How Psychotherapy Actually Works

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

Any external detached observer immediately questions - what does psychotherapy do?

This is “just talk”, how can they help?

And if it helps, then what exactly?

Why are there so many different directions, how do they differ in final efficiency?

These questions also arose for me. Let's define what is meant by psychotherapy. Formally, this is a medical activity, and only a doctor who has received a specialization in psychotherapy can engage in it. This is true for Russia, but in many countries it is not, and psychotherapeutic activities are carried out by specialists with both medical and psychological education. I propose to proceed from this understanding, there are psychotherapists, there are psychologists-psychotherapists, and the differences are not in psychotherapeutic work, but in additional competencies, for example, the ability to combine psychotherapeutic and drug treatment where necessary. As a doctor, I can prescribe pills, a psychologist cannot. Violent disputes “who is the real welder here, and who found the mask in the trash heap” do not make sense. There are many psychotherapeutic concepts, often mutually exclusive and constantly competing. Psychoanalysis, gestalt, cognitive-behavioral, existential, humanistic, body-oriented, NLP, and others. This polyphonic choir is somewhat surprising. Moreover, in the final practice, in the head of an individual specialist, models are also mixed, few people work in pure forms, all eclectics are essentially. That is, a psychotherapist may declare that he is a gestaltist or a Jungian, but in fact, very few people live according to the precepts, if he is not a sectarian. It seems like psychoanalysts with stricter dogmas, but this is explained by the specifics of the psychoanalytic model - there is compulsory supervision and a retraining system, it all costs money, that is, there are people who receive this money, so they are interested in keeping the model clean … That is, the concept is designed in such a way that the community of practicing psychoanalysts gives some of its income to support the concept, such a very distant analogue of church tithe. And speaking in terms of evolutionary theory, this is a perfectly decent way for the concept to continue to exist, prosper and develop. But this is just one of the strategies in the struggle for survival in the world of competing ideas. Of course, this is not the only way. Gestalt works differently, there are many independent organizations that teach Gestalt therapy. In the cognitive evolutionary branch, in general, it is essentially open source, where integrativeness is declared in the ideology, in the spirit of "here's a working model for you, then do whatever you want." Therefore, in order to be a psychoanalyst, I need a document that says that I am a psychoanalyst and practice psychoanalysis, and to be a cognitive behavioral therapist, I need a document that says that I am a psychotherapist and practice cognitive behavioral therapy, but in there is no need for a separate CBT document. Meanwhile, despite the differences in approaches, practitioners, no matter what school they belong to, are rarely rigidly dogmatic, if you see a person who is clearly a fanatic, no matter what (psychoanalysis, gestalt, behaviorism), most likely he does not work with this tool, he is either a teacher, or an amateur, or a neophyte, or a client. Practicing psychotherapists are usually more relaxed about this, and are always, as they say, open to interesting commercial offers. Although there are sectarians, this also happens, yes.

Therefore, it makes sense to reason from a meta-position, and not from any psychotherapeutic schools. If they all exist, then people need it for some reason. There are reasons why people pay for this in order to maintain species diversity. If there were a universally all-conquering concept, it would have long ago supplanted competitors, which we do not observe. Many therapies coexist in the psychological services market, although there are ecological niches in which one model demonstrates a significant advantage.

For Western countries, this primarily concerns the conditionally "medical", clinical psychotherapy, where there is an absolute predominance of the cognitive-behavioral approach. In 1993, the American Psychological Association published guidelines for psychotherapy for mental disorders that meet evidence-based criteria for effectiveness, from which point a triumphant march of cognitive and behavioral models began in various forms. This did not happen by accident. The fact is that by that time in developed countries, health care costs were constantly growing, and the question for medicine was ripe in society: "OK, we are ready to pay your crazy bills, but explain why." This is how modern evidence-based medicine has developed. Accordingly, medicine has formed a certain request for psychotherapeutic paradigms. “It's nothing personal, we don't care what you call yourself, what your concept is and what you do. Show that you are a treatment, not just a conversation. We have Popper and the scientific method, you are required to meet the evidentiary criteria. We don’t care about anything else.” And then the cognitive-behavioral one came out from behind the tree and said "hello, mom." This is how it all began.

However, I repeat, this applies only to the "medical" sector of psychotherapy. It is important, significant, prestigious, but the industry is not limited to it, and in all other areas of psychological assistance, a variety of areas are successfully practiced and feel great. For example, in Hollywood films, as a reflection of the mass consciousness, psychotherapists are mainly represented by psychoanalysts, until they completely merge, and for many people psychotherapist = psychoanalyst. In Russia, the situation with clinical psychotherapy is somewhat different. Firstly, our adherence to evidence-based principles is rather formal in our country, and this entire evidence-based approach is not very much instilled in the community. Secondly, domestic medicine has taken a different path. They did not choose, as in the West, which of the psychotherapies suits them. “We take all psychotherapy for ourselves. Pack us all, please, then we'll figure it out. " Therefore, as mentioned at the very beginning, in Russia, psychotherapy is an exclusively medical specialty. And the cognitive-behavioral approach is present in the country, has its share and place on the shelf, but there is no talk of any dominance. At the moment in Russia, perhaps, Geshalt, psychoanalysis and existential are the main players. Then the cognitive, humanistic and others. This leads us to an important thesis: Apparently, psychotherapies somehow work. There are reasons why people go there. Otherwise, they would not have gone. And this is not mysticism and esotericism, because at the services of the population there are psychics, fortune tellers, astrologers, magicians, and other hereditary witches. And they have their own super-competitive market and their own very tough struggle for minds, so those who are ready to go to psychics go to psychics, this person will not go to psychologists, or will go very optional. And still a lot of people, in principle, are not inclined to realize that they have such a thing as a "psyche", and when they are faced with some mental difficulties, they are not inclined to do something about this, they live like this, and never go to a psychotherapist will not go. And there are training and coaching activities, it has its own history and its own audience, this audience intersects with psychotherapeutic, but very partially. And a huge mass of people are actively interested in the issues of psychology, personal growth and improvement, but only within the framework of self-development and self-education, this is quite enough for them, and they do not need to turn to a psychotherapist

So it's not true that "everyone needs psychotherapy." That is, it can be necessary for everyone, according to psychotherapists, but in fact, not everyone comes for this. Very few. One in a hundred. But even if this is less than a percent of the population, it is still about hundreds of thousands of people. A lot of people do this. So someone needs it. Why would they? If you ask the experts themselves, the answer will be like “I help people with various problems to understand them, successfully resolve and achieve mental well-being,” or something like that. Yes, of course, a perfectly fair answer, not the slightest doubt, this is what psychotherapists do. For all the good versus all the bad. No doubt about it. But they all do it. So this answer is not very informative. Therefore, it is worth asking to describe what exactly they are doing. The answer, too, should not be taken literally, there will be terms and some good words, but you can see what is meant by these words, see what a person does and how he works, and evaluate from a meta-position. And if there is a sea of information on the history of psychotherapy and the state of psychotherapeutic concepts, there is practically no information on the analysis of therapeutic practice. Two very recent books: Cognitive Neuroscience and Psychotherapy. Network Principles for a Unified Theory "(2014) and" Psychotherapy. A critical guide”(2013), did not see anything else. Therefore, everything further is already personal conclusions and observations. Let's separate "medical" and "psychological" psychotherapy. If everything is clear with the "medical" part, what to do is clear, the answers have been received, then it is not interesting, then with the "psychological" part everything is much more interesting. I believe psychotherapy helps, but offers nothing unique. By analogy: all those tasks that a person solves in a fitness room, with the most modern exercise equipment and the best instructors, he can get the same results at home with two dumbbells. Dumbbells have been around for a long time, the fitness industry has recently, somehow coped with it before. But gyms exist and are in demand, because in practice a person does not exercise with dumbbells, but does in the gym. Therefore, in fact, if you remove the terminological and conceptual shell, psychotherapists offer basic enough, and banal things. And these commonplace things are in demand.

What is the product? What's on sale? Relationships and personal communication. Empathy and support. Justification and Acceptance. Specific tips and tricks. Common sense and rational behavior. And another thing, the list is not complete. Most often it is a relationship. Typically, at the level of justification, there will be something about "creating a psychotherapeutic space", "a joint working alliance between therapist and client", "active participation", or something like that. The challenge is to enter the small group without entering the small group. That is, a personal relationship must be established, but at the same time differ from the personal relationship that the client already has (or may have). You can not replace friends, relatives, sexual partners. And it must be a good relationship, otherwise what's the point? Additional good relations on the farm are not superfluous, people are ready to pay for it. And here it is easy to say "well, it's just …"

“Well, it's just a relationship. I can do that myself. " Looks like the "copy Malevich's black square" problem. But in reality, as with dumbbells, everything turns out to be not so simple. Theoretically it is possible. And practically? Few people are still so interested as about themselves, their beloved. And this is normal, this is generally the case for all the polls, this is correct. At the same time, some would sometimes like to talk to themselves, some do not. For example, I want to. Not often, but it happens. Obviously, I will not talk to myself with people with whom I am on bad terms, only operetta villains do that. It also makes no sense to talk to people who are generally out of interactions, they obviously do not care, with the same success you can talk with the TV or with a children's toy. I would like to talk about this with people with whom I am on good terms, but this is the problem. If I often do this with people I am on good terms with, I’ll soon find myself on bad terms with them, and I don’t want that. The psychotherapist remains.

As you can see, this is a completely non-trivial task - "just a relationship." This is a request, and a perfectly legitimate request. But people rarely reflect on themselves to such depth, so the request is declared in the category of "problems". Nobody will say "I want to be on the pens" or "to speak out." Moreover, in everyday life, people calmly voice these desires, and they do the right thing, a normal natural desire. But it is not the basic request that is voiced to the therapist, but the “therapeutic” one. Correct decoding of a therapeutic request is a separate big topic, since it is not at all obvious what the client came with, this still needs to be clarified. But from the client's point of view, this practice is quite justified, he does not have to find out, this is the task of the psychotherapist. In the same way, doctors do not come with the complaint "I have an ulcer in the duodenal section", they say "my stomach hurts." And, most importantly, the therapist will still offer the product that he has. If a person trades in sympathy, but does not trade in specific recommendations, then he will say so: "psychologists do not give advice." And sympathize. And the other will say: “therapy with success, specific solutions to your problems,” and rest assured, the advice will be specific. Not the fact that they are good, but certainly specific. At the same time, there may or may not be good ones. And this mismatch between client and therapist sometimes generates confusion and frustration. For example, a very rational person discovered some problems in himself, you can figure it out yourself, but it's easier to outsource, goes to a therapist, and there he is offered to talk to an empty chair. Of course, this makes a person unpleasantly bewildered and psychotherapy does not work out. Or a person needs to think about someone, and the therapist is very sincere, very understanding, but the phrase "I really sympathize with you" can be heard for free, and this is not quite what is required. Frustrations like these are common, but there is no malice or any fault, it is just that the client's basic request did not match the therapist's proposed product. And the experience with psychotherapy is limited to the fact that he came a couple of times, shrugged his shoulders and left, sincerely bewildered what it was. But just as often it coincides and everything works, otherwise therapists would have died out.

Thus, words are packaging; they are not a product. Each specialist collects his own product line and packs it in some terms. This is the tradable skill of the psychotherapist. Therefore, there is not and cannot be universal psychotherapists suitable for absolutely everyone. It is impossible to combine everything at once, this bacon in chocolate will work. I will illustrate on a personal case. I am in favor of a behavioral model and a rational approach. That immediately cuts me off from a number of spiritual practices, with all my desire I can not offer them, it will be too noticeable that I consider them complete nonsense. And this is not a problem with these spiritual practices, because they are doing fine without me and have their own large audience. Therefore, we take those concepts that are ready to accept. In my case, this is the entire "cognitive" branch of evolution, from cognitive-behavioral to third-generation behaviorism. “What a person does is important, not what he says. The final efficiency, adaptability and plasticity of the psyche are significant. Behavior is primary, a rich inner world is a tool for implementation. Man is a learning cognitive decision-making machine, and this system can be purposefully retrained and tuned. It doesn't matter whether we like our experiences or not, but it does matter whether they are useful or harmful. A rational actor is an optimal winning strategy. It is possible to control your behavior to the full depth and, at will, connect / disconnect from emotions - this is a technical skill.”And so on and so forth. The discourse, I think, is clear in general terms. But if you remove the entire terminological envelope, set aside explanations from cognitive psychology, social neurosciences and biology, then what will remain as the main product? Common sense. Technologized, brought into applied tools, grown into a complex concept, but if we abstract, then in fact, this is a psychotherapy of common sense. Another tradable skill. And, as with all psychotherapy products, it can be boiled down to "well, this is just …" Well, this is just common sense. However, if it were simple, people would not have irrational problems.

This is a pretty niche product. Common sense is, shall we say, very moderately in demand. That is, formally, everyone will agree that the thing is useful, but in reality people can do without it, and nothing. If a rational model is not close to a person, he will not take it, but take it, so he will not use it. If a rational model is close to a person, then he will accept and will apply it. Someone walks by, someone buys, this is normal.

Thus, all psychotherapy in fact comes down to the maintenance of the psyche. Nothing like that is replenished there, which would not have been originally in the device of the machine. A certain share of the population has a request for this, this share is stable and will not change in the foreseeable future. The psychotherapeutic variety of practices fully meets this demand, so no new "modern scientific" methods of psychotherapy can be expected. At the level of an individual client request and an individual person, one may get the impression that finding an effective specialist is an extremely non-trivial task. But at the level of the psy-industry and its work with an array of requests, the system is more or less stable and all incoming requests are processed. Therefore, at the moment there is no need for new psychotherapeutic tools and concepts, all the necessary ones already exist, and the task comes down to how a particular specialist from this set forms his personal "toolbox".

Summarizing. Psychotherapy works reliably, and all studies agree on this. However, its work cannot be explained "from the inside" of psychotherapy, because there is no "single theory" and all directions come from speculative concepts, each of its own. In addition, there is no unity in the understanding of what “works” means, because they all declare about the same thing, but when it comes to concretization, it turns out that people understand different things by “result”. It may be “the ultimate efficiency and adaptability of the psyche”, it may be “subjective satisfaction with the quality of life”, it may be “the absence of uncomfortable and unpleasant emotional experiences”, there may be something else. And these are not synonyms. A very effective psyche may or may not experience various negative experiences. A person who avoids any discomfort and experiences mostly positive emotions can be extremely maladaptive and ineffective at the same time. Etc. These gaps and lack of transparency in understanding create the impression that "the matter is dark and confusing." But if you look "from above", from a certain meta-position, the situation becomes clearer and ceases to be so mysterious. Of course, I am far from the opinion that I finally understand how this machine works. The topic requires additional study. Author: Pavel Beschastnov