Tools of Psychotherapy

by Meyer Rothberg From the Autumn, 2014 issue of Jewish Currents CARL ROGERS, THE FOUNDER OF NON-DIRECTIVE THERAPY (NDT) or Client-Centered Therapy (CCT), defined psychotherapy as the process of providing patients with an environment in which they can develop as well as change, in order to become the person they aspire to be. This involves leaving behind emotional conflicts and burdens like anxiety and depression, which limit people, cause them pain, and constrict their behavior. Rogers (1902-1987) defined three central qualities for the therapist to embody: empathy, being able to feel things as the patient does; positive regard, seeing the patient in an appreciative rather than critical or deprecating manner; and congruence, being honest and straightforward with patients and being able to express, supportively, exactly what you think and feel. Learning about these qualities marked the beginning of my learning about psychotherapy. The therapeutic tools that Rogers offered were clear and practical. “Reflection” is primary: grasping what the patient is expressing, and paraphrasing it back with an emphasis on feeling. This is not a parroting activity; it requires some analytic thought and the divination of the feelings embedded in the patient’s conversation, if they are not explicit. The therapist’s response is to be presented as a hypothesis, a question asking for validation. Tracking the patient also requires sophistication: knowing when to break in and reflect, for example, when the patient is talking non-stop. “Clarification” is a second fundamental tool. This primarily refers to the clarification of feelings, although other aspects of a patient’s narrative might require clarification, too. Rogers taught about other therapeutic interventions, such as open, non-leading questions — but Reflection and Clarification were the bedrock of NDT/CCT. Rogers considered an empathic, appreciative, and congruent therapy environment to be necessary and sufficient for his humanistic approach to treating children and adults who suffer from problems of a non-psychotic, non-organic nature. His presumption was that such problems develop as a result of oppressive, non-nurturing, hurtful experience, and that the natural process of healing and growth, in a therapeutic environment, will remedy them. One measure of therapeutic progress is the “Q-Sort,” in which clients consider and sort statements that describe how they see themselves and how they would like to become. The difference will narrow as therapy is successful. THESE QUALITIES OF EMPATHY, positive regard, and congruence, and the therapeutic tools that Rogers developed, can also be foundational for therapists who are guided by other theories of personality and psychopathology. However, NDT is by definition non-directive: No interpretations are made, and the therapist does not go far beyond the patient’s expressions. Therapies that are guided by other theories — such as Freudian psychoanalysis, Adlerian analysis (birth order and “dethronement”), Sullivanian therapy (interpersonal more than intrapsychic), and Heinz Kohut’s self psychology, a reworking of psychoanalytic psychotherapy for the hard-to-treat personality disorders (empathy rather than neutral posture) — will involve interpretations of what the patient “really means,” based on both previous knowledge of the patient and the theory itself. Let’s take the example of a play-therapy session with a 6-year-old girl — a foster child recently adopted — who has a problem with encopresis (soiling in her underpants). In her session, the girl happily wanted to make imaginary cupcakes for her family. An NDT therapist might observe, “You feel happy to provide food for your family.” A more psychodynamic therapist (this term is used to describe a variety of psychoanalytic approaches), considering the recent adoption, might make an interpretation and say, “You want to show your family that you love them so that they will love you” and, by implication, not give her away. A Freudian therapist might think that she felt guilty about something and was making food to alleviate her guilt, and might say, “Do you feel that you have done something wrong and want to make up for it?” Another psychoanalytically oriented therapist might see the cupcakes as related to feces, since encopresis is an issue for this child, and might say, “If you make cupcakes for your family, they won’t be annoyed if you poop in your pants again.” The range of theories (both theories of personality/psychopathology and of therapeutic practice) available to psychotherapists fill many books and is well beyond the scope of this article and, indeed, this writer. Few therapists would disagree with the premise, however, that a trusting therapeutic relationship is fundamental. One can argue that safety is a primary need both in living and for therapy; my own thinking is that while sex gets a lot of attention, safety is a far more important concept. The language of the different theories and the implications of the concepts may vary — family therapists speak of “joining,” whereas psychoanalytic therapists will refer to “positive transference” — but the need for this basic, trusting relationship for the work of psychotherapy is agreed upon. When people come to me as a therapist for help, there is an implicit, possibly explicit, contract that is formed. I am expected to be able to help and usually, but not necessarily, to be paid for it. It is understood that I do this for a living, and there is a presumption that I am trustworthy and competent, a relatively normal person free of psychopathology, and that the patients are in states of distress for which they seek alleviation. I will explicitly say, at times, that it is my job to help in whatever way I can. The job, to be done well, requires the development of deep levels of trust, for my work consists of “outsmarting” the client’s pathology or burying it in positivity and love. Take, for example, a 40-year-old man suffering from depression and outbursts of anger toward his wife and son. Most therapists would begin with an inquiry so as to comprehend the nature of this man’s distress and build trust. A CCT/NDT therapist would simply continue to do this, following the patient to wherever he goes. Questions could be a bit leading, consistent with the goals of CCT/NDT, such as, “How would you like to be with your family?” — or, when a situation is described with his child in which intense anger came up: “It seems that his disobedience is upsetting you greatly.” A more psychodynamic therapist might take this further and say, “It frightens you to see your son behave in a way that will get him into trouble in life.” — or, applying previous knowledge: “When you were a child, you had to toe the mark, and it angers you when he does just what he wants — you couldn’t get away with that!” If the patient reports feeling angry that his working wife gets to stay home and read while he has to go out to a stressful job, the psychodynamic therapist could make interpretations based on the patient’s personal/family history (“Your mother often would be reading when you wanted her attention”) or the “real” issue of his feeling angry that his wife doesn’t seem interested in sex and is more interested in her work. Most therapists are eclectic, drawing on different theoretical orientations and on their individual experience. The advantage of drawing on theory in psychotherapy is the possibility that the therapist will locate and uncover material that won’t necessarily be accessed by a purely non-directive approach. The “danger,” if one can call it that, is that the theory will lead the therapist away from the issues he/she needs to explore, and the process will, at best, be lengthened or feel non-productive to the patient. Studies have shown, however, that experienced therapists tend to be more similar to each other across different orientations. In all cases, patients/clients are coming for help and, as a patient in a New Yorker cartoon recently demanded: “Just tell me what to do!” THE FOCUS ON COGNITION and behavior has generated newer therapeutic approaches such as “behavior therapy/modification,” “cognitive therapy,” and “cognitive behavior therapy” often referred to as CBT. Behavior therapy arrived in the early 1960s in the person of Joseph Wolpe, a South African psychiatrist who insisted that just helping the patient change dysfunctional behavior was enough; feelings, he said, would follow suit. Psychodynamically-oriented therapists were sure that symptom substitution would occur if underlying feelings were not attended to, but behavior therapists were aggressive in responding that all of that analysis was wasting time. Similarly, Cognitive Therapy, originated by Aaron Beck, an American psychiatrist, went at patients’ beliefs about themselves, challenging them directly. CBT brought the two together and has dominated university-based training programs, whereas psychodynamically-oriented training is dominant in more purely clinical training institutes. Aside from differences in an emphasis on either feelings or behavior/cognition, there are differences regarding the importance of personal history. It might be added that Albert Ellis, an American psychologist, developed Rational-Emotive Therapy (RET), which does endeavor to address feelings although its emphasis is on thought and behavior. What is one to make of all this? As mentioned earlier, these are but a few of the many therapeutic approaches extant today, and there will be more tomorrow! My observation is that the success of therapy depends on the match between patient/problem and therapist/theoretical approach. A therapist’s development should include exposure, over time, to different theories, some new and some old. Those approaches that best fit the therapist will be most absorbed. I would argue that there is and will never be a final best theory and practice, although new approaches may be found useful for some patients and problems that heretofore were relatively untreatable. Examples of this are the new treatments in the domain of “energy psychology” such as EMDR (Eye Movement Desenstization and Reprocessing) for early trauma and syndromes such as Post Traumatic Stress Disorder (PTSD), the latter a concomitant of war experiences. This discussion could not be complete without consideration of the advent of biological psychiatry and treatment with psychoactive medications, a subject worthy of its own column. Unfortunately, as seen with behavior therapy and psychodynamic therapies, competitiveness arises, and some advocates of biological psychiatry have denigrated what they call “talk therapy” (and vice versa). One integrative argument that has been put forward is that since non-biological changes in consciousness have a biological representation in the nervous system, both talk therapy and medications can be said to have biological effects. An objective look at the controversy between medication and talk therapy will inform us that, again, depending on circumstance, either or both will be helpful. Studies have shown that both, together, across groups of patients, are more effective than either alone. It should, however, be kept in mind that for individuals, one or the other may, indeed, be best. Meyer Rothberg has been a psychotherapist for nearly half a century.