the 1950s, and is still practiced today by some, it seems unlikely that it would have retained its popularity for more than half-a-century had it been totally ineffective. 

But so much has changed in psychology and psychiatry since the mid-twentieth century. Starting in the 1930s, stimulated by the writings of former Freud disciple Otto Rank, psychodynamic psychotherapy, an approach distilled from psychoanalysis, but typically entailing fewer meetings per week and permitting  face-to-face sessions with patients rather than the technique of using the couch, became widely accepted among mental health professionals, and is still practiced by many in some form. 

Then, in 1958, psychologist Rollo May co-edited a book called Existence: A New Dimension in Psychiatry and Psychology, which introduced Americans to the work of the European “existential analysts.” Their critique of classical psychoanalytic theory and treatment, coupled with the penetrating insights of philosophers like Kierkegaard, Nietzsche, Heidegger and Sartre, and based on what was described as the use of a “phenomenological method” in therapy, was highly influential for practitioners of psychoanalysis, psychodynamic psychotherapy, and other forms of depth psychology, giving rise to a more humanistic and existential approach to therapy.

Next, behaviorism, based on the work of B.F. Skinner, became the predominant paradigm for psychotherapy, supplanting psychoanalysis and psychodynamic therapy, particularly in academia. Then there was the psychopharmacological revolution, which has, by far, become, to this day, the predominant mode of treating most mental disorders. The 1960s and 70s saw the rebellious and experimental countercultural influence on psychotherapy, spawning Humanistic Therapy, Primal Therapy, Gestalt Therapy, and Family Systems Therapy, and, in the 1980s, psychologist Francine Shapiro’s EMDR (Eye Movement Desensitization and Reprocessing) for treating trauma.

These new approaches (some saw them merely as technical tricks) were followed by the so-called Cognitive Revolution, which, alloying itself with behaviorism, led to the advent of today’s extremely popular and pervasive cognitive-behavioral therapies, and the emphasis on supposed evidence-based, pre-scripted, standardized or manualized therapies. Currently, there are literally hundreds of different forms of psychotherapy available to consumers, all claiming to be superior to others, some citing specific scientific studies to support their often dubious claims. The person seeking assistance with psychiatric symptoms in the twenty-first century is confronted with a dizzying array of remedies. But this begs the question: Has psychotherapy really improved over the past hundred years?  Or is it getting worse?

Most psychotherapists today are trained to take a predominantly technical, symptom-centered approach to treatment. CBT is a prime example of this standardized, manualized, mechanistic type of therapy designed specifically to reduce or suppress a patient’s symptoms and suffering as quickly and economically as possible. Psychopharmacology–the mainstay of contemporary psychiatric treatment–is another example of a bio-mechanical, medicalized, symptom-centered orientation. But is this what real psychotherapy is about? Is this all psychotherapy has to offer? Rapid, rote symptom-reduction? Drugging away or suppressing emotional pain or discomfort? Rationally rooting out and restructuring the patient’s “distorted” and irrational cognitions? Modifying and “normalizing” or making more socially acceptable his or her aberrant, eccentric or maladaptive behavior? To be sure, timely pharmacological relief of intolerable and crippling psychiatric symptoms is practical, valuable and sometimes life-saving. There is something to be said for the clinician’s ability to alleviate or at least mitigate the patient’s debilitating symptoms straight away. But ought that be the end or merely the beginning of therapy?

With the advent and wild popularity of psychopharmacological and brief cognitive-behavioral treatments today, is there any room or reason left in the therapeutic process to speak of esoteric subjects such as beauty, God, evil or death? To address the person’s spiritual and existential concerns? To muse about the meaning of life, or the absurd lack thereof, and to endeavor to find and fulfill one’s destiny? And is there still a segment of the postmodern population still interested in and committed to doing so? I wonder what you, our readers, have to say about that. 

One of my former mentors, existential psychoanalyst Dr. Rollo May, passionately argued that psychotherapy should be less about technique or what he pejoratively called “gimmicks” designed to subdue symptoms than about enhancing the patient’s capacity to feel, experience, create, find meaning, and in general to become more receptive and accepting to life and love in both their positive and negative aspects. In some ways, this is a radically divergent view on the nature, meaning and purpose of psychotherapy compared to the conventional, symptom-centered approach of today. Dr. May’s neo-Freudian, and especially existential attitude toward psychotherapy and his humanistic emphasis on the healing power of the relationship between patient and therapist over the primacy of technique is closely related to that of C.G. Jung, who quipped that psychotherapy “demands all the resources of the doctor’s personality and not technical tricks.” Clearly, real psychotherapy of any sort depends partly on specific techniques. But the utilization of such techniques is secondary to and never a substitute for the working relationship between patient and therapist.

How Psychotherapy Works

Bruce E. Wampold, Ph.D., is chair and professor of counseling psychology and clinical professor of psychiatry at the University of Wisconsin-Madison. Dr. Wampold is a groundbreaking researcher and theoretician, bringing the rigor of his training in mathematics and the sciences to understanding psychotherapy. He has published more than 100 scientific articles and is the author of the acclaimed book, “The Great Psychotherapy Debate,” which is a synthesis of empirical research on psychotherapy using sophisticated methods that is situated in a historical and anthropological context. APA spoke to Dr. Wampold about how psychotherapy works and what the research tells us about different types of treatment, including psychiatric drugs.

Q. How exactly does psychotherapy help people?

A. Patients often come to psychotherapy with explanations for their difficulties that leave them feeling that the distress will continue indefinitely. Every treatment provides an explanation for the distress that is adaptive – that is, the patient understands that he or she can do something to improve his or her situation. This leads the patient into healthy actions in that the psychotherapy improves some aspect of their lives, whether it is thinking more positive thoughts, creating better relationships, more appropriately expressing emotions, or enacting other positive changes. The critical aspect is not which treatment a person receives but rather that the patient believes this particular treatment is effective and works collaboratively with the therapist.

Q. You have studied the research data; are you any closer to understanding what makes psychotherapy work, and what might make one type of psychotherapy more effective than another?

A. From my reading of the research evidence and my own research, it seems that the differences among treatments in terms of benefit to patients are small, if not negligible. This observation applies, however, to treatments that are intended to be therapeutic, are delivered by competent therapists, have a cogent psychological rationale, and contain therapeutic actions that lead to healthy and helpful changes in the patient’s life. When such treatments are compared in clinical trials, the typical finding is that these treatments are superior to no treatment or some type of psychological placebo (usually contact with a therapist who responds empathically but does not actively provide a treatment) but that there are few if any differences among the treatments.

Q. Some therapists consistently produce better outcomes than others, regardless of treatment and patient characteristics. Can you explain why that is?

A. The most effective therapists know the research and have a dynamic approach to treatment options. The research indicates that effective therapists form a strong therapeutic alliance across the range of patients seen in therapy. They are able to form a bond with their patients, regardless of the patient’s characteristics, and induce the patient to accept the treatment and work collaboratively with the therapist. Effective therapists have an ability to perceive, understand and communicate emotional and social messages with their patients. It also appears that effective therapists are cognizant of patient progress, either informally or through the use of outcome measures, and are willing to address issues that impede therapeutic progress, including the relationship between the therapist and the patient.

Q. Clinical trials have shown that psychotherapy is as effective as psychiatric medications for depression and anxiety without the disagreeable side effects such as weight gain, sleep problems and loss of libido. So why is it that so many people are prescribed drugs first when they are exhibiting psychological distress and psychotherapy second, if at all?

A. It is indeed disturbing to know that, despite the effectiveness and safety of psychotherapy, increasing numbers of patients are being treated with psychiatric medications. The explanation for this phenomenon is complex and intricately woven into the health care system in the United States. First, the pharmaceutical industry spends an inordinate amount of money advertising psychiatric medications to physicians and to the public, resulting in a perception that mental disorders are due to “chemical imbalances in the brain” that can be remediated easily by medications. Second, increasing numbers of mental disorders are being treated in primary care settings and primary care physicians are not trained in or aware of effective psychotherapies, but they are trained to prescribe drugs. Third, psychotropic medications suggest that the problem is biological, which relieves the patient of responsibility for his or her actions. It is simpler to take a pill and go on with one’s life than to accept that changing involves intentional and purposeful work.

Q. How do you as a psychotherapist determine when psychiatric drugs are the correct course of action for a given patient? And what is the therapist’s influence when treating a patient who is also on psychotropic medication?

A. Health services are always more effective when care is coordinated. Therapists’ collaboration with primary care physicians and psychiatrists is no exception. Of course, effective psychiatric consultation requires that the therapist be knowledgeable about the disorder and its treatment. There are instances in which psychiatric medication is an appropriate adjunct to psychotherapy — for example, in the treatment of severe and persistent depression, bipolar disorder and some anxiety disorders. There is evidence that effective psychotherapists are often the best judges of when their patients can benefit from a pharmaceutical treatment program and work collaboratively with the patient to get the best response to the medication. Some psychologists are now trained and licensed to prescribe psychiatric medications as part of the treatment.