Psychology Articles by Dr. Arthur Dingley - Psychotherapy

Dr. Art Dingley

Psychotherapy is a human relationship, with specific aims, bounded by a set of rules. Although it is a relationship, the therapist is not trying to be a friend. The aims of therapy are to help the client achieve better control of her thoughts, feelings, behavior, self image, and relationships. The rules are simple, but critical. First, the therapist does not talk about herself. Second, the therapist does not give advice. Third, the sessions are conducted on a regular schedule, for an agreed fee, in the therapist’s office. Fourth, the relationship between client and therapist is confined to the session. There can be no business dealings, socializing, or romantic relationship between patient and therapist. Finally, with limited exceptions, the therapist must keep the client’s confidence. There are many kinds of psychotherapy. This is a very brief look at three of them.

Any discussion of psychotherapy must include a word about Sigmund Freud and psychoanalysis. Although full psychoanalytic technique is not commonly used today, its theories rank among the most important ideas of the last 200 years. Dr. Freud was born in Moravia in 1856. He grew up in Vienna, Austria, where he attended medical school. Freud had always been interested in neurology, but worked as a primary care physician and then a surgeon to support his family. In 1885, he obtained a grant to study neurology with Dr. Charcot, a famous French neurologist. Charcot was treating hysteria (Conversion Disorder) with hypnosis. Back in Vienna, Freud worked with another neurologist who was using hypnosis.

One case, in particular, had a powerful effect on Dr. Freud’s thinking. A young woman named Anna, with a confounding array symptoms, suddenly improved under hypnosis when she recalled some past events, together with the emotions she had experienced during the events. Freud saw this case as strong evidence that part of our mind is “unconscious”; that the unconscious can be a repository for disturbing urges and memories; that unconscious processes can affect our thoughts, feelings, and behavior; that bringing unconscious material into awareness can release its power and free us of its influence. These ideas have become so much a part of our thinking that they seem unremarkable and self-evident. In 1895, they created a revolution.

Freud was a dedicated scientist and a keen observer. He abandoned hypnosis when he discovered that, if they were simply relaxed and did not attempt to censor their thoughts, his patients could recall things as well as if they were in a trance. Freud accomplished this by having his patients lie on a soft couch in a dimly-lit room and say whatever came into their minds. Still, many patients resisted recalling past unpleasantness, or acknowledging unacceptable impulses. The unpleasantness had been “repressed” into the unconscious. Now, recent events were stirring the repressed material which was threatening to come to the surface. This resulted in symptoms such as anxiety, depression, and physical complaints. Freud learned to look for clues. He quickly realized that, without knowing it, his patients were transferring their ideas and feelings about other people onto him. Freud learned to facilitate “transference” by revealing little about himself. He became a “blank slate” on which his patients were free to draw a portrait based entirely (and unconsciously) on their previous relationships, usually going back to childhood. Freud also learned that his patients’s unconscious wishes were revealed in dreams, slips of the tongue, or apparent mishaps.

Freud left Europe in 1938 when the Nazis came to power. He died the following year of throat cancer caused by years of cigar smoking. However, he left a legacy of trained psychoanalysts, most of them physicians, who formed the core of modern psychiatry. Over the next fifty years, psychoanalysis evolved and spun off other psychotherapies usually referred to as “psychodynamic psychotherapy”. Therapists using these techniques are more interactive with patients and address the patient’s defensive style and personality traits early on. Modern psychodynamic psychotherapy still attends to the unconscious forces which drive symptoms, but therapists strive for symptom reduction and improved insight in as few as twenty sessions instead of the hundreds of sessions required by pure psychoanalysis.

Cognitive psychotherapy proceeds quite differently. Cognitive therapists zero in on symptoms right away. The therapist and the patient work together to identify “automatic thoughts” which may be driving unpleasant feelings. Automatic thoughts are spun off by “core beliefs” and core beliefs may be part of a larger view of the world called a “schema”. This is detective work. The patient and therapist identify the exact negative thoughts which are resulting in a symptom, such as anxiety or depression. When the thoughts are identified, patient and therapist move on to the underlying “core beliefs” which give rise to the thoughts. The core beliefs are then challenged. When the belief has lost its power, the automatic thoughts stop, and the symptoms get better.

Imagine a man who presents to a psychodynamic psychotherapist complaining of depression which has lasted for a month. The therapist notes that the depression started right after the patient applied for a job which was given to another applicant. She also notices that the patient complains angrily that the employer disliked him. The patient begins to get angry with the therapist when she asks questions that he thinks are too personal. She recognizes that the patient has a paranoid personality style and is using projection to attribute his own unacceptable unconscious impulses to others. The therapist is careful to be very honest with the patient, letting him know immediately, for example, if his behavior is making her angry as well. Her goal might be to help the patient recognize his own anger and aggression, and to help him realize that he can discard these feelings without leaving himself vulnerable to attacks by others.

A cognitive therapist might begin with this patient by pointing out the connection between the feelings of depression and the thought that the employer disliked him. Once the patient saw the connection, they might begin looking for other examples of how this automatic thought (“other people don’t like me”) had caused similar feelings in the past. For example, the patient might recognize that he had been angry and depressed after being turned down for a date, cut off in traffic, or ignored by a receptionist. The patient and therapist are able to figure out that these negative thoughts are coming from the patient’s core belief that he is not loveable or “as good as” other people. Now, the therapist’s job is to challenge the patient’s conclusions about why others appear to treat him badly (“Yes, maybe people act that way because they hate you, but what else could explain it?”) The therapist’s goal is for the patient to learn to challenge his own conclusions and to keep an open mind about other people’s motivations.

Notice that, although these therapists are using different techniques, both are directing their efforts to helping the patient change his thoughts, feelings, behaviors, self-image, and relationships. Both recognize that the patient is unaware of what is causing his symptoms. Both recognize that once the “unconscious” motivation is better understood it will lose its power.

Psychotherapy has some risks. An incompetent therapist may violate the rules of therapy and exploit the patient to satisfy her own emotional, sexual, or financial needs. These “boundary violations” are contrary to ethical rules, and may constitute criminal behavior. A therapist may engage the patient in weekly, unfocused, “chit-chat” with no clear treatment goals. This has no lasting benefit and may even cause harm by making the patient feel increasingly hopeless. A therapist may give the patient advice about how to proceed with relationships under the guise of “self-esteem building”. This is apt to backfire and damage the relationship between patient and therapist. A therapist may insist upon the patient revisiting traumatic events, which are clearly remembered, in the mistaken belief that the horrific feelings which accompany the memories will somehow be discharged. This may cause lasting emotional damage.

Professionalism is probably the best criterion for selecting a therapist. People sometimes want a therapist of the same gender, or a therapist whom they feel is kind and supportive. In fact, they might benefit much more from having a well-bounded relationship with a therapist of the opposite gender or one who pushes them a bit harder in treatment.

Dr. Dingley is a psychiatrist at Evergreen Behavioral Services in Farmington. He may be contacted at adingley@fchn.org.