The psychotherapeutic approach to mental disorders
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:
  1. To turn the internal dialogue of the patient into an external dialogue with the psychotherapist, either directly (as is done in psychoanalysis, existential psychotherapy, and cognitive behavioral psychotherapy), or indirectly — in the form of the patient’s dialogue with images of internal objects (as may be done in gestalt therapy). In the latter case, such dialogue nevertheless reflects split-off aspects of the psychotherapist–patient dialogue, and the images of internal objects in fact form transitional objects in this dialogue.
  2. To create safe conditions for involving the patient in that external dialogue and for further developing the patient–psychotherapist relationship, along with mobilizing all the feelings and emotions evolving in the process.
  3. At appropriate moments, the psychotherapist intervenes in order to affect the parameters of the relationship developing in the dialogue and those parameters’ modifications. The moments for intervention are chosen in the process of monitoring those parameters. The relation parameters the psychotherapist focuses on vary according to the type of psychotherapy employed. For instance, psychoanalysis will regard resistance/psychological defense mechanisms as well as dynamics of transference/countertransference relations (Greenson, R.R., 1967) (which also helps reach a conclusion about the level of personality organization: neurotic, borderline, or psychotic (Kernberg, O., 1967)); humanistic psychotherapy will concentrate on the ways patients avoid authentic, meaningful contact with their psychotherapists in the “here and now” situation (ways of interrupting contact cycle in Gestalt therapy (Perls, F. S., Hefferline, R., Goodman, P., 1951)), along with congruence/incongruence (Bugental, J. F. T., 1987; Rogers, C. R., 1951); cognitive-behavioral psychotherapy will consider cognitive distortions as well as all the stimuli triggering and reinforcing patients’ problem behavior (Beck, J. S., 2011). Successful interventions and modifications of the above-mentioned parameters (in the case of successful psychotherapy) would result in developing more constructive relations in the psychiatrist–patient dialogue.
  4. Psychotherapists facilitate the patient’s eventual departure from the psychotherapist–patient relationship (from the psychoanalytical standpoint, “transference neurosis” is resolved (Greenson, R.R., 1967)). At the same time, relations modified in the process of the psychotherapist–patient dialogue become internalized, which leads to a more productive attitude of patients toward themselves (in terms of psychoanalysis, there are changes in the ego psychic structures, derived from object relations, that is, internal self and object representations, along with super-ego modification (Kernberg, O., 1966); according to E. Erikson, the patient’s sense of ego identity changes (Erikson, E. H., 1950); in H. Kohut’s opinion, patients develop a strong, cohesive sense of self (Kohut, H., 1971)), and patients’ attitudes towards other people and their environments become different, too. This is what strategic psychotherapy refers to as second-order change (Nardone, G., Watzlawick, P., 1993). Psychotherapy is thus completed.
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.