Psychotherapy and the psychological concepts on which it is based use a
different language, a different notion of norm, and different methods of
intervention and treatment, with goals and objectives that are rather
different from those of psychiatry.
Although each of the main branches of psychotherapy — psychodynamic,
humanistic, and cognitive-behavioral, — employs its own terminology,
intervention methods, and goal-setting, still the main instrument of
treatment and achieving changes (results) in psychotherapy is the
interaction between the patient and the psychotherapist.
As an overview of psychotherapy in general, the tasks of a
psychotherapist of any of the main branches are as follows, in
sequential order:
During the first stage of their interactions with patients, it is very
important, both for psychiatrists and psychotherapists, to create the
kind of environment where patients are willing to reveal their inner
experiences (feelings, emotions, and thoughts), and to get involved in
the external dialogue. The next stage, however, demonstrates significant
differences in practices. While interacting with their patients,
psychiatrists examine their emotional experience only looking for the
information that is required for placing them (patients) as observation
objects and carriers of certain symptoms into specific diagnostic
categories that facilitate choosing the right biological treatment. In
the process, psychiatrists disregard everything (certain complaints,
emotional experience, beliefs, behavior, and speech peculiarities) which
does not meet this goal. In such circumstances, it becomes
psychiatrists’ priority to guarantee maximal objectivity by retaining
pure scientific observer status. Emotional over-involvement in
patient–psychiatrist conversation on either part may hinder the
fulfillment of the task. Therefore, the conversation is structured to
minimize such involvement (just enough for patients to reveal their
emotional experience relevant for the task of psychiatric diagnostics).
Psychotherapists, on the other hand, aim to create safe conditions for
maximizing their patients’ emotional involvement (including their
innermost emotions, feelings, and thoughts) in the external dialogue.
This is the only way psychotherapists can succeed. It is important,
therefore, for psychotherapists to be emotionally involved in the
dialogue with their patients, while at the same time achieving a balance
between empathizing with their clients (that is, staying emotionally
involved) and retaining a certain distance appropriate for a scientific
observer. Thus, apart from the initial stage of
interaction with their patients, psychiatrists and psychotherapists
greatly differ in their goals, process structuring, focus of attention,
terminology, and even their position in conversation with their clients.
To summarize, psychotherapy employs a special process modality differing
in quality from that used in psychiatry.
In different fields of psychotherapy, the “impartial observer –
emotionally involved participant” ratio may vary. Cognitive-behavioral
psychotherapy, for instance, may require less emotional involvement on
the specialists’ part; nevertheless, to achieve therapeutic success, it
should be still deeper than in psychiatry. Postulated neutrality of the
analysts’ attitude during psychoanalysis implies that they will refrain
from injudicious and impulsive emotional disclosure and expressing
(acting out) of their own emotions and desires in their actions and
behavior, including interpretations; it does not, however, mean complete
emotional detachment. On the contrary, emotions and feelings
psychoanalists experience during their interaction with analysands serve
as indispensible tools for dealing with their patients and understanding
what is going on in their minds. All that requires from psychoanalysts
relatively deep involvement in psychotherapist–patient interaction
while maintaining a balance between such involvement and impartial
observation. This setup is also typical of humanistic psychotherapy.
Whichever methods psychotherapists might use, the main change agents in
psychotherapy, according to a number of authors, are relations
established between psychotherapists and their patients (Bugental, J. F.
T.; 1987, Kohut, H., 1971; Rogers, C. R., 1951; Stolorow, R. D.,
Brandchaft, B., Atwood, G. E., 2000; Yalom, I.D., 1995). If this is the
case, in order to be effective, psychotherapists cannot act simply as
outside experts observing with detachment the independent
object-patients whose state and behavior they logically analyze and
divide into separate units. The focus on relations is more pronounced in
humanistic and psychodynamic therapy; still, cognitive-behavioral
psychotherapy concentrates on dysfunctional interpretation patterns
(cognitive errors, dysfunctional basic beliefs) manifested in automatic
thoughts — patterns which are actual characteristics and properties of
patients’ relations with their environment and their attitude toward
themselves, rather than properties and characteristics of patients as
objects in themselves (Beck, J. S., 2011). A number of studies have
demonstrated that the most effective and successful interventions
employed by cognitive-behavioral psychotherapists (according to
psychotherapists’ own accounts and demonstrated by objective
observation) had pronounced interpersonal focus and placed emphasis on
the psychotherapist–patient relationship (Jones, E. E., Pulos, S. M.,
1993; Milton, J., 2001; Wiser, S., Goldfried, M., 1996).
Therefore, in order to successfully navigate the psychotherapy process,
clinics should be provided with a diagnostic system describing
characteristics of psychotherapist–patient interactions, not just a set
of patients’ internal characteristics (traits) regarding a patient as an
observation object entirely independent and detached from the observer.
That system should correlate the psychotherapist–patient interaction
characteristics with those of patients’ relationships with other people
and with their own selves. Even assessing the level of personality
organization, such as integrity of self, in clinical practice, a
psychotherapist largely draws on consistency/inconsistency, on
cohesion/incohesion in the patient’s communication with him, on
compliance of the patient’s communication patterns with the accepted
cultural “normal” ones, and on the extent of his involvement in
communication. That is why the notion of norm and the grades of
deviation from it for psychotherapy clinic practice convenience should
be linked to the characteristics of patients’ relations (with their
therapists, other people and themselves), and not to the characteristics
of patients as “things in themselves”. The goal of psychotherapy
should be defined accordingly: as harmonizing the patients relations
with others and with themselves; as further deepening and developing
these relations until patients are satisfied with them; and maintaining
the flexibility of these relations in adapting to changing life
circumstances and the patients’ demands and needs. All the above
emphasize that whichever psychotherapy is employed, it should consider
patients in terms of interaction and relationships, and not in terms of
object properties and traits. And that requires a special language for
psychotherapy, a language unlike that of psychiatry.