Psychotherapy: How to Steer a Course for Success

Psychotherapy can be frustrating. It may begin with a motivated patient and an eager therapist, only to unexpectedly lose momentum. The patient’s enthusiasm wanes, and the therapist feels increasingly ineffective. Unproductive sessions are followed by canceled or missed appointments. Lack of forward progress leads to a stubborn treatment impasse. The patient may drop out or remain in an interminable, static dependency. These failed cases almost always reflect inadequate or absent treatment planning.

Contrast these adverse outcomes with the observation that, early on, some patients, perhaps half, improve without any apparent contribution from the therapist. (Some patients even report these “remissions” while on a waiting list!) The placebo effect and nonspecific factors—a supportive relationship, mobilized affect, cognitive structure—account for most of this progress. The timely easing of environmental stress and the natural history of the disorder may also contribute to these “spontaneous” recoveries. If the effectiveness of psychotherapy is to be measured by outcomes, these improvements, which are independent of the therapist’s interventions, obscure the data and question the value of psychotherapy. Worse, they suggest that even an inept therapist can achieve a 50 percent success rate. The challenge to a skilled therapist is to help every willing patient: 100 percent or as close to it as possible.

In today’s mental health care landscape, with its emphasis on cost containment and the intrusion of third parties into the clinical setting, psychotherapists are under increasing pressure to deliver efficient and time-limited results. Early termination and spontaneous remission may gladden the hearts (if, indeed, they have hearts) and help fill the pockets of third parties, but these unplanned, short-lived encounters leave the psychotherapist dissatisfied, self-doubting, and vulnerable to burnout.

An outcome that benefits the patient and satisfies the therapist requires an effective, “top-down” treatment plan. It will first designate the optimal result; second, delineate the objectives needed to achieve it; then select the best psychotherapeutic modality; and last, anticipate the necessary techniques. Elsewhere, I have labeled this hierarchy as the AIM (the desired outcome), the GOALS (the enabling steps), the STRATEGIES (the selected therapies), and the TACTICS (the tools each modality provides) that comprise a completed treatment plan. If the top-down approach was a car trip, it would first determine its final destination; then identify the intermediate waypoints; next, select the best routes; and, once under way, use tools like traction control and GPS navigation.

By contrast, unplanned or poorly planned treatment exemplifies a “bottom-up” approach. Bottom-up therapy begins without a determined outcome. It lacks clear treatment objectives and relies on the “usual and customary” therapy. It focuses technique only on immediate concerns.

Bottom-up therapists take an opportunistic approach and focus on day-to-day problems. Any squeaky symptom gets the therapeutic grease. They choose an intervention—medication, interpretation, support, advice, instruction—in response to the latest complaint. The bottom-up car trip would begin by tapping the fuel gauge and kicking the tires. It would head off in whatever direction seemed promising. It might stop halfway to change the oil or adjust the brakes. It would alter course each time a new landmark appeared. Whether this haphazard excursion reached its destination, or any destination, would be a matter of chance.

An effective treatment plan emerges from a thorough assessment of the patient’s needs and wants. Next, a formulation with cause-and-effect statements generates an initial hypothesis for the question: why does this patient have these problems at this time? The answer determines the best therapy outcome and the goals, strategies, and tactics needed. Patient and therapist must then reach agreement and forge a therapeutic contract. Instead of a hopeful reliance on spontaneous recovery, planned treatment seeks targeted improvement through active collaboration.

Treatment planning is a high-yield investment. A good plan supports the working alliance between patient and therapist. It promotes efficiency and effectiveness. It avoids therapeutic impasses and patient dropouts. It facilitates a successful outcome. It helps satisfy third-party demands. Patients benefit from better results, and therapists experience greater satisfaction with their work. ■