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What Works in Psychotherapy?

(or What We Talk About When We Talk to Our Therapists)

Sharon M. Van Sluijs

The analyses presented in Principles of Therapeutic Change That Work, as detailed and

exhaustive as they are or seem to be, reveal to us that many things we would intuitively

assume to be important in successful psychotherapy are indeed significant: Relationship,

participant, and treatment factors, such as an effective working alliance, a patient with a good

motivation to change, an appropriately directive (or judiciously non-directive) treatment plan,

and dozens of similar seemingly obvious factors all contribute to success in the treatment of

many psychopathologies. The medical model, with its emphasis on manuals and strict

adherence to step-by-step procedures, CBT (Cognitive-Behavioral Therapy) in particular,

does have its place. For example, it seems to apply well to the treatment of some anxiety

disorders and in AODA treatment protocols. However, the books extensive research results

show that in the end, the contextual model trumps the medical model in the treatment of most

psychological afflictions. Even so, while the contextual model seems a better approach in

most cases, the most difficult kinds of psychopathology nonetheless remain resistant to

treatment: that is, the three clusters of personality disorders that comprise Axis II, and of

those, particularly narcissism, borderline, and anti-social personality disorders, as well as

OCPD with its insistent perfectionism. Indeed, Table 2.3 The Role of Personality Disorder

in the Treatment of Depression (Castonguay & Beutler, 2006, 24-25) presents no fewer than

19 treatment studies in which patients diagnosed as depressed with co-morbid personality

disorders showed results described as worse outcomes, slow response, poor therapeutic
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outcomes, logistic regression, worse social functioning, high neuroticism, and less

likely to recover across all groups.

Personality disorders, especially when co-morbid with depression and/or anxiety, are

resistant to manualized procedures; they are only marginally effective, if not completely

useless or even detrimental.* Manuals do not work in these cases. The medical model fails

in the treatment of personality disorders simply because in personality disorders context is

everything.

Yet, while creating an epistemological ground from which the clinician can begin to

perceive and consider, the contextual model itself does not point to a specific treatment path;

rather it seems to note what has not worked, to advise what may not work, to warn what to

avoid, to lower ones expectations, and even to cultivate humility in the face of obdurate and

fierce resistance.

So then, the question: How Does Psychotherapy Work? Especially in these most

difficult cases? My answer is seemingly obvious, and seemingly, deceptively simple:

Psychotherapy works when three things are simultaneously present, fully available,

and used:

1) A broadly-educated, appropriately skilled, and experienced clinician, who, if not an

M.D., works in tandem with one or several M.D.s

2) The clear ability to determine the true cause of the patients affliction.

3) Time (and its corollary, Money).

* The notable exception is Lorna Benjamins Interpersonal Reconstructive Therapy (IRT).

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This is not to say that I consider the many relationship, participant and technique

principles derived from the research presented in Principles of Therapeutic Change That

Work to be irrelevant. Rather, I think those principles that address the skill of the clinician

and the need to determine the true cause are the most important (e.g., Castonguay & Beutler

(2006), pages 357-358).

The clinician I describe above is educated both inside and outside of the box of empirical

science. He is well read in the classics: the Bible, Milton, Dante, Shakespeare, mythology,

fiction and poetry from the 500 years of the much-maligned Western Canon (and has, as well,

an understanding of why it is maligned). This aspect of ones education cannot be ignored.*

She has a grounding in major religions, and in both western and eastern philosophy,

particularly post-WWII schools of thought concerned with meaning after the Holocaust,

Hiroshima and the death of God.: existentialism and its difficult ideas concerning lifes

meaning. He has read widely in the literature of psychology and psychiatry: Freud, Rank,

Jung, Reich, Klein, Balint, Sullivan, Winnicott, Kohut, Kernberg, Mann, Benjamin,

Gustafson, Safran, Luhrmann, others. She actively discusses ideas from these readings with

colleagues, she write papers that examine these ideas; he uses them in his clinical practice.

He is trained in manualized treatment procedures, knows how to use them, knows when to

change them, knows when to put them aside. He has worked closely with one or more older,

experienced clinicians for many years ( a clinical internship, residency or the like). His

*Literature educates the imagination: No matter how much experience we may gather in life, we can
never in life get the dimension of experience that the imagination gives us. Only the arts and sciences
can do that, and of these, only literature gives us the whole sweep and range of human imagination as
it sees itself (Frye, 1964, p.101).
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intake notes, diagnoses, treatment choices, methods, delivery, interaction are all examined,

critiqued, discussed. She has studied videos of herself in session with patients. She has also

studied closely and knows the subtle signs of hidden or unconscious emotion. He has,

perhaps, studied the Facial Action Coding System of Paul Ekman et al., or may be naturally

adept at reading subtle expressions. She is empathetic, supportive, compassionate, accepting,

open-minded, flexible, tolerant, patient, strong and encouraging, but also quite able to stay

within the frame of therapy. That is, he is able to give as much as one must as a

psychotherapist, but also able to protect and preserve himself. He is, in short, a kind of arms-

length surrogate mother, a kind of substitute father, a good coach, the guide-to-the- territory

who was missing at some essential transition in the patients life. In a short talk he gave in

1960 entitled, Aggression, Guilt and Reparation, D.W. Winnicott said, [F]or in

psychotherapy nothing really new ever happens; the best that can happen is that something

that was not completed in an individuals original development becomes to some extent

completed at a later date, in the course of treatment (Winnicott, 1986).

The second item essential to successful psychotherapydetermining the causebegins

with my inclusion of a medical degree or access to a licensed physician. I believe that a

medical education or close work with an M. D. is essential to successful psychotherapy. First,

it is absolutely necessary that prospective patients for psychotherapy be examined by a

physician to rule out the possibility that their cognitive and/or affective signs and symptoms

may be secondary to some physiological trauma, pathology, toxicity, or abnormality. There

are many possibilities here: hypo- and hyperthyroidism, ADD, Cushings Disease, Addisons

Disease, Huntingtons Disease, Alzheimers, CJD, HIV, head trauma, herpes encephalopathy,
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tumors and other neoplasms, vitamin deficiencies, heavy metal toxicity, sleep disorders,

substance abuse (including caffeine), dehydration, etc. The list is quite long.

The person who presents himself to a psychologist with a complaint of fatigue and

depression has already taken more than a few steps into self-diagnosis. In too many

instances, that diagnosis may entirely miss the mark. A comprehensive examination by a

physician should be the first step.

Second, psychopharmacology is not a panacea, but some drugs may be very useful, even

when used very sparingly. Anxiolytics work quickly and can calm a distressed patient enough

to provide psychic breathing space: some modicum of mental clarity that may allow day-

to-day functioning. Anti-depressants may be useful, though are more problematic. Any

medication, however, requires a physicians prescription and monitoring; a psychologist is

not trained or licensed to do this. While the psychologist may be extremely skilled, the

biological/neurological aspects of many psychopathologies cannot be ignored. (In my

opinion, one of the failings of Principles of Therapeutic Change that Work is that most, if not

all, of the research examined seemed to accept the unspoken premise of mind/body duality.)

A physician with training in complementary medicine would also serve here. There have

been many studies in the use of breathing techniques (pranayama) to alleviate anxiety and

depression (Brown & Gerbarg, 2005). It has been proven to be effective. Psychologists may

opt to learn these techniques as well, as they go beyond the usual slow breathing techniques

for relaxation.

The most important and most difficult aspect of determining the real cause of a patients

problem, especially in the case of those with personality disorders, is to see beyond the signs

and symptoms to what is the core deprivation, the core question the patient is trying to
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address with his perceptions, beliefs, and behaviors. In my view, personality disorders are,

essentially, elaborate coping mechanism that have ossified into a character. Through careful

examination and judicious questioning and listening, the clinician must learn the patients

story. What is the seed that generated the patients suffering? The need for armor and

protection? What is shape of his drama? What is the plot? (Gustafson, 1995).

There is no time or space to discuss this in great detail here, however, let me say that I

believe that the underlying cause of most personality disorders, perhaps the underlying cause

of most depression, is a sense of meaninglessness. Castonguay and Beutler touched upon

this problem when they revealed that while most therapists would choose not to discuss

religion, most patients wanted to. This is a sign of a yearning for meaning and connection

(Safran, 2003). Narcissism, that most potent personality disorder from which all others stem

and branch, is a reaction to loss and vulnerability, to the threat of being nobody (from

discussions with Dr. Kenneth Burg). Without God, without the consolation of a heaven,

without community, without stable truths and valueswithout a mother who loves you even

when you are bad, it is easyeven inevitableto feel cut loose from meaning and purpose.

The narcissist creates a masque of self-importance and demands that the world pay attention.

The borderline is the insistent victim, a narcissist without active out-going power: the

borderline manipulatespassive-aggressivelyto get the attention the narcissist actively

demands. Both crave reassurance that they matter, that they are not Nobody. This is an

existential issue; it can become an existential crisis, and it is why I would insist that those

who would be psychotherapists become conversant in the concept and its responses to hard

questions.
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What do we talk about when we talk to our therapists? Death, meaninglessness, the cold fear

of being Nobody. The clinician finds herself practicing philosophy in the most cogent,

practical, and necessary way, facing her patients question: Why am I here? Or far more

dangerous: Whats the point? Will she have an answer?

Finally, time is necessary for successful psychotherapy: weekly or bi-monthly sessions for

a year or more. Time requires money in this system. The nine or twelve sessions of outpatient

therapy allowed by most HMOs is simply inadequate. It is like using tape to repair a broken

window pane: its cheap and it holds things together for awhile, but no one would call it

fixed. Successful psychotherapy in the U.S. would follow the example of state-supported

psychotherapy in Britain and Germany: long term psychodynamic therapy. It has been

proven to work, and because it works, in the long run it is most economical.
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References

Brown, R.P. & Gerbarg, P.L. (2005). Sudarshan kriya yogic breathing in the treatment of

stress, anxiety, and depression: part 11: clinical applications and guidelines. The Journal of

Alternative and Complementary Medicine, vol. 11, no. 4 711-717.

Castonguay, L. G. & Beutler, L. E. (2006). Principles of therapeutic change that work.

New York: Oxford University Press.

Gustafson, J.P. (1995). The dilemmas of brief psychotherapy. New York: Plenum Press.

Frye, N. (1964). The educated imagination. Bloomington: Indiana University Press.

Safran, J. (2003). Introduction: psychoanalysis and Buddhism as cultural institutions, in J.

Safran (Ed.), Psychoanalysis and Buddhism: An unfolding dialogue. Somerville, MA:

Wisdom Publications.

Winnicott, D.W. (1986). Aggression, guilt and reparation, in C. Winnicott, R. Shepard, M.

Davis (Eds.), Home is where we start from: essays by a psychoanalyst. New York: W.W.

Norton & Co.