What is psychotherapy?

This question evokes visceral responses in psychologists, and has ignited really fascinating – and heated – debates for over a century. Since Freud, theorists have crafted complex and convincing theories about how the mind works and why symptoms and psychological pain emerge. Researchers have nobly attempted to drill down into the mechanisms of action in psychotherapy, specifically seeking to answer What is it? and How does it work?

Theory and research has brought us closer to answering these questions. Research findings have highlighted the importance of working with an experienced, attuned, and flexible psychotherapist. Research has also shown that it’s what the patient thinks about her own improvement in psychotherapy that predicts the outcome of treatment. Decades of research have also tentatively established that certain treatment modalities (for example, cognitive behavioral, psychodynamic, or family systems) may be better for some problems than others. Beyond that, we don’t really know a lot, other than that psychotherapy is effective for most people with most types of psychological problems. (In later blog posts I’ll talk more about what psychologists do and don’t know about how and why psychotherapy works.)

In this initial post, what I can say about psychotherapy is that it is an utterly unique relationship that grows when a skilled and attuned psychotherapist creates a protected space in which the patient can safely experience herself. This may sound like psycho-babble (“protected space?” “attuned psychotherapist?”), but believe me, it’s not. A good psychotherapist provides the patient with one hour a week during which she is not judged, shamed, needed, expected, or blamed and is encouraged to experience herself as authentically as she can. That could mean anything from feeling empty, real, whole, jealous, proud, furious, and many more states in complex combination. This level of self-experience is only possible in psychotherapy, not with a parent, spouse, partner or friend.  

This relationship lives in a specific time and place, and during that hour, in that room, the therapist and patient attempt to engage. And that’s where the theoretical and research debate lives. What’s the purpose of that engagement? What does that engagement looks like? What do we do with our patients, and does it matter? What questions do we ask, what ‘data’ do we value, and how do we crunch that data when it comes at us?    

The truest answer I have to these questions is that it’s the attempt to engage in and of itself that is the beating heart of psychotherapy. That includes your struggle to reveal yourself to your therapist, who is at first a total stranger to you, and you and your therapist's mutual struggle to focus your joint attention on what really matters to you.  The attempt to engage also includes you allowing your therapist in to help regulate you, which I could describe as, from the therapists point of view, ‘when you feel this, I enter; I can pull you back, push you towards, or help you stay and find meaning.’ Your attempt to engage also includes allowing your therapist to know you, your family history, what has shaped you, how you achieve closeness and distance from others, how much shame you carry and how it limits you, and what great things you’re ignoring about yourself that need your therapist's laserbeam. This is how I work with patients, and reflects what I believe is the mechanism of change in psychotherapy.