Therapeutic Factors in Psychotherapy

The field of psychotherapy seems more chaotic today than ever. For many decades psychoanalysis and its modifications dominated the therapeutic scene and conflicting claims were confined to proponents of variants of dyadic interview therapy growing out of the theories of Freud, his disciples, and his opponents. Then group therapies entered the picture, also dominated for a long while by psychoanalytic thinking, although many were influenced from the beginning by the theories and methods of Moreno. Recently group methods have exploded into a kaleidoscopic and still expanding spectrum that defies any simple classification. Concomitant with this development, psychologists have introduced a growing repertory of behavior therapies based on the work of Pavlov and Skinner. Finally, abreaction in various guises is being vigorously promulgated by new therapeutic schools. The explosion of psychotherapeutic methods has been accompanied by a proliferation of healers with all types of training, or even none at all.

Research efforts to clarify the principles and modes of effectiveness of some of these approaches have also expanded but, as always, they have not begun to keep pace with the innovations of practitioners, each of whom is no less insistent than his forebears that his particular method surpasses all others.

The bulk of the clinical and research literature on psychotherapy has focused on detailed analysis of different methods or on the relative effectiveness of their outcomes. In both cases the center of attention has been features which distinguish the particular therapy under study from other therapies. Features which all therapies share have been relatively neglected, since little glory derives from showing that the particular method which one has mastered with so much effort may be indistinguishable from other methods in its effects.

My own preoccupation has been an effort to isolate features of the psychotherapeutic relationship and the context of the therapeutic situation common to all forms of psychotherapy which may contribute to their success. Once the part played by these shared features has been identified, we may be better able to determine the differential effects of different techniques with different types of patients. Today I should like to approach this question from an historical and cultural perspective.

A brief historical overview of Western psychotherapy since Freud highlights two points. The first is that the dominant psychotherapeutic approach of an era reflects the cultural attitudes of its time and place; the second, that the same techniques keep recurring under different guises, suggesting that, despite their superficial differences, they all may be variations on a few underlying themes.

Freud developed psychoanalysis, the fountainhead of Western psychotherapy, within a competitive culture which placed a high value on individual integrity and achievement. Its ideal person would be an inner-directed one, guided by high moral principles, striving for success, and resistant to social pressures that might lead him to violate his principles and ideals. Such a person would be fearful of too much openness. For one thing, it might give others knowledge of his weaknesses which they could then exploit to their own advantage. Furthermore, if he allowed himself to become too concerned with the welfare of others, this might hamper him in achieving his own goals, which necessarily involved hindering others from reaching theirs.

His success depended on his maintaining a righteous, self-confident façade, which required denying or suppressing inner impulses that, if admitted to consciousness, could create self-doubts. Freud postulated that self-deception and repression of unacceptable impulses and feelings were major sources of psychic distress, disturbances in intimate relationships, and poor work performance.

The family structure of Freud’s society was authoritarian and intimacies were confined within the family circle, but openness was unilateral, not mutual. The child was expected to have no secrets from his parents, but not the reverse.

A form of therapy modeled on this pattern of child-parent relationship, that aimed to help the patient become more accepting of his hidden feelings so that he could drop his façade and thus become more successful in both love and work, and one, furthermore, that was conducted in the strictest privacy, would be fully in keeping with Freud’s cultural setting as a member of a Western industrial society. (For completeness, one would have to add, as Bakan has shown [1], that much of psychoanalysis also derives from Freud’s Jewish heritage, but that would lead too far afield.)

Psychoanalysis also accorded well with the nineteenth-century faith in science as holding the solution to all problems, a belief which Freud, as a medical scientist, fully shared. He insisted that the information about the patient’s past revealed by psychoanalysis had the status of scientific fact because it was elicited by an impartial, trained observer, the psychoanalyst. We now know, of course, that this was to some extent erroneous, because the patient’s productions are so strongly influenced by the analyst’s expectations. But the scientific method is not the only path to truth, and there is no doubt that, with all its sources of error, psychoanalysis has greatly increased our knowledge of human nature.

As a cultural offshoot of Europe, with more stress on competition and a greater faith in science, America was highly sympathetic to both the goals and scientific pretensions of psychoanalysis, so that it was readily transplanted to American soil.

Two distinctive features of American society, however, contributed to new developments—its pragmatism and its gregariousness. The pragmatic outlook is action-oriented, therefore sympathetic to attempts to modify feelings and behavior by direct assault rather than through the leisurely, roundabout way of free association, leading to the still mushrooming growth of so-called behavior therapies. Like psychoanalysts, proponents of these methods claim them to be scientific, often with some justification. Behavioral phenomena can be counted and measured, so goals and outcomes of behavior therapy can be stated with far more specificity and objectivity than those of psychoanalysis. But it must be remembered that, despite the name, many behavior therapies rely heavily on the patient’s imagery and fantasies, which cannot be measured directly, and their theoretical underpinning seldom is as rigorous as it appears. I concur with those behavior therapists who maintain that the central contribution of behavior therapy is methodological (2). All forms force the therapist to make specific predictions and modify his own behavior in accordance with the outcome. This encourages flexibility of approach, permits the formulation of questions that are amenable to precise research, and makes possible experimentation with a single case, leading to real gains in knowledge of the limitations of behavior therapies as well as the sources and nature of their therapeutic effects.

The second relevant feature of American culture, as contrasted with European, is its greater gregariousness, which may be related to the popularity of group therapies. Gregariousness has always existed along with, and to some extent has ameliorated, the American stress on competitiveness and individualism. The isolation and hardships of frontier life, for example, were periodically relieved by religious revival meetings, characterized by intense emotional outbursts, public confession of sins and, for many participants, intimate sexual activities.

American sociability, however, too often is the servant of competitiveness rather than a genuine expression of liking for others. While nineteenth-century Western man had to maintain a mask of righteousness, his modern counterpart, at least in America, feels impelled to wear one of affability, behind which may lurk considerable hostility and suspiciousness. To get ahead, one must be likable; so the need to be liked has replaced the need to appear righteous as an important source of inner conflicts.

With the increasing complexity and interdependence of modern life, a value system holding that the good of society as a whole emerges from the free competition of its members in pursuit of their individual goals is proving to be increasingly inappropriate. As a result, more and more Americans question the goal of worldly success and seek instead, among other aims, enhanced capacity to give and receive genuine affection, often through participation in groups.

Another cultural contributor to the popularity of group therapies, itself probably a response to the hunger for greater intimacy, has been the emphasis in mass media, and especially TV, on revelation of intimate details of personal lives. An extreme manifestation of this trend has been the broadcasting of live group therapy sessions over national networks.

Privacy in some circles has become almost a vice. To quote Dr. Ross Speck, the originator of network therapy: “Many individuals who would not consider going to private or individual treatment are quite willing to discuss their problems in the presence of members of the immediate social field” (3).

Network therapy involves inclusion not only of the patient’s family but neighbors and friends, and Speck points out its similarity to tribal healing rituals in which the extended family, and usually other members of the tribe, join to heal a sick member by participating with him in time- and energy-consuming rites that stress mutual confession and mutual aid, conducted by a healer and his acolytes (4).

The newer group approaches, however, reflect more than a hunger for honest, intimate relationships to combat the sense of isolation behind false affability. They also may be responses to other stressful characteristics of American society. These include bureaucratization with its fragmentation of persons into roles, a sense of dislocation from the past because of rapid changes in the conditions of life, and the widespread suspicion that Science may be a false god luring mankind to destruction.

The result of these forces is a weakening of the sense of identity coupled with pessimism about the future. To combat identity diffusion and despair many are turning away from the outer world to explore the inner one, through two apparently opposed routes. One involves immersion in the present and search for revelations about oneself through highly charged emotional interactions with others. This route is typified by marathon groups, about which one commentator has remarked: “The frenetic liaison comes to stand as the acme of interpersonal achievement” (5). The other path involves detachment from the outer world altogether and looking inward, with or without the help of drugs, for new experiences that will give meaning to life. This is the age-old route of mysticism. It, too, be it noted, often involves participation in group exercises, as in Zen.

These activities still embody the nineteenth-century therapeutic goal of discarding one’s mask, in the hope of gaining greater self-awareness and more rewarding relationships with others. They have abandoned the goal of enhanced ability to work, which is no longer essential in an affluent society and which plays into competitiveness and careerism. With this, however, often goes also a rejection of the values of self-discipline and long-term responsibility for the welfare of others. (Members of marathon groups may be deeply involved in each other’s troubles during the life of the group, but not afterwards.)

A new form of group approach which accepts the newer values while integrating them with more traditional ones may be exemplified by Synanon, which started exclusively as a treatment for drug addicts but now has expanded into a commune that also appeals to many other Americans searching for a more satisfying life. Interestingly, it embodies principles that must date back to antiquity. Thus it resembles monastic orders of the Middle Ages in many ways. Many obstacles are placed in the way of the applicant, who must convince the group of his complete sincerity. Furthermore, just as the applicant to a monastery had to declare himself to be a poor miserable sinner, the applicant to Synanon must admit that he is a drug fiend. In both situations the applicant gives up all or a substantial portion of his personal property to the Order. He then undergoes a long period as a novitiate in which he starts with the most menial tasks and gradually works his way up to better ones and to positions of increasing responsibility. The Order gives him food, lodging, clothing, and a little pocket money. If he is able to work, he turns over the proceeds.

Although the Order itself is wealthy, its members must remain poor. Thus reimbursements to members for their work start at $1.00 a week, eventually reaching a maximum of only $50.00 a month. Finally, the activities of the Order include frequent group exercises, designed to intensify group pressures on the individual and to imbue him with its ideology. In monasteries there were many hours of rituals and prayers; in Synanon the “game” goes on virtually continuously.

The efforts of encounter groups to stir their members emotionally is paralleled in dyadic therapy by the revival of interest in emotional abreaction. The arousal of intense emotions has always characterized healing rituals in a religious context and played a large part in Mesmerism, the precursor of modern psychotherapy. Its rediscovery by Freud is not as easily traced to cultural influences as some other features of psychoanalysis, but seems to have been the result of his ability to grasp the therapeutic potential of an unexpected occurrence in therapy. Initially, he viewed it as the essence of psychoanalysis. Then it gradually receded in interest, except for a few hypnotherapists (6) and mavericks like Wilhelm Reich. Possibly this was because it ran counter to the values of a science-worshipping culture. Nothing is less appealing to the scientific mentality than uncontrolled emotion. In any case, the same disenchantment with science, coupled with the search for intense experiences that have fostered encounter groups, may also be related to the sudden re-emergence of therapies devoted to producing abreactions, among them implosion therapy (7), primal scream therapy (8), and re-evaluation counseling (9).

In short, in psychotherapy, as in so many other fields, it appears that there is nothing new under the sun. Innovations that at first glance seem revolutionary turn out to be modified applications of newly rediscovered principles of learning and healing. Behavior therapies systematically use modeling, reward, and punishment, and extinguishing of fears through repeated exposure to the feared situation in the absence of reinforcement. New methods of facilitating emotional release, and thereby resolving pathologic feeling states, are variants of abreaction; while most, if not all, of the novel methods of encounter groups are ingenious applications of well-established principles of learning, of abreaction, and of the utilization of group pressures to change the attitudes of group members. Some of these techniques will probably become permanent additions to the psychotherapeutic armamentarium, but their apparent novelty should not be permitted to obscure their shared features or their historical origins.

The facts that the prevalent method of psychotherapy in any given era is strongly influenced by the prevailing cultural standards and values, that no one method has succeeded in eliminating its rivals and that many forms of contemporary treatment embody rediscoveries of age-old healing principles, all suggest that features common to all forms of treatment contribute importantly to their effectiveness. The same conclusion is implied by the fact that choice of therapeutic method still depends largely on the personal predilection of the therapist.

I believe the following six features are common to all psychotherapies.

1. An intense, emotionally charged, confiding relationship with a helping person, often with the participation of a group.

2. A rationale, or myth, which includes an explanation of the cause of the patient’s distress and a method for relieving it. To be effective, the therapeutic myth must be compatible with the cultural world-view shared by patient and therapist. The hypothesis that all mental illnesses, insofar as they are treatable by psychologic means, are products of damaging early life experiences, underlies all Western psychotherapies. Psychotherapies based on it, however, may be ineffective for patients in cultures that attribute mental illness to, for example, spirit possession.

I have used the provocative word “myth” to emphasize that, although many rationales of Western psychotherapies do not invoke supernatural forces, they resemble the myths of primitive ones in that they cannot be shaken by therapeutic failures. That is, they are not subject to disproof.

As one young adherent of a psychotherapeutic school remarked to me: “Even if the patient doesn’t get better, you know you are doing the right thing.” The infallibility of the rationale protects the therapist’s self-esteem against his therapeutic failures. In addition, it provides the powerful emotional support of a like-minded group, whose members may gain further ego-support by viewing themselves as a select few, superior in some respects to ordinary mortals.

Therapists in academic settings seem better able to question their rationales than those in private practice, perhaps because their group identification is with a university and their self-esteem depends primarily on academic recognition and research skills, rather than therapeutic prowess.

By supporting the therapist’s self-confidence, the therapeutic rationale indirectly strengthens the patient’s confidence in him, which is another of its therapeutic functions. In addition, it supplies a conceptual scheme for making sense of the patient’s symptoms. Since he often views them as nonsensical, which adds to his anxiety, being able to name them and fit them into an overarching conceptualization is in itself powerfully reassuring. The first step to gaining control of any phenomenon is to give it a name.

The techniques based on the rationale, furthermore, serve as the vehicle for transmitting the therapist’s influence—after all, patient and therapist have to do something together, they cannot simply sit and stare at each other. The point is that it may be the functions of the rationale and technique rather than their specific content or form which really count.

3. Provision of new information concerning the nature and sources of the patient’s problems and possible alternative ways of dealing with them. Much of this information probably is gained through self-discovery, but a lot also comes from the therapist and, in therapy groups, from the group members whom the patient uses as models as well as sources of knowledge. In any case, the information is typically formulated in terms of the therapeutic rationale.

4. Strengthening the patient’s expectations of help through the personal qualities of the therapist, enhanced by his status in society and the setting in which he works. Experienced therapists explicitly strengthen the patient’s expectations and tailor them to the therapeutic program in early interviews (10, 11).

Despite their conviction that the effectiveness of behavior therapies depends primarily on specific techniques, experienced behavior therapists recognize that arousal of the patient’s hopes is also important and go to considerable lengths to accomplish it. A group of research psychotherapists who spent five days observing two leading behavior therapists (incidentally, one of the great virtues of the behavior therapists is that they allow their work to be studied by others) state that they were amazed at the amount of suggestion involved during the orientation period.

5. Provision of success experiences which further heighten the patient’s hopes and also enhance his sense of mastery, interpersonal competence or capability, to mention some commonly used terms. The detailed structure of behavior therapies, the objective measures of progress and the emphasis on the patient’s active participation virtually assure that he will experience successes as treatment progresses. Although not as obvious in interview therapies because of their lack of structure and imprecise indices of improvement, the patient experiences success when he gains insights or experiences a new feeling, especially since the therapist characteristically disclaims any attempt to influence him, so he perceives any progress as being due to his own efforts. Insight therapies seem ideally suited to provide success experiences for intelligent, verbally adept persons who rely heavily on words to cope with life. Thus all successful therapies implicitly or explicitly change the patient’s image of himself from a person who is overwhelmed by his symptoms and problems to one who can master them. This goal is explicit in Frankl’s method of paradoxical intention (13).

6. The sixth shared feature of all psychotherapies is facilitation of emotional arousal, which seems to be a prerequisite to attitudinal and behavioral changes. As already mentioned, emotional arousal is receiving renewed emphasis today.

It should be emphasized that the patient-therapist relationship is a necessary, but not sufficient, condition for all the other common features. If the patient distrusts his therapist, he will not accept the therapeutic rationale or listen to the information he receives, nor is he likely to gain hope or experience successes. And any emotions he experiences under these conditions are apt to be ones that drive him out of treatment, such as anger, resentment, and suspicion.

Just as the various methods of therapy have certain features in common, so, too, do their aims. All psychotherapists try to modify the patient’s inner states and his behavior in directions that, it is hoped, will yield him more satisfactions and less distress: in short, they try to change his attitudes. All attitudes have an affective, cognitive, and behavioral component, and therapies differ in which they stress, but all involve all three. Thus behavior therapies by definition concentrate on changing the patient’s behavior, but also rely heavily on manipulating his imagery to change his perception of himself vis-à-vis his symptoms, and some emphasize emotional arousal. Interview therapies have stressed to varying degrees interchange of feelings with the therapist and cognitive reorganization in the form of insight, but all also overtly or covertly try to change the patient’s behavior. Therapies focusing on eliciting abreaction assume that these will yield new insights with corresponding changes in behavior.

Group therapies range over the same spectrum from almost exclusive emphasis on imparting information in didactic groups to the equally exclusive emphasis on feelings of some encounter groups.

To this point I have considered different forms of psychotherapy without reference to the reasons for their existence—the persons whom they seek to help. The implication has been that because of the therapeutic power of their common features, they probably do not differ greatly in their effectiveness with most types of patients. And, indeed, with the exception of a numerically small group of patients, this is probably the case. A review of the types of persons who have sought psychotherapy in the past and seek it today may clarify why this is so.

In the early days of psychoanalysis, those who sought Freud’s help conceived of themselves as being medically ill and were initially seen as such by him. The medical model was if anything strengthened by the subsequent application of psychotherapeutic techniques to schizophrenics, but as understanding of psychiatric disorders increased, it became apparent that life experiences leading to distorted perceptions of the world and defective coping mechanisms contribute to the distress and disability of all psychiatric patients. Later it became clear that the whole range of psychiatric symptoms could be displayed by many persons who were simply reacting to a crisis. Finally, persons who were suffering from a host of malaises which the Germans aptly lumped under the term Weltschmerz (world pain) sought psychotherapy.

Thus today those who come to psychotherapists can be roughly classified into four groups with considerable areas of overlap. The first, to whom I have just referred, contains the legions in today’s confusing world who are struggling with problems of identity, alienation, and what can best be termed existential anxiety. They are searching for new values and experiences accessible to group approaches; others may need the privacy of the dyad.

Some of these patients merge with the first group I described in that their symptoms may reflect existential anxieties as well as damaging early life experiences. Long-term interview therapies embodying an implicit or explicit philosophy of life—for example, freudian psychoanalysis, jungian analytic psychology, Frankl’s logotherapy—may supply the integrating concepts that give these patients a sense of identity and of connectedness to others, so essential to mental health. But this is speculation. When it comes to reasonably well-established facts, desensitization seems to be more effective than interview therapies for circumscribed phobias, aversive conditioning may have a special place in the treatment of some sexual deviations, and token economies can improve the behavior of very regressed hospital patients; but this is the extent of progress to date in fitting techniques to patients.

A major task of research in psychotherapy, so far barely attempted, would be to learn to categorize patients in such a way as to be able to select the most appropriate method of therapy for them. One reason for the slowness of progress toward this goal may be that it is premature. First we need to gain a better understanding of the interactions between patients, therapists, therapeutic settings, and therapeutic rationale that arouse patients’ hopes, provide them with success experiences, arouse them emotionally and offer alternative solutions to their problems. Only as this knowledge is gained may we be able to sort out the specific contributions of different techniques from effects common to them all.