Dr Levine is Clinical Professor of Psychiatry at Case Western Reserve University School of Medicine, Cleveland, and Codirector of the Center for Marital and Sexual Health, Beachwood, Ohio. He reports no conflicts of interest concerning the subject matter of this article.
processes of psychotherapyDisturbances of thinking, feeling, perception, and behavior constitute the formal domain of the mental health professions. By defining psychiatry’s arena of responsibility in this manner, our vocabulary emphasizes psychopathology. We tend to assume that the problems brought to our attention are manifestations of an underlying disorder. We routinely interchange the adjectives mental, emotional, and psychiatric to modify disorder, disturbance, illness, or disease to explain our interventions. In this way, psychiatrists treat illness just as medical and surgical colleagues do.
Psychiatry needs these terms to help early-career psychiatrists make their transitions from basic medical education to the domain of psychiatry. As psychiatrists, we gather experience in outpatient settings and our understanding of the nature and sources of psychopathology changes. We become more aware of the process of personal, highly individualized development. This not only helps us clarify what may be pathological and why it is, but it also enables us to realize that other domains are invaluable to our work. As we come to understand motivation; interpersonal relationships; sexuality; adaptations to life changes; religious, cultural, and economic forces; ethical/moral standards; existential issues; etc, our discrete illness model becomes less compelling.
What is psychotherapy?
Psychotherapy is a rubric—an umbrella under which a vast array of differing interventions exist. Its diverse forms are supported by different ideologies and vocabularies. No one brand of psychotherapy is applicable to everything that ails humans. A professional’s preferred form of psychotherapy often generates passion, identity, and affiliation patterns.
The central idea of psychotherapy is the desire to understand what led to the patient’s current predicament and past predicaments. The goal is to take the mystery away to better position ourselves to remove or attenuate the patient’s symptoms.
Psychotherapy is a purposeful, professional, intimate, conversational process that focuses on the patient’s subjective, interpersonal, developmental, and biological life in order to benefit the patient. Psychotherapy has rules for its conduct, concepts about its processes, and ethical obligations. Psychotherapy rests on a core assumption: emotional growth and symptom relief can occur through relationships. Ultimately, this assumption requires faith. Many people indirectly express their faith by participating in psychotherapy or by showing disappointment when they receive an intervention without psychotherapy. Not every person who seeks psychiatric help believes in the core assumption, however. Disbelievers (and some believers) may want something else at a particular time—for example, hospitalization, medication, agreement with their position in a conflict, or to be found competent to continue administering their affairs.
The basic tool of psychotherapy. A refined quality of listening is our basic tool. Refined listening rests on our pleasure in and appreciation of the patient’s narrative. We strive to comprehend what is being said, noting the style of the narrative and wondering about what is not being said. We seek to understand the emotional tone of the patient’s words by observing the postural and facial expressions that accompany the narrative. We listen in an effort to recognize the patient’s meanings, to create a bond with the patient, and to derive our separate meanings from the narrative.
The therapeutic alliance. The patient is always evaluating us. In the early sessions, we are auditioning to be the patient’s therapist. Only if we pass our audition, does the therapeutic alliance begin. Later in therapy, the patient’s new negative evaluation of us can lead to an abrupt cessation of our work together. Nonetheless, our refined listening creates a therapeutic alliance. The therapeutic alliance is the culturally approved bond that enables further revelation and a deepening trust.
The therapeutic alliance constantly evolves in distinctive ways. The continuing conversation within the therapeutic alliance, the patient’s changing life circumstances, and the evolution of the therapist’s skills, knowledge, perspective, and style all contribute to the uniqueness of psychotherapy.
While doctor-patient interactions are by nature one of a kind, they are not chaotically idiosyncratic. They are unique only within an ethical framework shaped by 5000 years of professional tradition. The rules for professional behavior are subtly incorporated within the therapist and the patient. Patients have expectations about how therapists are supposed to behave and what they can and cannot do to relieve suffering. These rules are referred to as boundaries. Clinicians are expected to continue to learn throughout their careers about patterns of suffering and their means of relief. The major reason psychotherapists can be helpful is their commitment to understand the sources of their patients’ suffering.
Listening. The obvious object of our listening is the patient’s narrative. We listen to what occurs between us during the session and, in the subsequent session, we listen to the patient’s thoughts that occurred between our meetings. We also listen to our own feelings, thoughts, and memories that arise during and after the session with our patient.
Some of the patient’s thoughts and reactions to us during and between sessions is transference. Because of the psychoanalytic origin of the term, transference is often erroneously assumed to not exist in other forms of therapy. Transference is a human rather than an ideological experience. Transference originates in unconscious processes that mysteriously link us with the patient’s past through his or her thoughts, feelings, and perceptions of us. It sometimes surfaces during a session, but most of its manifestations arise between sessions. Transferences reside in the patient’s privacy and tend to be kept from the therapist.