The Therapeutic Attitude in Psychotherapy

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COMMENTARY

The psychotherapy frame refers to the basic ground rules for psychotherapy: the attitude of the therapist toward the patient, boundaries, meeting arrangements, and other contractual elements of the psychotherapy relationship. It can be conceived of as the environment and relationship in which psychotherapy takes place. The late psychiatrist Robert Langs, MD, devoted much of his career to the study of the frame, the maintenance of which he described as the therapist’s “most fundamental arena of intervention.”¹

In the past few decades, as psychotherapy has broadened beyond its psychoanalytic and psychodynamic origins, the concept of the frame has become less known in psychotherapy training and practice. Indeed, many modern therapists have never heard the term or, alternatively, view discussions of it as archaic and reflecting a bygone era of psychotherapy. This unfortunate misunderstanding has led to a shift in the view of the psychotherapy relationship wherein, to borrow from Kernberg, many modern therapists “let it all hang out”² and adopt a theoretically loose or unprincipled stance. Such therapists may talk about themselves, give advice, or impose their personal beliefs and worldviews onto patients.

Given these recent trends, it may be helpful to revisit the concept of the frame and, in particular, the therapist’s attitude toward the patient in the psychotherapy relationship. Such a discussion may be useful not only to psychotherapists, but also to psychiatrists who may find value in these ideas as they pertain to the psychiatric treatment setting.

The Attitude of the Therapist

The basic attitude of the psychotherapist toward the patient represents the most important element of the psychotherapy frame since it informs the therapist’s role in the treatment situation. An understanding of the therapeutic attitude yields information about other components of the frame, such as the establishment of boundaries and meeting arrangements.

The therapist is a professional and expert on the workings of the human mind who is consulted by the patient because the patient is having some difficulty in their experience of life. At times, this is due to psychiatric disorder. The therapist must remember that their role is that of expert or doctor—not friend or acquaintance. Although a liking for patients often evolves during the course of psychotherapy, the psychotherapy relationship is not a friendship. The therapist who seeks friends in psychotherapy may do so for a variety of reasons: loneliness, a dissatisfying personal life, or their own pathological narcissism. The boundaries between therapist and patient must be respected and the power differential not ignored.

Most individuals who become therapists are motivated by a desire to help others deal with the burdens of emotional despair. Although a desire to help is undoubtedly a necessary trait in a psychotherapist, it has long been recognized^3,4 that the therapist must not have too great a desire to help. The goal of psychotherapy is to help the patient free themselves from the constraints imposed on them by their conflicts, problems, and symptoms; it is not to help by doing anything to or for the patient. To put it another way, in ethical psychotherapy, the therapist must care about the patient—not take care of them.

Langs, commenting on these ideas, writes that the therapist⁴:

“avoids being too supportive, because he hopes not only to offer sustaining help but also, through his therapeutic attitude of being nonjudgmental, noncondemning, nonsubmissive, nonanxious, noncontrolling, firm, consistent, and realistic, to have a modifying effect on the patient’s personality. He knows that the constant playing of the note of supportiveness is not enough. He knows, further, that a too empathic or too profound sounding of this note may infantilize the patient.”

Perhaps the most dangerous risk of psychotherapy is that the therapist will use the patient as a tool or instrument to gratify their own narcissistic impulses. This can take many forms, from gross boundary violations to more subtle attempts to persuade, manipulate, and control, or to model the patient after oneself. The patient’s autonomy—their right to make their own decisions—must be accepted and protected by the therapist. The patient must be seen as an autonomous individual—not an object to be fixed or controlled. It has become fashionable for some therapists to proffer in advice-giving. This practice is countertherapeutic and antithetical to psychotherapy; it infantilizes the patient and promotes helplessness and passivity. It deprives the patient of the very thing psychotherapy aims to provide: freedom.⁵

Freud, writing beautifully on this subject, reflects, “We refused most emphatically to turn a patient who puts himself into our hands in search of help into our private property, to decide his fate for him, to force our own ideals upon him, and with the pride of a Creator to form him in our own image and see that it is good.”⁶

A vital feature of psychotherapy is therapeutic neutrality. What this means is that the therapist maintains an observing stance in relation to the patient and avoids taking sides with any the forces in conflict in the patient’s life. The reason for this is that such a stance helps the patient observe and reflect themselves and eventually to solve their own problems. This does not mean that the therapist is indifferent or blank; the notion of the “blank slate” therapist itself has always been somewhat of a myth. It should also be understood that absolute neutrality is impossible, but the concept should guide therapists in their interactions with patients.⁷

Psychotherapy is a contractual relationship. It is essentially the keeping of promises. The therapist promises the patient to do certain things (to analyze, to aid in understanding, to provide a safe environment), and those things the therapist must do. The therapist also promises not to do certain things (to speak to third parties, to moralize, to control), and those things the therapist must not do. It is the contractual nature of the psychotherapy relationship that permits the other therapeutic work to occur, but the contract itself—and the therapist’s maintenance of it—is a significant therapeutic intervention.

Concluding Thoughts

The psychotherapist’s attitude vis-à-vis the patient represents a fundamental, and currently underappreciated, element of the psychotherapy frame. It is the attitude of the therapist that opens the door to good psychotherapeutic work; the therapist’s stance, too, is a key intervention, since it places the patient in an autonomous position and fosters introspection and self-initiated growth. The therapist must be neutral but not indifferent; firm but not judgmental; warm and empathic but not overly involved. They must recognize that the way to help the patient is through exploration—not imposition. They must be and do all of these things, but above all, they must respect the uniqueness and creativity of the patient as an individual human being.

References

1. Langs R. A Primer of Psychotherapy. Gardner Press; 1988.

2. Rankin C. Otto Kernberg on Psychoanalysis and Psychoanalytic Psychotherapy. 2000. Accessed June 27, 2022. https://www.psychotherapy.net/interview/otto-kernberg

3. Brenner C. An Elementary Textbook of Psychoanalysis. International Universities Press; 1955.

4. Langs R. The Technique of Psychoanalytic Psychotherapy. Aronson; 1973.

5. Szasz T. The Ethics of Psychoanalysis. Basic Books; 1965.

6. Freud S. Lines of Advance in Psycho-Analytic Therapy. In: Strachey J, ed & trans. The Standard Edition of the Complete Psychological Works of Sigmund Freud. Hogarth Press; 1955.

7. Yeomans F, Caligor E. What is neutrality in psychotherapy anyway? Psychiatric News. June 1, 2016. Accessed June 27, 2022. https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.6a20