REFLECTIONS ON THE ART & PRACTICE OF PSYCHOTHERAPY (Part I)

Mickey Skidmore, AMHSW, ACSW, MACSW

The origins of psychotherapy are easily rooted in Freud’s ground breaking work and his profound contribution to the fields of medicine and psychology. Traditionally, as I understand it one had to undergo and complete their own psychoanalysis before referring to themselves as a psychoanalyst. The aspect of personal and professional growth and development along the lines of Maslow’s self-enlightenment is evident here, but was limited and available largely to the elite, rather than being more readily available to the masses. Eventually it gave way to psychotherapy, where many underpinnings of Freud’s theory remained relevant.

Clinical supervision emphasising principle’s of transference (the redirection to a substitute, [usually the therapist] of emotions originally felt/experienced in childhood) and countertransference (the emotional reaction of the clinician to the client’s contribution) are hallmark principles in psychodynamic theory — and in my view to the underlying process of psychotherapy (or any counselling process) one is drawn to. In my view, countertransference — the feelings a client evokes in me during sessions is without a doubt one of the most valuable non-verbal clues that are experienced during therapy.

The process in psychodynamic psychotherapy sets the stage for clients to delegate (often unconsciously) their unacceptable feelings to a therapist; who holds everything they are afraid (or unable) to feel, and essentially feels or contains it for them. Then, ever so slowly, as trust and rapport deepens, the therapist feeds their feelings back to them. The intention through this process is they can internalise a new kind of relationship with another human being; one based on mutual respect, honesty, and kindness — not recrimination, anger, and violence. From this process they can gradually begin to feel differently inside about themselves — less empty, more capable of feeling, and less afraid.

Psychoanalyst W. R. Bion is credited with the concept of containment, describing a mother’s ability to manage her baby’s pain and discomfort. Remember, babyhood is not a blissful time for the baby. They have been thrust into a alien world, constantly surprised at their bodies, alarmed by hunger and wind and bowel movements, overwhelmed by their feelings. They rely on their mother to soothe their distress and make sense of their experience. In doing so, they gradually learn to manage physical and emotional states on their own. Whether you view this through the lens of developmental, attachment or psychodynamic theories, a child’s ability to contain themselves directly depends on their mother’s ability to contain them initially. Someone who has never learned to contain themself can almost always point to an inadequate or toxic relationship with their mother in their earlier years and are often plagued by anxious feelings of nameless dread for large portions of their life — typically seeking their unconscious desire for unquenchable containment from external sources.

There are parallels in the process of psychodynamic psychotherapy as well. While being receptive to your clients feelings when sitting (in silence) with them, any number of experiences can manifest in the therapist. Awareness of throbbing at the temples — the beginnings of a headache. A telltale symptom. A sudden wave of sadness — the desire to die. This thumping in the head is not the therapist’s pain. The emotional currents of anguish and despair do not belong to the therapist either. We are temporarily feeling it for them — essentially serving as a type of advocate. Crucial to this process is the realisation that the therapist must not hold on to them and facilitate returning them to the client to process and work through.

For some time now, the dominance of psychodynamic theory has faded increasingly to the background. The prominent standard for most professional disciplines today is captured in the catch phrase “evidence based” practice. Perhaps the early criticisms of psychodynamic theory were highlighted in early research that suggested that 50% of clients improved with psychodynamic treatment; and 50% of clients also improved with no treatment at all (by doing nothing). In the 1950’s a fresh model began to emerge offering alternative theoretical understandings based largely on behaviouralism, initially thought of as “contextual” therapy which would eventually lead to what we know as cognitive behavioural therapy (CBT). While there are hundreds of theoretical models or approaches practiced around the world, this essay will largely over simplify the contrast between these two psychodynamic and behavioural models acknowledging that many are somewhere in-between these two methods.

Over the course of my career, I estimate that I may have been exposed or engaged in varying degrees of training with up to 50 theoretical approaches or more. In fact a criteria to maintain my credentials with AASW requires me to undergo new professional development training targeting focused psychological strategies in order to remain fresh and current with the latest frameworks of evidenced based practice. At some point however, from my perspective many of the new or “cutting edge” approaches emerging today are repackaged and updated versions of previously established frameworks.

At face value, the concept of evidence based practice seems reasonable. However, evidence based practice places great value on brief, time-limited, outcomes. Thus, the unspoken yet powerful expectation on progress and improvement emphasises short-term practical approaches over process with little regard whether this is realistic or ultimately useful across the board. The explicit notion of evidence based approaches conveys to clients at the outset that insurance companies (or Medicaid) will not pay for seemingly endless therapy sessions over the years with little evidence of progress or improvement to show for it. Approaches that tout progress in time limited frameworks are favoured over longer term approaches that has underpinnings in a process that is idiosyncratic to a client’s circumstance.

While the dominance of the medical model remains a largely prevalent approach, the medical model tends to keep psychodynamic thinking at bay. Instead it favours a more one dimensional biological, chemical (i.e. medication) model that is largely accepted as a practical approach (after all it is easy to count pills at the end of the day).

On the other hand, CBT is the gold standard for evidenced practice.They were the first social science camp that developed a nomenclature and integrated their framework into a fundamental epidemiological research model enabling them to effectively measure behavioural outcomes in the mental health arena. Today there are more than 500 outcome studies touting the effectiveness of CBT. Moreover, they can cite evidence that this approach can contribute to changing brain chemistry by challenging negative and inaccurate thoughts and altering behaviours enabling an increased tolerance of certain emotions (i.e. anxiety). However, I take issue with some of the assumptions that during times of anxiety that the amygdala may be exaggerating or providing inaccurate information that CBT processes can then aid the client to “ride out the wave of anxiety.” Such explanations fall flat if the amygdala is actually providing accurate information. Thus, while I find CBT can be an effective approach given the right circumstances; its de-emphasis on the importance of history, and the cherry-picked emphasis in bolstering evidenced based research claims leaves this approach feeling less like a comprehensive theoretical model and more like a collection of technique-oriented clinical tools.

For example, a closer examination from a research perspective point out the limits and cherry picking of some of this research. For example, CBT research often does not include clients with complex mental health or cognitive/learning issues. CBT is more present orientated and often does not emphasise issues from the past; nor does it effectively address systemic issues. And it is too difficult (and thus counter-indicated) for some people who have limited resources without first stabilising living and/or social supports. And while it has been proven to be between 60-90% “effective” not everyone gets well — and clearly it is limited to a limited target population.

My professional observation (anecdotal — not evidenced based) during the last 10 years is that psychologist in Australia are largely armed initially with basic CBT training which they attempt to augment by identifying strategies that might prove useful to their clients in concert with CBT principles — and then they send clients on their way (as their 10 session MHCP is exhausted). I have experienced countless stories in my practice of how inept and dissatisfying clients have found this approach. And yet, there remains an entrenched and pervasive belief in the general public as well as in the professional community that psychologists are essentially the only “credible” mental health providers in Australia.

The other observation that pushes my buttons is clients rather frequently ask for “strategies” to address their sadness, anxiety or other presenting concerns. I have spoken about this in previous writings (Skidmore, May 2022) but I will mention it again here. My view is that if you find yourself in a psychotherapist office there is a strong probability that addressing that concern is beyond a request for strategies. In fact, I dare suggest that many would have already attempted this approach (i.e. Google search) and been unsuccessful. Because it likely requires that they undergo a deeper (and probably more meaningful) approach involving a therapeutic process with another human being. Additionally, when you cut through all the junk, when I hear clients ask me for strategies, what I am largely hearing is they want me to tell them what to do — rather than invest in a process to discover something about themselves and come to their own determination about their solution resulting from engaging in a therapeutic process.

The primary goal with psychodynamic psychotherapy is for the therapist to be present and receptive to their feelings as they sit with the client. That’s all that is required. The rest unfolds on its own. While psychodynamic psychotherapy may also not be practical or relatable for many would-be clients, I have come to respect the value of some of its underlying principles. Thus, I believe this fundamental psychodynamic principle may be a crucial and meaningful component for the process of whatever psychotherapy or counselling approach, method or model you may be drawn to or employ in your professional work.

I have come to view the practice of psychotherapy as a craft that requires skill; but a process that is also an art form. Emphasising superficial outcomes on limited population groups; pressing for shorter episodes of care to contain costs rather than employ containment in the clinical sense that recognises the value of an underlying process in the healing experience, I would argue has contributed to diminishing effective psychotherapy treatment in the long run (and making it a hit-or-miss experience for clients in a time where the recognition for mental health services has never been higher). It seems reasonable to acknowledge that there has to be room for limits in this conversation as well. Given that there is somewhere between 300-600 forms of psychotherapy being practiced around the world, I’d like to think that we can achieve some reasonable form of balance that welcomes the practical expectation of evidence based principles while also honouring the fundamental process of such an experience.

REFERENCES

  1. Michaelides, A.  The Silent Patient. Copyright  2019 by Astramare Limited for Celadon Books, New York, NY.
  2. Skidmore, M. Strategies (May 2022).