What Does a Good Therapist Do Every Day?
One characteristic of psychotherapy sessions can make a big difference
Posted July 31, 2019
In the early 1950s, a psychologist named Albert Ellis set out to re-define the practice of psychotherapy. Like most psychologists of his time, he initially embraced psychoanalysis. But he became rapidly dissatisfied with multiple aspects of it. One of his concerns was the passivity of psychoanalysis. Ellis’ new method, in contrast, was to help patients not only understand how their beliefs affected them but to help them act on their understandings.
One of the techniques in Ellis’ method was having the therapist provide more structure to the sessions. This was a radical departure from the tradition of psychoanalysis. It differed in regards to the speed of moving to solutions and the partiality of the therapist. His rational emotive behavioral therapy is considered the first cognitive-behavioral therapy (CBT).
Shortly thereafter, in the early 1960s, a psychiatrist named Aaron Beck set out on a similar path. Beck was intrigued by the streams of automatic negative thoughts in his depressed patients. His concern was that traditional psychoanalytic interpretations, which related these thoughts to sexual impulses or desires to seek failure, were wrong. Beck emphasized the importance of different kinds of core beliefs about oneself and the world. Influenced in part by Ellis’ work, Beck developed his own form of CBT that was active in helping patients evaluate and restructure these thoughts.
Ellis and Beck had in common that they were dissatisfied with the business as usual of the passive impartiality of the psychoanalyst. Those who followed them experimented with even more structure and more directiveness. There are now hundreds of structured protocols or step-by-step manuals for nearly every psychiatric problem.
Ellis and Beck helped create a shift in the practice of psychotherapy. They succeeded in part because they made the simple realization that patients come to psychotherapists because they want expertise. They want someone to structure the path of discovery. If the patients knew how to get there on their own, they would have done it already.
The structure represents the idea that clinicians have expertise. A mind is a complicated place. It is cunning and it hides the unconscious from the conscious. It is designed to deceive ourselves, so as to better deceive others (Trivers, 2011). Allowing a patient to participate in therapy every week without structure, and letting them decide nearly everything about the content and process of exploration is inefficient, and a waste of their time and money. Yet that is exactly how much of psychotherapy is still practiced. Patients come to my clinics regularly because they have left their previous therapists in search of more structure.
When Ellis, Beck, and the other pioneers of the directive and structured psychotherapies first showed that their new therapies worked, it must have seemed a given that if there were new methods that worked better, faster, and could be more easily disseminated amongst therapists, they would spread to every therapist. But the idea of the structure has not stuck with many therapists. In fact, in light of the dismal reports on the efforts to disseminate evidence-based treatments (EBT), it appears that the majority of therapists do not employ EBTs.
Structure is vital to the EBT protocols, but it is not just for EBT protocols. For the Fixer-Uppers (see my last post) who are sorting through temporary life problems, the structure is needed to focus on maladaptive habits and help them point in the right direction. For those on the path of Enlightenment to uncover the unconscious, structure is needed to use the appropriate techniques and provide accurate interpretations. Even for the Blamers, who have limited capacity for insight into their pattern of behaviors, structure is needed to give them constructive feedback about what is possible and what is not.
The Slipperiness of Structure
Structure turns out to be difficult to provide in many psychotherapy situations. Some of the concerns of therapists include that providing structure will appear patronizing or demeaning to patients. Some patients are inherently tangential and resist linear discussions. Patients who are introverted or extroverted present unique challenges. Others may have controlling personalities, oppositional streaks, or unconscious conflicts that actively work to derail any attempts at structure. For trauma survivors with PTSD, structure is uniquely important because avoidance to talk about the traumatic events is part of the syndrome. A good therapist knows the difference bertween when patients need more structure and when they need less. A great therapist can actually provide the structure without it feeling patronizing, simplistic, or demeaning.
The effective implementation of structure is a function of therapist skill, and I think the main challenge for therapists in terms of providing structure is the risk of being disliked. Therapists are people who by their nature are highly sensitive to interpersonal status with others; that is part of what makes them good therapists. This strength, however, in excess is their weakness. The lesson of structure is that patients need it, and most want it. Therapists need it, but many lose their grip on it.
Robert Trivers (2011). The Folly of Fools: The Logic of Deceit and Self-Deception in Human Life. New York: Basic Books.