How Psychotherapy Really works - When and If It Does
by Robert Langs, M.D.
I want to offer the first of two essays that will deal candidly with how therapy works and what therapy can and cannot accomplish. The communicative approach, with its method of trigger decoding, has revealed some remarkable and unexpected findings in this regard. These insights provide a far more realistic picture of the intricacies of the therapeutic experience than the idealized and unrealistic view generated through other approaches. What, then, are the factors that account for how therapy actually works?
The Simple Answer:
Therapists working with a strikingly wide variety of therapy forms have staked strong claims for the healing powers of their particular endeavors. One of the most striking features of these claims is the extent to which the principles and techniques used in one healing modality stand opposed and contradictory to other forms of therapy in use by therapists of a different mind. For example, one method speaks for confrontation and insight, another for psychological training and conditioning, while another makes use of paradoxical interventions in which therapists say the very opposite of what they mean to convey to the patient.
How, then, can there be 350 different ways of repairing psychological or emotional damage, each claiming a notable degree of success? Naïve efforts to resolve this dilemma speak for the broad healing powers of a so-called therapeutic alliance between patient and therapist, and for the seemingly universal healing effects of a positive, concerned, and dedicated attitude of the therapist-the idea is that a caring attitude, no matter how it is conveyed, does the job of therapy.
This type of thinking is not only simplistic, it also is superficial to an extent that seriously underestimates the complexity of the human mind and ignores the powerful effects of unconscious processes on all emotional transactions. The truth in regard to therapeutic healing-if it does indeed occur-must be far more profound than these statements indicate.
Some Basic Problems
The first question that needs to be asked is this: To what extent do these diverse forms of therapy actually help their clients or patients?
To answer in principle (i.e., without exploring the data, which are, in any case, quite suspect; see below): first, there are comparative studies that suggest that regardless of how a patient is treated, about 65% show some improvement. Second, there are studies that show that a particular mode of therapy-usually the type favored by the researchers-produces results that are better than those seen in untreated patients. And third, there are a large number of psychotherapy outcome studies, mostly in the form of questionnaires given to patients, their therapists and relatives-questionnaires that have been prepared by people who are committed to a given treatment approach. With few exceptions, this method indicates that the mode of therapy in question has led to notable improvement in the symptomatology of the patient. How, then, are we to understand these broad, positive results?
I shall answer based on explorations using the communicative approach with patients who have had prior therapies and with supervised cases, as well as an in-depth interview study designed to explore this very issue (Langs, ). This work takes into account not only patients’ conscious responses to therapy (the usual level of study), but also their unconscious (encoded) assessment of the treatment that they have received. The communicative approach has shown that conscious evaluations of a therapy experience is almost totally unreliable because the conscious mind is basically inclined to deny poor therapy results (negative conscious assessments of therapy tend to emerge only when the therapy has failed badly and the patient has been severely traumatized-and even then, denial of harm may prevail). As a result, the damaging aspects of personal therapy are obliterated consciously (although they do appear in patients’ encoded stories-the deep unconscious mind does not share in this type of denial).
Four other factors promote the use of denial in assessing one’s own therapy. First, there is a strong tendency-and it may exist either or both consciously and unconsciously-in patients to over-idealize their therapists, who are the heirs to the auras surrounding shamans, priests, rabbis and other mystical and religious figures. Second, there is the guilt that plague all patients-some of it consciously, but much of it unconsciously-that prompts them to seek, stay with, and erroneously believe that they have been helped by, harmful therapists. It is this need to suffer-to be punished-that plays a role here. Indeed, some patients find temporary relief in these situations because of the punishment and harm meted out by their therapists-an ounce of suffering brings a few days of relief.
Third, except for the communicative approach, all present-day forms of therapy fundamentally operate as modes of treatment whose interventions and underlying theories and beliefs deny the inevitability of death and the existential death anxieties that this prospect evokes in all humans-patients and therapists included. It is this denial function that prompts patients to feel better for a while, although the cost in unrecognized pain to self and others is enormous. It can be fairly stated that Freudian psychoanalysis and its later-day off-shoots is an interpersonal, sexual, focus-on-the-past denial-of-death system, while Jungian psychoanalysis is a religious denial-of-death system.
Fourth, the questionnaires used in these studies tend to measure superficial traits and to overlook deep personality features. They focus on easily modified attitudes and surface symptoms, but seldom touch on dysfunctional enduring traits. In addition, patients who report symptom relief in one sphere of functioning typically fail to recognize those aspects of their symptoms that have not changed to any notable extent. They also either completely overlook the appearance of fresh symptoms that have replaced those that have been ameliorated, or if they do recognize a new symptom, they do not hold their therapies and therapists accountable for them. These were extremely consistent findings in the interview study of patients who had completed one or more therapy experiences.
Standard Theory/Mythology
Despite the lack of definitive information (data, validated observations, and such), there is a standard, analytically-oriented, general answer to the question of what factors account for healing in therapy. It is long on theory and short on substantial data, but generally accepted nevertheless. It is well to note again that all forms of therapy assume that they can constructively affect emotional dysfunctions or maladaptations-in plain language, emotionally-derived symptoms like anxiety, depression and interpersonal difficulties. These changes are thought of as symptom relief, enhancement of ego functioning such as controls, relating, drive management, capacity for delay-also referred to positive structural change which includes a lessening of the severity of the superego or conscience, and a diminution of pathological sexual and aggressive drives. The highly abstract qualities of these ideas render them virtually impossible to define consensually and clinically-put the other way around, they allow for completely arbitrary claims of cure. As I will show, there are many reasons to question this entire line of thought.
There are three basic ways in which therapies are said to bring about these purported changes. These are: (1) Insight into the unconscious factors and meanings that underlie a particular emotional symptom; (2) Identification with, or the introjection of positive features of, the well functioning (by naïve assumption) therapist; and (3) Benefits from the interpersonal transactions with the again assumed healthy healer.
Absent from this work is a study of the details of daily sessions in which, most importantly, the vicissitudes of deep unconscious perception and experience are taken into account.
For the moment, then, I’ve established the highly idealized standard view of cure, one that renders the belief a patient has achieved symptom relief - to a large degree in the eyes of the patient and to any extreme degree in the eyes of the therapist or analyst who is or has treated the patient. In next month’s essay I will present an extensive communicative critique of the prevailing viewpoints and offer a much revised series of communicatively oriented ideas that come closer to some of the basic ways relief is achieved in the many forms of psychotherapy and some skeptical questions about just how often this relief genuinely arises.
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