Sixteen Ways Psychotherapy Can Help You

Today Alex discusses 16 factors common to most kinds of therapy which help people to improve the quality of their lives including skills development, gaining new insights about old patterns, forming a reparative relationship with the therapist, being challenged, having their experiences normalised and much more.

The book referenced in this podcast is Integration in Counselling & Psychotherapy by Lapworth, Sills and Fish (2001). 

Dr. Alex Curmi is a consultant general adult psychiatrist with a sub-speciality in addictions who completed his training in the South London and Maudsley NHS foundation trust. He is also a UKCP registered training psychotherapist, and has a special interest in mindfulness meditation.

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Transcript

 Welcome back to the podcast. My name is Alex. I'm a consultant psychiatrist. I'm traveling for a couple of weeks, so unfortunately were not able to provide a full length episode. But there are some ideas that I've been reading about which I'd like to share with you today. A few days ago, I spoke at the Trinity Rugby Club in South Croydon, and I want to thank the club for hosting me a very hospitable and had a lot of fun talking to the guys all about men's mental health and practical strategies that people can use to maintain a more robust sense of mental health. There was a Q&A portion and someone asked me a really good question, which is what does therapy actually look like? I think it's a really good question, because to a lot of people who have never tried therapy or who don't work in therapy, the whole process can seem kind of opaque and unnecessarily mysterious. And this isn't helped by the way therapy is portrayed often in TV shows and films, which I think add to this unnecessary sense of mystery. One of the reasons I make this podcast is to try and demystify many aspects of working in mental health, and many aspects of psychotherapy. So I thought it was a really good question for him to ask. And along the same lines, I'm currently reading a book called The Integration in Counseling and Psychotherapy by Papworth Seals and Fish. I would recommend this book to anyone that's training in therapy, because it helps a practitioner to understand how to integrate different schools of thought of psychotherapy into one's practice. So there are lots of different schools of thought and therapy like psychoanalysis, humanistic approaches, cognitive behavioral approaches. And this book helps you understand how you can practice pulling from those different schools of thought and deliver what's called an integrated therapy. And many, many therapists do practice in an integrative manner nowadays. So it's really helpful to understand that in the first few chapters of the book, it discusses why therapy works. So what are the actual active ingredients in the therapy that helps to improve someone's quality of life? And again, I think this is a really good opportunity for demystifying things. So in chapter three, the book actually outlines 16 different factors which are present in most kinds of therapy, which are likely to help people actually improve in some way or another. I'm going to list them, and I'm going to discuss them so that people actually have a clear understanding of what they mean, and then they can give these factors their own time and consideration. I think this will be especially important if you're considering going to therapy or training in therapy, or if you work in mental health more generally, because I think these factors can apply not just in a psychotherapy situation, but even in a nursing situation, or if you're a psychiatrist or just working with people who are vulnerable or mentally distressed in some way. So this is the list of generic elements common to different kinds of therapy, which the authors of the book feel are really helpful. One. The therapeutic alliance. Two. Double listening. Three. Being acknowledged and accepted as you are for receiving empathy. Five. Gaining insight. Six. Being in the presence of another who has no personal investment in how one should or could change. Seven. The creation of a relationship which may have been lacking in the past. Eight. The therapist as model. Nine. Normalizing the client's experience. Ten. Challenging and confronting. 11. Time structuring for self-reflection. 12. Consistency and continuity. 13. The opportunity to practice skills. 14. Managing the parallel process. 15. Humor and 16. The matching of therapist and client. So again I'm going to go through these briefly. So we all have an understanding of what these mean. So taking them one by one one the therapeutic alliance. This is the idea that the therapist and client have a strong working relationship. And they're working collaboratively, working as a team to help the client to deal with their problems or work through their issues. It's worth noting that in many, many large scale studies, the therapeutic alliance is often singled out as the single most important factor, again, irrelevant of the kind of therapy that someone is working with that helps people to improve. It can also define it as a positive emotional bond, a sense of mutual collaboration. It's usually involves that the client and the therapist have an agreement on the goals of the therapy, agreement on the tasks which need to happen in order to reach those goals, and the personal bond developed between the therapist and the client, affirming their commitment and their understanding of what they're doing in therapy. So therapeutic alliance is really, really important. Two double listening. So this is the idea that most people in most areas of their life, and I brought this up in the talk at the rugby club, don't really have many people where they can talk to in a totally unfiltered way. If we're speaking to our spouse or to our friends or to our colleagues. We can, of course, take into account our concerns and our experience. But usually at some point we have to check in with someone else. We have to attend to their needs. We have to make sure they're okay as well. We need to listen to them in therapy, have this unique opportunity to be listened to without the need to really check in on the therapist. The therapist is going to be fine. They're the professional. You don't really have any responsibility as the client for the therapist's wellbeing. What this means is you're just allowed to elaborate on your problems with all the complexities, the thoughts, the feelings, the different sensations and perceptions. And being listened to in this way allows you to elaborate your stream of consciousness and deepen your levels of self-awareness, which can then allow you to see what are the different choices you could make in your life. Generally, people have the time to elaborate their problems and their dilemmas in a way they can really understand them in much more depth, and then they can bring that depth to the rest of their lives. So that's the idea behind the three. Being acknowledged and accepted as you are. So you can also think about this as having a non-judgmental environment. Again. Much of the time in our lives, people are invested in us in different ways. Even as children, our parents often aren't able to give us that pure, unconditional love that we might crave. But people want certain things from us. They want us to behave in certain ways. And obviously, part of that's good, because part of those conditions helps to shape individuals into competence. People, people who can interact well with others and with society. But there is a downside, which is when people don't get enough acceptance and they get too much conditionality mixed in with love and affection. It can lead to a lot of self-criticism, a lot of self-doubt, and in extreme cases, things like self-loathing. And it can also be a barrier to change. As I mentioned, I think in last week's podcast, when I was talking about the idea of being paradoxical, the theory of change from Gestalt therapy, it's very hard to change if you don't accept yourself wherever you happen to be. And if you don't allow yourself a modicum of dignity and a sense that you deserve good things in your life, if you don't accept yourself for your art, it's going to be really difficult to put into action the things you need to do to change in a positive direction. So by having a baseline level of non-judgment and acceptance, the therapist then allows a very fertile ground for change to happen. Obviously, the therapist does want to promote change in the client, but it's not in the fixated way. Most people in our lives want us to change. And so that provides a layer of conditionality, which the client can then use as a springboard to do the things that they need to do. There are some schools of therapy which emphasize acceptance more than others. So, so probably road therapy or person centered therapy. Those are the kinds of therapies which really champion this idea of acceptance and unconditionally, but is generally accepted that being non-judgmental is a good feature for any therapist to have in most therapeutic situations. Number four receiving empathy. So being the social creatures that we are, where so much of our wellbeing revolves around having strong social relationships, being empathized with being understood. Having someone step out of their worldview and into your worldview. Being able to see things from your perspective is intensely therapeutic. The truth is, we all kind of live in our unique worlds. The way our perceptual systems are organized means we all live kind of in our own little micro universes, especially nowadays, and that can make us feel quite isolated. It can easily make us feel judged or misunderstood again in an increasingly polarized society. So having a therapist, being willing to regularly step out of their world and into yours and understand things from your perspective, that doesn't necessarily mean they agree with or approve of your actions or your perspective, but they're willing to see things from your point of view that is inherently therapeutic in and of itself. And again, is a feature you're gonna find in most kinds of therapy. Number five gaining insight. So this is part and parcel of increasing your self awareness. This is the idea that you're not just being listened to and empathized with, but you're actually gaining some new insights about the way you work. What is your process? What is your pattern of going through life? For example, someone on the more paranoid side of things might feel every time they're in some kind of social interaction people are trying to take advantage of, or they've been taken advantage of. And this is a theme. And in their therapy, they may gain the insight that actually there are several things they're doing that they're not conscious of, that are making people react to them in a certain way. And also, perhaps the client is filtering the information that they're seeing in such a way to confirm all of their worst fears, not taking into account the times when people are being fair. So the clients might gain the insight that there's a specific way that they're seeing and interacting with the world that has that common theme that is not ultimately serving them. So that's the idea behind that. Number six, being in the presence of another who has no personal investment in how one should or could change. So to me, this is pretty similar to being acknowledged and accepted as you are. It's the idea that even though the therapist has a professional investment in your well-being, they don't have a personal investment. So our family, our friends, our colleagues, they have a personal investment in our changing in a particular way. That means they're way too attached to the outcome to be therapeutic. Whereas actually if you have someone who is invested but from a bit more of a distance, that can allow some flexibility, that can allow the client to first accept themselves before they put those changes into action, and that can be very helpful. Number six creation of a relationship which may have been lacking in the past. So this is the idea that relationships with our therapists are often reparative. The easiest example would be if we perhaps lacked a parent who had unconditional acceptance and love for us, and then we formed a relationship with a therapist who is much more unconditional and accepting. This can help to repair this deficit, but this can take different forms. For example, a client may have not had a father figure which encouraged the person to go into the world and take risks and try different things, and this can make them feel anxious and insecure and make them reluctant to take certain actions and take certain risks in their life. And then they could start working with a therapist who takes up that role, who tells them, listen, these are some risks you can take. It's okay to take risks. Taking risks are part of life and trying different things. And so the therapist is helping to account for that deficit that was lacking in the client's life previously. Number eight, the therapist as a model. So this is the idea that hopefully therapists themselves have done a lot of work on their own growth and their own self-development. I would want to point out that especially in the UK, where therapy is not a regulated profession, it's very important to find a therapist who is accredited, who does belong to a registered list of therapists like the Bacb or the UCP, because in the UK at the moment, anyone can call themselves a psychotherapist and start practicing tomorrow. But assuming the therapist has gone through an accreditation program, usually they'll have had to do with their own personal therapy, and that obviously includes going through their own personal self-development. I would encourage even asking a new therapist that you're seeing, have you done your own personal therapy and what that what that was like for you? Because I think this factor is really important. So continuing on this point, the therapist has model. This is the idea that the therapist will often be able to verbally and non-verbally illustrate what it's like to have gone through some personal growth. And that can be simple things like showing a high amount of congruence, in other words, having an alignment between their thoughts, words, actions and their demeanor, their reliability, their ability to do what they say, their trustworthiness. Their ability to be assertive when necessary. Their ability to be kind from a place of strength, their own personal integrity. By talking to and working with someone, you can start to unconsciously adopt some of these strategies in your own life. So that's the idea behind therapist as model number nine normalizing the client's experience. So often when people come to therapy, they believe their problems are uniquely theirs and uniquely terrible. And this in itself can feel very isolating and make the client feel that their problems are that much worse. Now, obviously, there's going to be aspects to everyone's experiences which are unique, so I wouldn't want to diminish that. But at the same time, there are many, many common patterns to people's problems. So, for example, someone that's addicted to a drug like cocaine because it helps them feel good and compensates for their insecurities, that's a problem common to many, many people. And having your therapist normalize that experience by saying yes, I actually have worked with people who have had that problem or having them confirm. Yes, that is a problem common to many people that can provide that sense of relief that yes, even though I have difficult problems that I need to confront, they are problems that have been worked with before. There are problems that are solvable. One of the things that I might make explicit when I'm working with someone is that whatever problems you're bringing are solvable. They are things that you can work on and improve on. And that's really good because it instills hope. And I think hope is a very important part of psychotherapy. Number ten challenging and confronting. So this is the idea that in a gentle way, the therapist will challenge and confront the client with different things that they need to know, and that could be inconsistencies in their thought process or ways that their behavior is actually getting in their own way. Self-sabotaging. It's a bit similar to the insight. So for example, a therapist may point out to their client, hey, I noticed every time you talk about your mom, your voice gets really small and really quiet, and I see your body language goes into a really defensive posture. So that's an example of what challenging or confronting may look like. Number 11. Time structuring for self-reflection. So nowadays, in an increasingly secular society, it's increasingly less common. Let people carve out a time in the week just to reflect on their life, to take some altitude on things, to get a bit of a bird's eye view, and having something as simple as a one hour therapy session once a week can help to provide clients with that time just to reflect on how their life is going and help them to make those big picture decisions as to how they can make their life better. Number 12 consistency and continuity. So as you work with a therapist for increasingly long periods of time, you don't only get the value of the individual therapy sessions that you're doing, but of course, your therapist is getting an increasingly detailed picture of who you are, what your patterns are, what your history is, and really importantly, how your history may be influencing your present and your future. And that is the value of working with one therapist over a long period of time. They're getting this increasingly rich picture of who you are. You guys are developing an increasingly rich relationship, and that means any new problem you encounter and a new therapy session you do with that therapist gets the benefit of that increasingly rich understanding of you as a human being and the continual journey you've been on for the past few months and years. Number 13 the opportunity to practice skills. Many of the things a person learns in psychotherapy can be conceptualized as a skill, whether that's social skills, the art of meeting with and forming relationships with people, skills at work and getting tasks done, skills and self-reflection, mindfulness skills, skills and setting and using boundaries. Therapy is an opportunity to practice all of those kinds of skills. Sometimes that's explicit where you and your therapist will actually do exercises like, say, a mindfulness exercise or role playing exercise where you practice saying no or practice telling someone what you want or practicing having a difficult conversation. There are many, many opportunities in therapy to practice all the concrete skills which can help us improve the quality of our lives. Number 14 managing the parallel process. So this is an interesting idea that often in therapy, we replicate the same theme or kinds of relationship patterns that we have outside of the therapy relationship in our everyday lives. And it's the job of our therapist to help diagnose and manage that parallel process. So, for example, a person may go through their whole life feeling they've been abandoned by everyone, abandoned by their partner or by their friends or their colleagues. So in the therapy situation, what often happens is they'll end up feeling abandoned in some way by their therapist. And so the job of their therapist is to point out that that is happening so they can start to understand those patterns. And similarly to the inside point, they can understand how they're contributing to that problem, perhaps how they're selectively seeing the world to amplify that problem and so on, and then they can avoid it and make different choices, hopefully in their lives from that point on. Number 15 humor. Humor obviously isn't something that exists at baseline in psychotherapy, but some of the most therapeutic situations in therapy involve humor, usually some point of mutual recognition between client and therapist when they can see the comic tragedy of a situation or the absurdity of a situation, as I talked about in a recent Q&A. Humor is a kind of a magical solvent for human beings. It really helps us to manage tragedy and how often the difficult situations we get into are just part and parcel of the very, very strange lives that we lead. And recognizing the humor of that can be very, very therapeutic. And lastly, number 16, what helps make therapy therapeutic is the matching of therapist and client. So this is quite similar to the therapeutic alliance. And what I usually advise people is that you want a therapist with whom at baseline you feel comfortable, comfortable speaking to in a way that's authentic, that's unfiltered, but also that someone who can challenge you and with whom you can go a little bit outside of your comfort zone. Because psychotherapy that's comfortable all the time is unlikely to be helpful in the long term. It might help you feel better in the short term, and maybe that's more something you could call counseling rather than psychotherapy. But in psychotherapy, obviously comfort needs to be there. But we also need to have a therapist that can provoke us a little bit, kind of similar to that challenging and confronting idea we mentioned earlier that can help us do something different, something we're not used to. And that might feel a bit frightening, but I think that's the essence of having a good chemistry with someone is it's something that feels comfortable, but where there is the possibility of novelty, of newness, of risk taking something like that. So those are the 16 points that the authors want to mention as generic elements common to all kinds of psychotherapy, which they feel are helpful. I'd be curious what you guys think. Are there any other aspects of therapy which you think are helpful? Feel free to email us about this at Thinking Mind podcast at gmail.com. And also, if you're interested in having me speak for your team or for your organization, you can email me at that same email address and just put speaking inquiry in the subject line, and I'll get back to you as soon as I can. This is the Thinking Mind podcast, a podcast all about psychiatry, psychology, psychotherapy and self-development. Thank you very much for listening and we'll see you here next time.