A Model of Psychotherapy for the 21st Century

Theory has long been the well-combed tail wagging the psychotherapy dog. This article presents a model that turns theory-based psychotherapy on its head.

During this first century of Western psychotherapy, arguments among and between the schools of psychotherapy have dominated discourse. The psychotherapy of the next century is likely to place theory and associated techniques in their appropriate, practical places in the psychotherapy outcome puzzle.

Behavior therapy, cognitive therapy and interpersonal therapy, for example, appear to be equally effective in the aggregate for the treatment of depression (Frank and colleagues).

The predominant influence of personality-based theorizing is multidetermined. Sigmund Freud can, of course, be blamed. Hoping to stay on the faculty of the University of Vienna, Freud worked in neuropathological research. Finding himself dismissed and married with a family, he had to find work. Viennese internist Josef Breuer, Freud's mentor, suggested hypnotism for patients with neurological disorders having no apparent neurophysiological basis. The ideas of his mentor proved viable. Freud's practice developed reasonably well, but he was more interested in developing a theory of mind than a model of therapy (Gay). His creative energies brought the world a compelling, complex and evolving system that captured the imagination of many. He became disenchanted with the therapy he had introduced (Freud), as did others who brought empathy (Rogers 1942 and 1951), interpersonal relationships (Sullivan), cognitions (Ellis, Beck), emotion (Perls), behavioral exposure (Wolpe) and systems thinking (e.g., Minuchin) to psychotherapeutic conceptualizing. They and their successors felt compelled, sometimes by textbook editors (e.g., Corsini and Wedding) to imitate Freud's system by describing their school's theory of personality, theory of psychopathology and theory of therapy. None had theories of psychopathology and personality as elaborate as Freud's, yet they struggled to match his complexity.

Of course, school-bound concepts have many benefits. They provide a rallying ground for believers who can form and maintain ideological organizations. Knowledge of personality and psychopathology theory allows therapists to conceive of themselves as experts and feel confident in what they do. But the reality of clinical practice requires different concepts generally unacknowledged by the general body of psychotherapeutic thinking-patient readiness to change, nature of the social network, symptom type and severity, and strength of the working alliance.

The pragmatic emphasis of managed care is loosening therapists' attachment to schools of therapy and forcing conceptual refinement of practice. Only theories and techniques that correlate with cost-effectiveness and quality are likely to survive in the managed-care environment (Cummings and Sayama). Other developments are also forcing the de-emphasis of schools of therapy. The movement to integrate the psychotherapies has been gathering momentum and support (Norcross and Goldfried). Compelling findings of reductions in caudate and prefrontal hypermetabolic activity associated with cognitive-behavioral treatment of obsessive-compulsive disorder direct therapists to consider how psychotherapy alters brain function (Schwartz and colleagues).

Goals of Psychotherapy

Psychotherapy can be defined by its goals, its process (stages), its tools and the principles for using those tools.

Future-oriented psychotherapy's intent is to help patients do something positive for themselves after they leave the office. The goals of most psychotherapy relationships fall into six categories:

Crisis stabilization. A person is distraught because his wife has suddenly left him for another man, for example.

Symptom reduction. A person has been depressed for several months, which is interfering with his work and social functioning.

Long-term pattern change. A woman repeatedly develops intimate relationships with abusive men.

Maintenance of change, stabilization, prevention of relapse. A woman with chronic medical disease, a disabled husband and recurrent depressive episodes requires continuing support to help maintain current functioning.

Self-exploration. A person with reasonably good social and work functioning wants to understand himself more fully.

Development of coping strategies to handle future problems. A person learns to handle emotions that increase the likelihood of wanting to drink alcohol excessively but wants to generalize this coping strategy to other situations.

Psychotherapy does not usually cure people of problems. Patients may return for a different set of problems or recurrence of the same ones. In this way therapists may act like primary care physicians.

Major Patient Variables

The practice of psychotherapy takes place in the real world, in the lives of patients functioning in their social networks. Several "functional inputs" play greater roles in influencing outcomes than do theory and technique:

Client readiness to change (Prochaska and DiClemente) and nature of social network (Marziali, Moos, Bankoff and Howard).

Symptom type, severity and chronicity

Strength of the working alliance (Horvath and Greenberg).

Number of sessions (Howard and colleagues, Mental health, Lambert 1996).

A critical next phase in psychotherapy research should relate these functional inputs with outcome findings to determine the degree of influence of each of these factors.

Patient strengths and limitations strongly influence outcome. Therapists do not "do it to them," but instead help patients find the means to change themselves. A study by Jones, Cumming and Horowitz supported the conventional wisdom that higher levels of client pretherapy adjustment correlated with successful outcome. In addition, perseverance, depth of affective experiencing, a specific problem versus a pervasive problem and acute difficulties versus chronic problems are well-established correlates of improvement (Robertson).

Courage (willingness to take risks, to face fears) may also be a crucial but difficult measure variable since change often requires trying the unknown or attempting new action without the certainty of the desired outcome.

Stages of Psychotherapy

Psychotherapists generally help patients solve problems. The dysfunctional pattern(s) need to be defined in a way that suggests solution. Then the patient has a set of guidelines for how to proceed. As the problem or problems are being defined, therapist and patient must be engaged in a working relationship that fosters collaboration. The therapist is responsible for managing their time together efficiently.

All relationships move through the same general stages. Stages guide interventions by providing subgoals for the process of change. These subgoals include engagement, pattern search, change and termination (Beitman 1987). Some patients may change by simply becoming involved in an empathic, understanding relationship (e.g., Rogers). Some may change when, together with their therapists, they clearly define a pattern or set of patterns to change. They may not need the therapist's change-inducing skills.

Change can be divided into three substages: relinquishing an old pattern, initiating a new pattern and maintaining the new pattern. Guided by the subgoals of the psychotherapy process and the substages of change, therapists confront choice points. At each of these choice points (silence, intense affect, report of homework, couple disagreement), therapists access an array of alternative intentions and response modes appropriate to the goals of each stage.

Psychotherapy takes place within patients' psychosocial context. In once-weekly therapy, there are 167 hours outside of the therapists' office. Family members, supportive friends, problem-specific books, cocounseling (Jackins), self-help groups, as well as homework, can all assist.

Tools of Psychotherapy

Patients change during psychotherapy for a number of reasons, some of which have little to do with therapeutic technique. A multitude of studies both pharmacological and psychotherapeutic demonstrate a "time effect," namely, that patients improve simply by the passage of time and being part of a study. Factors contributing to the time effect fall under the broadly defined categories of spontaneous remission and placebo response. The first refers to factors outside of the therapeutic relationship and the second to expectancy factors within the relationship.

In other words, patients sometimes improve because of events in their environments and sometimes because they believe the treatment program will be effective (Lambert and Bergin).

Outlined below are the primary tools of psychotherapists:

Relationship skills. These include the constructive use of empathic understanding; careful management of the therapeutic contract; demonstration of expertise, warmth and nonjudgmental acceptance. A strong working alliance is closely correlated with outcome (Horvath and Greenberg).

Activation of the patient's observing self. Most psychotherapists activate their patients' capacity to self-observe (Deikman). Disciplined self-observation fosters the opportunity for insight. Using empathic reflections, cognitive homework, affective exercises, behavioral instructions, interpretations and other methods, therapists encourage patients to look within themselves in order to find the data to delineate dysfunctional patterns.

Knowledge of basic patterns of psychological difficulties. Experienced therapists possess a broad array of generic patterns that characterize the common problems confronting their patients. The themes of these patterns contain cognitive components and generally concern interpersonal relationships. Patients struggle with lack of awareness or excessive anxiety about their own emotions, particularly anger; have poorly constructed and misconstrued interpersonal schemas; and struggle with unresolved tragic, disheartening and/or frightening memories including unresolved grief and traumatic events. Many have used maladaptive, repetitive responses to distressing events, retreating into substance abuse, depression, anxiety and eating disorders. Many patients reflect problems inherent in the thematic crosscurrents of the culture.

The schools of psychotherapy have elaborated on these themes in remarkable and stultifying detail. Commonly used change strategies extracted from the schools are contained in the Table.

The 21st century is likely to witness the realization of Freud's vision when he attempted the "Project for a Scientific Psychology." We will better understand the mind by better understanding the brain. We will continue to witness changes in the brain associated with changes in mind as suggested by research in obsessive-compulsive disorder (Schwartz and colleagues). Theorizing will increasingly be tethered to the organs of the brain (Beitman 1994).

Inductive reasoning. Such reasoning requires therapists to generalize from bits of information presented by the patient to explicit patterns of dysfunction.

Information can be gathered in a number of ways including: questions, confrontations, clarifications, homework assignments, reports from significant others, observation of the patient in the office and therapist reactions to the patient.

Persuasion. Therapists encourage patients to increase emotional awareness, modify cognitions and/or regulate behavior (Frank 1961; Karasu) and/or to refine their self-definitions in relationship to others. The strategies which guide these efforts include encouraging patients to face their fears, helping them to alter the way in which they anticipate the future and offering ways to redesign their role-relationship schemata and scripts.

General Principles

Effective therapists seem to possess both a solid grounding in the basics of psychotherapy and disciplined flexibility. Disciplined flexibility requires structured ways to adjust psychotherapeutic ideas to the therapist's personality as well as to the individualized needs of patients and to move easily, but prudently, among various strategies for change.

Theory and technique are molded to the individual personality of each therapist. No matter how leaders of schools might attempt to create therapists who strongly resemble each other, most practitioners seem to adjust their selections of school-bound ideas to their own interpersonal styles and world views.

Theory and technique are shaped by the cultural context in which it is being practiced. Psychotherapy is strongly influenced by its sociopolitical context and may sometimes influence the culture in which it grows.

Therapists adjust to influences patients bring to the psychotherapy relationship. Generally, therapists strive to match client characteristics and problems with the most potentially effective interventions rather than attempting to force patients into therapist-imposed restrictive formats.

Effective therapists learn to move easily among the commonly accepted change strategies. Three meta-strategies guide the application of change strategies:

Key-change strategy: Sometimes the available evidence suggests that one strategy offers the quickest, most efficient avenue to change.

Shifting-change strategy: Therapy begins with the most easily used change strategy. If not effective, switch to another strategy.

Maximum-impact strategy: With some complex cases, therapists must work simultaneously on several patterns. Instead of hoping for a sequential effect, therapists may need to work for a synergistic effect as multiple changes mass together to bring about a desired state. The use of these strategies relies on the principle of using the least amount of energy to produce the greatest output (Prochaska and Prochaska).

Effective therapists reflect on and analyze their own thinking: Effective therapists seem to reflect upon their own responses to patients to differentiate their own neurotic responses from patient-induced ones. They attempt to utilize this understanding to help patients and also to help themselves grow as individuals and as therapists.

Overall, the guiding strategy of psychotherapists is an ethical one: everything therapists do is intended to help their patients.

Knowledge Sources

The pressure of cost containment is painfully squeezing out the inefficiencies in the helping professions. One such inefficiency is how new knowledge enters the mainstream of clinical practice. Because psychotherapy is not a profession, little formal obligation exists for continuing education in psychotherapy. Because busy clinicians are often caught up in economic and personal concerns, their expansion of psychotherapy knowledge is likely to be haphazard and idiosyncratically built upon their own clinical biases. The primary sources of new knowledge for psychotherapists are theory, clinical experience of both their own and of other clinicians and research. Therapists may also acquire new ideas from the media and from their own personal experiences. For the practice of psychotherapy to become coherent, a new organization for the screening of new ideas may be required. There are numerous psychotherapy journals and newsletters. None seems dedicated to defining only that which therapists need to know in order to improve practice. A publication disseminated through the Internet as a public service to psychotherapists could be created to fill the continuing education need for this constantly evolving process. The organization behind this publication would need to filter information from the four primary sources: theory, clinical practice, controlled research and naturalistic outcome research.

Particularly useful will be feedback from well-constructed data sets based upon outcome and process data from actual clinical practices. Such data bases are currently being formed by managed behavioral health organizations. Simple but profound questions looking, for example, at the relationship between working alliance, stages of change and clinical outcomes could inform clinical practice.

Toward the Future

Psychotherapy is not a profession. It is an activity of many different professions. It has no organization to set and uphold professional standards and ethics. In 1996, the American Psychiatric Association established the Commission on Psychotherapy to address the erosion of psychotherapeutic practice. For the long-standing survival and flourishing of psychotherapy, psychotherapists may need to create a multidisciplinary group dedicated to the growth and survival of psychotherapy.

References:

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