Two Aspects Are Preventing Psychotherapy from Being More Effective
This article proposes that there are two aspects in the current mainstream view of how psychotherapy is understood that are preventing it from advancing as a science and being considerably more effective. One factor is that psychotherapy does not understand its subject matter. It is proposed that the client’s experiencing be recognized as the subject matter of psychotherapy and that it is understood in the following way: (a) it has (until shown otherwise) a psychogenic origin, (b) it is understood in an atheoretical way as all human experience is unique, and (c) a conscious act is not likely to have a significant effect on how it is manifested. The second factor is a fundamental reconceptualization of how catharsis has been historically understood. The proposed new concept, therapeutic catharsis, offers an up-to-now nonexistent criterion for when emotional experiencing is therapeutic and when it is not.
This discussion proposes that there are two aspects to how psychotherapy is currently understood that prevent it from advancing beyond its current “preparadigmatic state” (Goldfried, 2019, p. 494). Or, as Goldfried (2019) also stated, psychotherapy lacks a consensus on “an agreed upon core” (p. 486).
The nature of this aspect is proposed as follows: Psychotherapy does not have – and never has had – an effective enough of an understanding of its subject matter. Over the past several decades, notable commentators have expressed their view on why this aspect of psychotherapy should be more productively understood. Lazarus (1977), for example, proposed that psychotherapy lacked a sufficient understanding of its fundamental aspects, such as, “I would like to see an advancement in…the understanding of human interaction…the alleviation of suffering [and] the know-how of therapeutic intervention” (p. 553). Held (1995) suggested that “there is no consensus about how to answer the most fundamental questions about psychotherapy [i.e.,] what causes problems and causes solutions” [emphasis added] (p. 1). Kihlstrom (2006) held that “medicine has an unequivocally accepted subject matter; psychotherapy does not! Medicine knows the cause(s) of illnesses. Psychotherapy does not understand what causes psychological problems” (p. 43). Kazdin (2014) stated that “there is little empirical research to provide an evidence-based explanation of precisely why treatments work and how the changes come about” (p. 87).
A Proposed Subject Matter for Psychotherapy
This author proposes that the client’s experiencing be considered as the subject matter of psychotherapy. As a concept, the client’s experiencing is understood in the following way: (a) the typical presenting problem has (until shown otherwise) an interpersonal origin; (b) it is therefore understood in an atheoretical way as all human experience is unique; and (c) a conscious act is not likely to have a significant effect on how such a problem is manifested. These three elements are proposed as representing a psychological injury. The manifestations of which are to be found in the emotional, cognitive, and physiological stimuli that arise in the client’s awareness during a therapy session.
This aspect has to do with the proposal that there exists a natural healing process for a psychological injury, just as there is one for a physical injury. That process, therapeutic catharsis (TC; Von Glahn, 2018), is proposed as a fundamental reconceptualization of how catharsis has been historically understood. The most critical aspect of this understanding is a proposed criterion for when emotional experiencing is therapeutic and when it is not.
That criterion is the unforced activation of the client’s emotional experiencing. In this author’s experience, such activation seems to spontaneously occur when the client has received sufficient support for their experiencing. That support includes the explicit, or verbally expressed, dimension of the client’s experiencing, and in most cases also the implicit, or not-yet-verbalized, dimension. This latter aspect is where unprocessed injurious experience is assumed to be stored in a not-yet-verbalized state as an imprint. The forced activation of the client’s emotional experiencing is not therapeutic (see below).
For several currently mainstream therapies, it was necessary in the course of their development for their originators to suggest that the therapist provide more support for the client’s experiencing in order to make each one of these therapies more effective: e.g., Imaginal Exposure (Hembree et al., 2003); Acceptance and Commitment Therapy (Twohig, 2012); Dialectical Behavior Therapy (Neacsiu et al.,, 2012).
Providing Sufficient Support for the Client’s Experiencing
This author’s view on the therapist providing sufficient support for the client’s experiencing starts with Rogers’ (1959) – and seemingly universally overlooked – statement that the therapist’s congruent behavior includes “the experience of unconditional positive regard, and the experience of empathic understanding….” (p. 215).
Unconditional positive regard is understood here as the unqualified acceptance of the client’s experiencing, and the most succinct understanding of empathy as “…an accurate …understanding of the client's awareness of his own experience” (Rogers, 1957, p. 99).
Accordingly, this author (Von Glahn, 2018) proposed that the therapist’s congruent behavior be thought of as the delivery system for empathy and unconditional positive regard. In this matter, a therapist’s behavior is congruent when all aspects of it (i.e., verbal and non-verbal, convey the same message). An example of when the therapist’s behavior is notcongruent is when their tone of voice or facial expression convey a different meaning than that person’s words.
A therapist’s congruent behavior is a critical factor when not-yet-verbalized injurious experience starts to emerge into the client’s awareness. At this therapeutically sensitive time, the therapist’s nonverbal behavior (e.g., facial expression, eye contact, tone of voice, body posture and gestures, provides extra support for the client’s experiencing and increases the therapeutic effectiveness of the therapist’s interaction with that person; Von Glahn, 2018).
Von Glahn (2018) also proposed that support for the client’s experiencing be conveyed in a way that does notdistract that person’s attention from their sense of their own experiencing. This author views this suggestion as a logical consequence of the proposal that the client’s experiencing be the subject matter of psychotherapy.
Here, it is of significant historical interest to note that Rogers’ (1951) proposed the therapeutic conditions of congruence, unconditional positive regard and empathy as sufficient to “inaugurate” (p. 95) a process, and not as techniques.
Intuition and Understanding the Client’s Experiencing in an Atheoretical Way
This section proposes how an original understanding of the concept of intuition (i.e., skilled intuition; Khaneman & Klein, 2009) supports the therapist’s understanding of the client’s experiencing in an atheoretical way. Skilled intuition has two interrelated features. One is that there is a stable relationship between an action taken on an identifiable cue in a particular setting and the resulting response. The second feature is that such an action results in feedback that is both “rapid and unequivocal” (p. 524). The practice of psychotherapy, especially over time with the same client, would seem to have both of these features. Counter examples to skilled intuition are the prediction of a prospective value of a stock and a distant political event. Both of these counter examples lack the two conditions for skilled intuition.
Commentary that is supportive of the therapist’s use of intuition for understanding the client’s experiencing in an atheoretical way is that by Rogers (1955). “[Science] never has anything to do with the experiencing me….therapists recognize, usually intuitively, that any advance in therapy…must come from the experience of the therapist’s and clients, and can never from science,” (Rogers, 1955, p. 271).
Schore (2012) also supported the therapist’s understanding of the client’s experiencing in an atheoretical way. For example, “At the most fundamental level…psychotherapy is not defined by what the therapist explicitly, objectively does.…or says to the patient….the key mechanism is how to implicitly and subjectively be with the patient, especially during affectively stressful moments….” (p. 143). Additional relevant commentary in this context is by Safran and Messer (1997), who wrote that “The challenge for…psychotherapy and… researchers is to live with the ‘irreducible ambiguity’ that characterizes our subject matter” (p. 8).
TC is understood as a sympathetic-parasympathetic (S-P) autonomic nervous system (ANS) sequence, and where the S phase is the pre-therapeutic part and the P phase is the therapeutic one.
Von Glahn (2018) proposed that the S phase in an S-P sequence is a delayed fight or flight reaction. That is, it is a manifestation of an unresolved psychologically injurious event during which a lack of sufficient support for the person’s experiencing prevented it from transitioning to the P phase and becoming a healing experience.
When an S phase reaches an intensity (assumed to be determined by the ANS), it spontaneously transitions to the P phase. In this author’s experience, this happens when the therapist has provided sufficient support for the client’s experiencing. When this transition occurs, there are two immediate reactions. The first is that the S phase elevated vital signs in the most effective S-P sequence) instantaneously drop to below the client’s baseline values, with a dramatic decrease in physical tension, emotional upset, and an eagerness to continue talking about the experience in an insightful way.
The most apparent feature of the P phase is that the S phase fight or flight reactions (in the most effective S-P sequence) are immediately replaced by the therapeutic reactions of crying, for the most injurious experiences, indignation (preferred over anger), for objectively unfair/unjust treatment, and clients arriving at their own understanding of how they had been affected by the adverse event. The client’s insight is typically more profound than any understanding anyone else could provide. The most effective results of TC, and especially where crying has been particularly pronounced, seem to be that the stimulus that had activated an S phase no longer has that effect, and if there is any remnant of the adverse experience that clients report handling it in a spontaneous and productive way using their own resources.
There seem to be two factors that have the most influence on the effectiveness of an S-P sequence. One is how injurious was the adverse event. The other is the degree of experiential access the person has to the distressful aspects of the original experience. With clients who have little “t” trauma and ready access to emotional expression, the P phase may last just a minute or two and result in quite a significant psychological change. For a person with big “T” traumas and fears of deep emotional experiencing, major change takes considerably longer and requires considerably more patience from the therapist.
Typical Example of Therapeutic Catharsis
Perhaps the most common example of an S-P sequence is when a client arrives without any apparent sense of where or how to start the session. In such an instance, this author waits with an attitude that, hopefully, says “take all the time you need” (For this author, therapy starts when therapist and client sit down and lock eyes on each other). The client, somewhat hesitantly, starts talking about a recent event during which they were more of a bystander but in a way that is an objective overreaction to what actually occurred. The more the client talks, the more emotional that person becomes and is soon focused on an unresolved adverse event from their past that was triggered by the recent event.
Examples of Therapeutic Catharsis
A woman in her mid-twenties sought therapy because of a lack of “emotional closeness” with her husband. In her fifth session, she gave a brief, factual account of a recent interaction with him and then stared over the therapist’s shoulder. Nonverbal indicators prompted the therapist to invite her to say again how she felt about that experience. After a brief hesitation, her short answer was again emotionally protective and she resumed staring over his shoulder. Nonverbal indicators remained as they were.
Given the excellent rapport that had existed between the therapist and the client and in the therapist’s most caring and encouraging manner, he said, “Do you think you can try again?” For a few seconds, the client stared over the therapist’s shoulder. Then, she suddenly buried her face in her hands and sobbed quite deeply for about half-a-minute.
After discarding a handful of tissues, she stared at the therapist with an intensity in her eyes he had never seen, and declared, “I feel like I have a new toy, and the new toy is me!” It may be surmised that the “new toy” was that part of her basic humanness that had never been unconditionally accepted; i.e., needing emotional closeness.
A similar example is found in Shapiro (1989). A young woman, upon describing the details of an incident of childhood molestation, “exploded into tears and cried for about 1½ min.” When asked how she felt, she replied, “I feel as though I’ve just been exorcised” (pp. 215–216).
Forced Activation of Emotional Experiencing and Re-traumatization
The most typical example of the forced activation of emotional experiencing is when a client arrives in a heightened emotional state and quite quickly starts talking about an adverse event since the last session. With the therapist staying in a supportive role throughout, the client’s heightened emotional experiencing gradually dissipates on its own. Although clients may express feeling better relative to their arrival, the experience is not therapeutic because the S phase did not reach a neurophysiological peak of intensity and spontaneously transition to a P phase.
The S phase fight-or-flight reaction to a psychologically injurious experience has been, in this author’s estimation, misunderstood as re-traumatization. In the literature, the impression is that this term is used when the client seems to be “too upset.” There is also no consensus in the literature on the meaning of re-traumatization and, therefore, it has yet to be operationalized (Follette & Duckworth, 2012).
This discussion proposed two reasons for how psychotherapy as it is currently understood could be substantially more effective. One is that the practice of psychotherapy does not yet have an effective enough of an understanding of its subject matter. It is proposed that the client’s experiencing be the subject matter of psychotherapy, and that it is understood conceptually in the following way: (a) the typical presenting problem (until shown otherwise) has a psychogenic origin; (b) it is understood in an atheoretical way as all human experience is unique; and (c) a conscious act is not likely to have a significant effect on how it is manifested.
The second reason for why psychotherapy could be substantially more effective is that the concept of catharsis has yet to be operationalized. That is, any degree of emotional experiencing is proposed as therapeutic when it has been activated in an unforced way; i.e., when clients have received sufficient support for their experiencing.
TC is understood as a sympathetic-parasympathetic autonomic nervous system sequence, and where the sympathetic phase is understood as a delayed fight-or-flight reaction precipitated by the unforced activation of an unresolved adverse psychological event.
With the therapist providing sufficient support for the client’s experiencing, the sympathetic phase spontaneously transitions to the parasympathetic, or healing, phase. The healing reactions in that phase are (a) crying for the most hurtful experiences, (b) indignation (preferred over anger) for objectively unfair/unjust treatments, and (c) clients arriving at their own understanding of how they were affected by the adverse experience.
Cite This Article
Von Glahn, J. (2022, April). Two aspects are preventing psychotherapy from being more effective. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/two-aspects-are-preventing-psychotherapy-from-being-more-effective
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