My Approach to Psychotherapy

At the end of the semester in my psychotherapy course, I asked my students to develop an essay describing their theoretical approach and how it informs their work. This year, I decided to write one myself and figured I would share it here, as readers might be interested to hear how a clinician who operates from a more integrative/unified way thinks about the work of psychotherapy.

My approach to psychotherapy is grounded in a new unified approach to the science of psychology that assimilates and integrates key insights from the major approaches (e.g., CBT, humanistic, psychodynamic) into a more coherent whole (Henriques, 2011). My frame provides the lens by which I listen to and organize the narratives and presenting problems of my clients. It further orients me to attend to particular themes and issues, which in turn lead me to hypothesize about particular developmental etiological pathways and guide me to consider potential treatment goals and desired outcomes that will come to frame the work as it progresses. In terms of locating my theoretical orientation in the context of the field, it can be thought of as a new wave in the psychotherapy integration movement, that of unified psychotherapy (see here).

People enter into psychotherapy to reduce suffering and to enhance their well-being. Such suffering is often the function of psychopathology, which can be characterized as maladaptive patterns of thoughts, feelings, and actions in a relational context. I consider psychotherapy as the process of entering into a professional relationship with a clinician trained in applying the science and art of professional psychology toward reducing such maladaptive patterns and fostering well-being.

I am informed by the scientific research about what works in psychotherapy, and consider one of the central evidence-based principles the key role of the therapeutic alliance. The therapeutic alliance is itself formed by three related, but also somewhat separate elements. The first element is the quality of the relationship; its levels of warmth, trust, and degree of mutual respect. According to the unified approach, one of the most basic needs humans have is the need for relational value, and many individuals lack the basic experience of being valued for who they are. Thus, for some, the mere experience of being valued can have healing properties. In addition, individuals filter their thoughts, both publicly and from themselves, especially if they feel disconnected or judged by others. As such, to get a clear and full picture of the presenting dynamics, it is crucial to have a relationship that is intimate, open, and honest.

The second element of the therapeutic alliance refers to the conceptualization and the extent to which both the therapist and client together develop an effective working narrative that helps explain the current difficulty and points the way toward more adaptive living. I advocate for a period of therapeutic assessment and consider the initial stages of therapy as “dumping out the pieces of the puzzle” to get a working formulation of the key dynamics. I listen to the client’s story and make inquiries guided by the unified approach to conceptualizing (as laid out here). Specifically, this approach orients me first toward a biopsychosocial conceptualization, in which I gain clues about the individual’s biological functioning, learning and developmental history, and relational and cultural context. I also look to develop a formulation of the individual’s personality functioning and possible useful diagnostic descriptors (i.e., the DSM taxonomy). I am particularly informed by McAdams and Pals (2006) model of personality functioning, and have further elaborated upon it by dividing characteristic adaptations into five separate domains or systems, which are: 1) the Habit System, which refers to daily routines and patterns of action, such as sleep, eating, sexual behavior, and substance use; 2) the Experiential System, which refers to the perceptual-emotional core of consciousness; 3) the Relational System, which refers to core relational needs, deep seated schema of self in relationship to other, and the strategies that individual uses to manage the experience of relational value; 4) the Defensive System, which refers to how the individual manages stress, stressful experiences, engages in experiential avoidance, or rationalizes their actions; and 5) the Justification System, which refers to the individual’s conscious self-narrative, the constellation of language based beliefs and values, and the public and private domains of verbal thought. Crucially, these five domains correspond strongly to major traditions in psychotherapy. The habit domain corresponds to the behavioral tradition, the experiential domain corresponds to the gestalt and neo-humanistic emotion focused tradition, the relational and defensive domains correspond to the psychodynamic tradition and the justification domain corresponds to the cognitive and existential traditions.

The initial portion of the work is to engage the client (or clients) in an in-depth discussion (or even formal assessment process) about relevant domains of functioning to determine if—given the environmental stressors and affordances they face along with the values they have regarding how they want to live—they are engaged in maladaptive patterns that reduces their well-being. This brings me to the last pillar of the alliance, which is developing a shared sense of the tasks of therapy.

There are three broad classes of therapeutic tasks, which I refer to as Awareness, Acceptance, and Change. Awareness refers to bringing into explicit consciousness feelings, frames, or pieces that were hidden and narrating them with the client in a way that clarifies and resonates. In short, a common task of therapy is to know thyself. The model of human consciousness mapped out by the unified approach delineates the three key domains of consciousness and provides a frame for explaining why people often lack insight into their feelings and needs and actions. In addition, the framework provided by the unified approach provides an excellent psycho-educational resource for helping individuals develop more sophisticated vocabularies for understanding the elements that make them up, how they actually function, and why they do what they do.

A second major class of therapeutic tasks falls under the heading of acceptance. Individuals, perhaps especially in modern Western societies, often have problematic--sometimes even phobic--attitudes toward negative feeling states. The problematic attitude they have toward their feelings (their experiential mind) generates experiential avoidance and much concomitant suffering. Learning to accept situations, one’s thought and feelings, and others, and doing so with compassion and grace is one of the great principles of healthy, adaptive living.

Active change is the third class of therapeutic tasks. I am informed here by research lines by specific intervention research and process angles, such as motivational interviewing, stage of change approaches, and the burgeoning literature on “changeology”. The essence of active change is to examine the consequences of one’s actions relative to one’s long term goals and develop more effective strategies for adaptive living. This can take many forms. For example, if someone regularly ruminates and catastrophizes about upcoming events, I might coach them in the use of dysfunctional thought records. If someone over-regulates or denies certain feelings, I might guide them in how to arrive at, narrate and leave strong emotions. If someone gets pulled into vicious relational cycles because they tend to stonewall or get hyper defensive, then I might coach them to be more empathetic or effective in their communication. The literature in psychotherapy is rich with possibilities for effecting change, and my unified approach allows me full access to the available tool box.

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Finally, I recognize the ultimate purpose of psychotherapy is not to conform to my philosophy or to enact some empirically supported treatment per se, but, in accordance with an outcome informed approach, the function of psychotherapy is to effectively move individuals toward their goals of less (unnecessary) suffering, improved functioning, and greater overall fulfillment. As such, I think in terms of the work I do in psychotherapy with my clients as a project we embark on together involving an “N” of one. Feedback, then, from the client regarding the therapeutic relationship, the conceptualization, the tasks, and ultimately whether the therapy is effecting change in the desired way is a final, but crucial, principle of my approach.