How Does Psychotherapy Work?

By: Jane Ryan
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It is said that the question "how does psychotherapy work?" cannot be answered conclusively - that we cannot reach into the depths of a deeply private relationship and pluck out a precise truth about what occurs within it. This book defies that notion. Here, the question is both beautifully explored and answered by leading psychotherapists from different schools to create a fascinating volume of ground-breaking ideas and theory.Each contributor unravels the procedures of the work, discussing the qualities of good psychotherapy from their own personal and theoretical perspectives. They explore the reasons why people seek help, how they can be helped and the goals of the therapeutic journey, each of them writing with precision, clarity and passion for the work they do. Despite the wide range of variations in their theory and technique the eleven contributors to this book are united in finding certain common denominators in successful psychotherapy.How Does Psychotherapy Work? presents a thought-provoking, cogent and convincing dialogue on the capacity of psychotherapy to help people who are in emotional pain, and the technicalities of that process.Contributors:Neil Altman; Roz Carroll; Sue Cowan-Jenssen; Nicola Diamond; Carol Holmes; Brett Kahr; Dianne Lefevre; Susie Orbach; James Pollard; Jane Ryan; Joseph Schwartz; and Robert Maxwell Young.

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CHAPTER ONE: The fifteen key ingredients of good psychotherapy

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Brett Kahr

Turn on your television set any night of the week, and you will be able to gorge yourself upon any number of newfangled cookery experts, or so-called celebrity chefs, who attempt to communicate the secrets of their trade to us in a stylish, entertaining fashion. Each evening at eight o’clock, we too, the ordinary viewer at home, can perch on our sitting room sofas, notepads nestling on our knees, as we learn an eminently transmissible sequence of culinary steps. First, we must choose our ingredients; then we rinse, slice and dice, baste and bake, heat or chill, lightly season, garnish with fresh parsley, and … hey presto … we have concocted a veritable replica of a British Broadcasting Corporation feast.

If only those of us who work as professional psychotherapists could communicate the nitty-gritty details of our craft with such grace and dexterity, and still manage to do so in an entertaining twenty-four minute broadcast. If only we could transform our ponderous, arcane, and stodgy textbooks into a foolproof do-it-at-home recipe, then psychotherapy would be available at the flick of a switch, and the mental health problems of Great Britain would be solved. And just imagine if some very visionary commissioning editor from the Channel Four Television Corporation did indeed commission a six-part half-hour slot on how psychotherapy works, how on earth would we translate our hard-won clinical expertise into a snappy format that would engage the attention of millions of viewers?

 

CHAPTER TWO: Relational perspectives on the therapeutic action of psychoanalysis

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Neil Altman

An historical perspective

Lewis Aron (1995) once commented that in order to make a creative contribution to the psychoanalytic literature, one has to be prepared to revise, even overturn, all of psychoanalytic theory. Psychoanalytic theory is an integrated set of conceptions that forms a system in which each part depends on all the other parts. Not everyone has agreed with this systemic conception of psychoanalysis; for example, it has been argued (Gill, 1976) that the metapsychology of psychoanalysis (e.g., the structural theory of id, ego, and superego) is independent of the clinical theory (of transference and resistance). Thus, one could get rid of the metapsychology without affecting the clinical theory. On the other hand, much of the literature in relational psychoanalysis over the past twenty years has been concerned with developing the far-reaching implications for psychoanalytic theory and practice of the “relational turn”, i.e., the shift from regarding drives as fundamental to mental life, to regarding relational configurations as fundamental in the external world and in the internal world. In 1983, Jay Greenberg and Stephen Mitchell shook up the psychoanalytic world by systematizing and making explicit this shift that they claimed was taking place across a range of psychoanalytic schools of thought, from drive theory to relational theory. Since then, the implications that have emerged include, but are not limited to: redefinitions of the notion of neutrality (Aron, 1996, 2003; Green-berg, 1986), the emergence of the concept of “enactment” (Aron, 1996; Bass, 2003; Black, 2003; Jacobs, 1986), the re-emergence of dissociation as a fundamental organizing principle of the mind (Bromberg, 1999; Davies, 1999), a reconsideration of self-disclosure in psychoanalysis (Aron, 1992), new psychoanalytic epistemologies (Hoffman, 1998; Mitchell, 1993), new concepts of “mutuality” and “asymmetry” (Aron, 1992), reconsiderations of gender (Benjamin, 1995; Dimen, 2003; Goldner, 1991; Harris, 1991), race (Altman, 2000; Leary, 1997, 2000), and sexual orientation (Domenici & Lesser, 1995). In this paper, I spell out some of the implications of the relational turn for the theory of the therapeutic action of psychoanalysis. In the background of this discussion are considerations of what constitutes health and pathology; thus moral judgments, considerations as to what constitutes a good life, will be inevitably implicated and I attempt to make them explicit when I notice them in the background of the theories being discussed. We will see that ideas as to what constitutes a good life will also be found in ideas about what constitutes a good analysis. Let us begin with the first generation of analysts: Freud and his contemporaries.

 

CHAPTER THREE: The questions we have to ask (ourselves) before we answer the question: “How does psychotherapy work?”

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Joseph Schwartz

Iwas an experimental physicist before I became a psychotherapist. The experimental part of my previous career has been very helpful in dealing with theoretical issues in psychoanalysis. Traditionally experimentalists have always been very very critical of theory. The important thing for an experimentalist is that the theory be right, not that it be intriguing, or interesting, or even beautiful. The experimental question is not “Well, could it be that?” The experimental question is “Is it that?”

Although there always needs to be space for exploration of theoretical issues, my appraisal of the field of psychoanalysis over the past twenty years is that psychoanalysis is at a particular point in its historical development where too many people are playing around with psychoanalytic ideas and not enough colleagues are asking, “Is it that?”

There are very many different ideas being put forward to answer the question “How does therapy work”, or indeed, “Does therapy work?” But what the field has lacked is a disciplined engagement between practitioners with a view to sorting things out. It is not good enough for us to sit in our separate corners, slag each other off, and turn up our noses at how our colleagues have understood the experience of the consulting room. There is a certain discipline in natural science, not very well understood within psychoanalysis, that our field sorely needs. My psychoanalytic colleagues seem to carry around a lot of the ambient mythology about the so-called precision, and the so-called objectivity of natural science that appears not to apply to the subjectivities involved in psychoanalysis. The result has been that our community has lost track of the salient point of any exploration of human experience: it takes discipline to get results.

 

CHAPTER FOUR: The psychotherapy relationship

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Susie Orbach

There are so many ways of describing how psychotherapy works and the purpose of this book is, of course, to try to address particular facets of it. I shall restrict myself to a discussion of how entrenched ways of being that cause distress can change through the therapy relationship.

The aims, conventions, and experience of therapy makes for an encounter that creates the conditions for reflection, feeling, analysis, and experimentation to occur. Reflection, feeling, analysis, and experimentation lead to a reinscribing of experience in which the individual’s present feels made by, but not bound by history and in which her or his past is animated by new thoughts and understandings. Transformation of the individual’s subjective sense of self is the outcome of a successful therapy: the individual experiences her or himself as an actor in their own life who has the flexibility to respond in novel ways to the emotional demands upon her or himself.

Psychotherapy is a very personal human endeavour. What I mean by this is that unlike psychological treatments, which are essentially procedural such as CBT or phobia desensitization, psychotherapy involves the therapist and patient in a relationship with one another. The therapy relationship itself is akin to a human laboratory for the exploration of change and risk. Although there for the benefit of the patient, the therapy relationship also affects the therapist in often profound ways. It can make the most enormous demand on the therapist as well as delivering considerable emotional and intellectual satisfaction (Orbach, 1999).

 

CHAPTER FIVE: Rhythm, reorientation, reversal: deep reorganization of the self in psychotherapy

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Roz Carroll

“Life itself is an expression of self-organisation”

(Sardar & Abrams, 1998, p. 77)

What makes psychotherapy work is a question that is both impossible to answer conclusively and yet necessary to address. In this chapter I propose that psychotherapy “works” in the same way that life works (or evolves), only in a more concentrated form by intensifying and containing specific processes that occur in all living developing systems (from cells to individuals, to communities, etc.).

Psychotherapy was once presented to the public as a detective story: clues to the unconscious expertly spotted by the therapist-sleuth leading to a reconstruction of traumatic events in childhood. In this linear account revelation brings catharsis, insight, and healing. Actually this search for a hidden story remains a fairly central feature of psychotherapy, but today’s version of therapy encompasses many more nuanced levels of information and interaction that are marked by non-linear cycles of disorganization–reorganization. The emphasis has moved from discovering the origins of neurotic patterns to working directly with relating as a human capacity.1

 

CHAPTER SIX: When thought is not enough

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Nicola Diamond

Introduction: the relational approach and attachment

In this chapter I will explore a form of relational psychoanalysis, which is particularly influenced by attachment theory and related contemporary developments. The emphasis here is on the centrality of relations with others, in the context of developing a body and a sense of subjectivity. From this perspective, disturbed relations with others in early and ongoing development give rise to emotional problems that can lead to psychosomatic dysfunction and problems with the sense of “self”.

In this theoretical context, the understanding of relationships involves the view that organism and environment are interdependent. The baby’s physiological and neurological functions require facilitating relationships with key attachment figures for their optimal development. The internal world is inseparable from interactions with others. Relationships with others inform the content and form of the world of the developing individual, which is renegotiated and reorganized in later relations in an ongoing way.

 

CHAPTER SEVEN: Primal psychotherapy

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Susan Cowan-Jenssen

Primal psychotherapy is a development of Arthur Janov’s cathartic primal therapy which flowered rather dramatically in America in the 1970s and 1980s. In this chapter I look at what was significant and useful in Janov’s contribution to psychotherapy what were its weaknesses, and how primal psychotherapy evolved. As I began to write on the background of primal therapy it struck me that catharsis, or abreaction, i.e., emotional release, has an interesting history in psychotherapy since it gets discovered and then rediscovered with rather monotonous regularity. But first: what is meant by the word “primal”?

The Oxford English Dictionary defines “primal” as “Belonging to the first age or earliest stage; original; primitive; primeval”. Freud was to use the expression “primal scene” to describe the impact of a child witnessing parental intercourse. Arthur Janov (1970) used the expression “primal pains” to describe the “original, early hurts upon which later neurosis is built”. For Janov, neurosis was not necessarily sexual in origin or necessarily linked to the trauma of one event, but is the culmination of hurts that result from the unmet needs of the infant and child:

 

CHAPTER EIGHT: Containment: the technical and the tacit in successful psychotherapy

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Robert M. Young

Idon’t know how psychotherapy works. However, I don’t find that very odd. I have some ideas, but to tell the truth I think of them as a way of comforting myself while I get on with doing psychotherapy, something I do more than thirty hours a week and think about for quite a lot more hours as I teach, write, edit, and talk to colleagues. What I propose to do in this paper is share those ideas and to look behind them to other ideas that I believe to be more helpful in explaining what I do.

First, of course, psychotherapists, at least ones of my persuasion, make interpretations. I was taught only to make transference interpretations, but after I stopped having supervisions, i.e., after a decade of training and postgraduate training, I slowly moved on to making any interpretation I thought might help my patients. Then one day a patient asked me what was the relationship between my interpretations and therapeutic benefit. There was a time I’d interpret the question, but I thought it a reasonable one, and this patient was not prone to use theory as a place to hide. The answer I had been taught was that a truthful or accurate interpretation of a patient’s unconscious motivations, the more primitive the better, and after being worked through, reduces primitive anxieties. This, in turn, makes the patient less trapped in his or her neurotic patterns. The emphasis was on the accuracy of the interpretation.

 

CHAPTER NINE: The value of attachment theory in understanding how psychotherapy works

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James Pollard

The conceptual and procedural problems in assessment of the effectiveness of psychotherapy are daunting. It is not possible here to review the many approaches that have been offered. Each approach raises its own technical issues and reflects a particular value base. The problems are so great that many psychotherapists have retreated from the problem altogether or become content to theorize the impossibility of the task.

In the public sector the profession faces demands for “evidence based practice” and measurements of outcomes on the model of the randomized clinical trial. Many individuals report that they have found psychotherapy to have been helpful to them. This individual experience is so persuasive that psychotherapy flourishes in the private sector. Psychotherapists owe it to those who finance their own psychotherapy, as much as to public sector managers, to remain committed to the task of developing and supporting an account of how and why psychotherapy works. Not least psychotherapists owe it to their patients to offer an account of what they mean by “psychotherapy works”.

 

CHAPTER TEN: The big picture

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Carol Holmes

The fact that the discipline of psychotherapy is recognizable by over four hundred competing models attests to its lack of a unified theory and it is this feature more than anything else that underlines the fact that we don’t know how psychotherapy works. What we do know is that these factions in psychotherapy are implicitly or explicitly committed to a particular philosophy of human nature that informs their conception of health and their method for achieving this satisfactory state. Existential psychotherapy for example, is grounded in existential philosophy and the phenomenological method and its practitioners view the recognition of anxiety as an indication and positive sign of the person’s understanding of their uncertain and mortal position in the world. Psychoanalysis, on the other hand, considers the prevalence of anxiety as an indication of unconscious conflict and psychopathol-ogy that requires psychoanalytic intervention. Each school within the profession is therefore underpinned by a philosophy that determines its conceptualizations of both mental health and pathology. Furthermore, unlike the scientific tradition, the schisms that characterize the field of psychotherapy are further compounded and estranged by a general lack of dialogue and cooperation between therapists and researchers from these competing hypothetical approaches. As Feltham points out “It is arguable that the field of twentieth-century psychotherapy has been fundamentally characterised by serious disagreement on views of human nature, aetiology of psychological dysfunction, treatment rationales and goals” (1997, p. 1). Feltham further claims that these divisions interfere with the likelihood of systematically examining these significant inconsistencies and suggests that we have difficulty in questioning our assertions of truth and reality: “It seems to me that we are as least as resistant to examining our therapeutic truth claims as our clients often are to examining their longstanding and unproductive scripts and narratives” (ibid., p. 2). I believe that it is not the lack of certainty that inhibits our ability to better understand how psychotherapy works, but the certainty with which psychotherapists from these clannish schools cling tenaciously to their denominational positions. From my own experience there also seems to be a general lack of courtesy, regard, and modesty on the part of psychotherapists for any position other than their own.

 

CHAPTER ELEVEN: Is the psychotherapist s authenticity a crucial key to therapeutic change?

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Dianne Campbell LeFevre

“Bion was very aware in his later years that psychoanalysis was not effecting change in patients. He was very aware of patients who looked as though they had changed; those who had put on the clothing of an analysed person, but remained unchanged within. In particular, he was conscious of those patients who subtly copied the analyst, took on his words, outlook and attitude, but in whom there was no change within. In other words there was an absence of alpha function and the articulations of the patient were an evacuation of beta elements. He tried to probe into this problem and his investigations into foetal life were one of his attempts to do so. The problem, however, remains unsolved”

(Symington & Symington, 1996, p. 173)

The subject being considered in this chapter is whether authenticity might be a key to therapeutic change, whether it contributes to what works, whether it helps—to use Wittgenstein’s metaphor— the fly to escape from the fly-bottle. Such a proposal carries the dangers of the author being seen to be encoding the message: “Am I not the most authentic, the most virtuous of you all?” and, like the ugly sister, getting the deserved reply. Similarly, presenting case material always carries the danger of exhibitionistically flouting one’s strengths or masochistically advertising weaknesses.

 

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