What is psychotherapy?

Psychotherapy is a talking process between a patient and a psychotherapist. Psychotherapy makes connections among feelings, thoughts, impulses, and behaviors to understand what works and what gets in the way of meeting life’s goals, reaching one’s fullest potential, feeling successful, and being fulfilled. This is accomplished by self-reflection. By examining life patterns, changing, improving, and unlearning emotional and behavioral habits that get in the way and are no longer working, strengthening habits that are working, and learning and developing new habits, life’s goals can better be met. The basic premise of psychotherapy is that the past influences the present, and understanding this connection can be helpful in planning the future. Psychotherapy is grounded in research and clinical knowledge. It is more than just “talking.”

The psychotherapist is the tour guide, mentor, teacher, coach, and supporter through this process. The patient’s part is to show up and be who he or she is. This means participating in the process, asking questions, challenging the psychotherapist when necessary, and continuing to work through any hard parts of psychotherapy as a partner with the psychotherapist. The psychologist-patient relationship, like the medical doctor-patient relationship, is a crucial part of the process.

Does psychotherapy work?

One of the arguments made by insurance and managed mental health care companies is that there is no proof that psychotherapy actually works. This is often used as a justification to approve only a few sessions or deny mental health services altogether. In addition, the general public has fears and doubts about whether psychotherapy actually works. Even the remote possibility or slight uncertainty about whether it works adds to the existing confusion and skepticism.

The answer to this question is that the evidence is overwhelmingly a resounding “Yes.” Psychotherapy works. Research consistently shows that psychotherapy works. Psychologist researchers have conducted many studies showing the value of psychotherapy. Different types of studies draw the same conclusions.

Two volumes of well-designed research studies, edited by psychologist Dr. John Norcross, contain reviews of studies that clearly demonstrate the therapeutic importance of psychotherapy, including influences of which we may not be aware (unconscious), and the importance of therapeutic alliances or “working relationships” between patients and their psychologists. Many of the studies reviewed in these book chapters also show links to psychotherapeutic results for specific issues.

Psychologist Dr. Jonathan Shedler and colleagues reviewed and analyzed hundreds of studies and demonstrated that psychodynamic psychotherapy is extremely effective. In fact, psychotherapy that includes aspects of psychodynamic psychotherapy is more effective than those that do not include those aspects.

Psychodynamic psychotherapy is defined as psychotherapy that includes the following features:

• Focus on affect and expression of emotions (instead of behavior or intellectual thoughts)
• Exploration of attempts to avoid distressing thoughts and feelings (including the unconscious)
• Identification of recurring themes and patterns, including some of which we may not be aware (unconscious)
• Discussion of experiences with developmental focus (looking at how the past has helped to form the present)
• Focus on interpersonal relations (relationships and attachments to others)
• Focus on the therapy relationship (the patient-psychologist relationship)
• Exploration of fantasy life (dreams, desires, fears, daydreams) that is put into words and brought forward rather than trying to reduce its presence or learning to think about something else

This is a different psychotherapy than getting advice, modifying thoughts, having steps or tasks to complete in order to make changes in behavior, or chatting. Behavior is still very important. This type of psychotherapy gets to the heart of matters that are of concern. Emotions and how they are recognized (or not) and expressed (or not) in various ways are the focus of this work. It takes a well-trained and experienced psychologist as tour guide and a dedicated patient to do this work. But it is worth it, and the research data support this conclusion.

So yes, psychotherapy works. Psychologist researchers are conducting more and more evidence-based studies to demonstrate that psychotherapy works. Good news, because in our country there is an incredible need for it. Depression is the number one health care cost for employers, with anxiety just behind it. Approximately 19.1 percent of adults in the United States (over 40 million) experienced an anxiety disorder in the past year. But direct health care costs aren’t the only concern. These and other behavioral health conditions also have hidden costs, decreasing productivity and increasing sick-day use, for example.

The psychologist’s contribution to why psychotherapy works and why psychotherapy fails.

There are some basics that are mandatory for the psychologist: being kind, responding to feedback about how the psychotherapy is working for the patient, not being chronically late to or regularly canceling client appointments, and being too aggressive or not being assertive enough in response to the patient’s requests about what they need. The book How to Fail as a Therapist: 50 ways to damage your patients by psychologists Drs. Schwartz and Flowers can be used as a checklist by patients as well as psychologists. However, these sorts of errors are in cognition, problem solving, or thinking. We are aware of them. These are, if you will, easier types of errors. The more challenging errors, just as is true with the more challenging aspects of psychotherapy, are those related to feelings and the unconscious in the psychologist—that is, of which we are not aware. This is the part of psychotherapy that is the most demanding of the heart and soul of a psychologist. In most cases, making errors, if they are addressed and corrected, does not have to mean a failed psychotherapy. The psychologist has to be willing to recognize and self-correct and acknowledge errors to the patient, so that they can continue to work together. This can actually strengthen the working relationship.

This is because the working relationship, the “therapeutic alliance,” between the psychologist and the patient is the key to successful psychotherapy. This seems obvious, but it has been called into question and its importance minimized by managed care and insurance companies seeking to reduce benefits and shunt patients to providers of their choice. The psychologist is the partner, guide, mirror, cheerleader, mentor, model, improved parental figure along the road of crisis resolution, anxiety reduction, self-understanding, fulfillment, behavioral self-control, and other sought-after goals. Again, this seems obvious, but some approaches to psychology, such as strict behaviorism (many people have heard of B.F. Skinner) and some cognitive behavioral psychotherapies, minimized the importance of the relationship in the past. As already mentioned, psychologist Dr. John Norcross edited a 400-plus page book, Psychotherapy Relationships That Work, in which he reviewed thousands of research studies showing the importance of different aspects of the patient-psychologist relationship. This includes how the psychologist deals with the unconscious parts of the process (on the part of the psychotherapist as well as the patient), impasses (particularly difficult parts of the process or disagreements), the need for empathy on the part of the psychologist, and continuity of treatment, to name a few aspects. This is precisely what managed care disrupts. This has negative implications for the outcome of psychotherapy.

The patient’s contribution to why psychotherapy works and why psychotherapy fails.

The failure of psychotherapy can originate with the psychologist, the patient, or a combination of the two. It can fail if the patient is so overcome with fears that he or she cannot bear the thought of calling a psychologist to get started in psychotherapy. I often have new patients tell me that they got my name from their doctor a year or so ago. It is really hard to take that first step, make a call, make an appointment, and then actually go. People often feel that there is something wrong with them, they cannot be helped, or that they will end up in a hospital. These and other fears are quite common, although each person feels alone in having them. In my experience, the vast majority of the time, things are not as bad as patients think they are in the beginning.

Psychotherapy can fail if the patient’s resistance to learning and change is so strong that the patient is committed to repeating the same scenario over and over again. For example, repeatedly cheating on lovers or being overly critical about small quirks will probably result in the relationship ending. This can then be interpreted as that nothing will work out and that the patient will be left alone. It can also fail because of “behaviors that interfere with treatment,” as explained by Dr. Marsha Linehan. Basics such as showing up for appointments, minimizing self-destructive behavior, not making demands on the psychologist that are outside of the boundaries of what is being offered (phone calls, repeated requests for duplicate bills, calling the psychotherapist at home, to name a few), paying on time, and not being verbally abusive to the psychologist are a few examples.

Patient contributions to the failure of psychotherapy are often difficult and confounding for policy makers, employers, and the public to understand. Why would someone apparently sabotage their own treatment, especially if they are claiming to want and need help? Unconscious motivations are challenging to understand and do not necessarily “make sense.” They may have made sense once and were once necessary for survival but are no longer. It is often difficult for patients to learn what is getting in the way of change in the unconscious, that they do not wish to recognize or legitimize, or that they have been trying so hard to do, but haven’t yet been successful. Managed care and insurance companies, not understanding and not caring, as they wish to save money, often become punitive, looking for excuses to cut benefits.

If the psychologist is able to help the patient see patterns and take responsibility for understanding and changing them, psychotherapy has a better chance of succeeding. But even with a competent psychologist, the patient may prefer to continue the pattern. As my mentor says, “Just because there is a clear pattern, doesn’t mean that you can do anything about it.” The patient has to help.

Psychotherapy can also fail if the patient is looking for a quick, easy, cheap fix. Just as it took time to accrue traumas, painful memories, worries, difficult experiences, losses, habits, dashed hopes, dilemmas and questions about life, mistakes, and other experiences, it takes time to solve them, work them through, and come out on the other side. Our society wants quick, easy, cheap fixes for everything. We want it NOW. We don’t want to have to put in the time or the money.

One of the fears about psychotherapy that looks at the past is that it will be endless. We all certainly know those stories. But my motivation to work with patients towards “graduation” from psychotherapy begins as soon as they walk in the door of my office. My goal is to do psychotherapy and get patients out so that they can go on with their lives. They can always come back, and I will be flattered if a patient chooses to work with me again in the future. I realize that psychotherapy might take longer than patients want it to take. But if patients stick with it, past all of the bumps, obstacles, impasses, and rough spots, they will be rewarded with a richer and more peaceful inner life and the ability to better meet life’s goals. It’s likely that before we met, patients would have tried several short-term quick fixes and found that they did not work. Thinking about all of the tasks in life, when they are done thoroughly and done well, they produce a better outcome. It may take more than one try. This is also true of psychotherapy. On the other hand, keep in mind that sometimes psychotherapy is short, and that this may not necessarily be the same as a quick fix. That might be all that is necessary to reach life’s goals.

Peggy A. Rothbaum is a psychologist.