What Makes Therapy Therapeutic?
Lloyd I. Sederer, MD
There are a number of forms of psychotherapy - cognitive-behavioral (CBT), interpersonal (IPT) and psychodynamic - to name a few. How do they work? What makes therapy therapeutic?
While there are differences in the techniques employed by these different therapies they all are rooted a few mutative elements: empathy, genuineness, warmth, active listening, positive regard, and trust. In fact, without these elements, a therapy isn’t going to be successful, no matter what technique is used. What are these key ingredients?
Empathy. Empathy is built into our brains. Humans have what are called “mirror neurons”, brain cells, which permit us to feel and behave like the person (or people) we’re with. Empathy is the capacity to feel what someone else is feeling. It is different from sympathy, where we feel sorry for another person. Empathy allows one person to live, however transiently, in the shoes of another, which can create a bond, and a basis for understanding. Empathy enables the work of therapy, often problem solving together, to proceed.
Genuineness and Warmth. These qualities are at the heart of human connection. Clinical studies have shown that people return to doctors and therapists who are warm and genuine (real) - sometimes even when the clinician’s technical skills are not all that good. Warmth also makes an important contribution to change, especially when a person is revealing painful or persistent problems that cause him or her suffering, guilt and shame.
Active Listening. Active listening is the capacity for a therapist to listen attentively, not just talk. A therapist needs to do more than just emotional handholding. Active listening also allows the therapist to appreciate what is not being said, but may be communicated through body language and other nonverbal cues. An active listener makes connections between past and present, people, feelings, ideas and behaviors, asks good questions, pushes gently, insists on movement that is in a person’s interest, and limits avoidance of difficult feelings or needed actions.
Positive Regard. This is an acceptance of the person without critical judgment. It also means believing that person can change and build a better life. With some exceptions (e.g., sociopaths), a therapist needs to believe in a patient’s goodness and capacity to change.
Trust. Trust is basic to all good relationships. A patient must trust that the therapist will provide a safe, confidential environment that places his or her needs before those of the therapist. Trust in therapy is the unshakeable belief that your therapist will not exploit you.
These critical elements are the building blocks of the therapeutic alliance, perhaps the best predictor of a whether a person will respond to therapy. You can tell when a therapeutic alliance exists when a person believes that the therapist will be there in a helpful, nonjudgmental, safe, and confidential way, no matter what happens. A therapeutic alliance trumps any credentials or training the therapist may have: the patient’s interpersonal experience with the clinician can be more important to success than the diploma on the wall.
Psychotherapy has had its share of New Yorker cartoons and more serious, less farcical but no less deserved, criticisms. But therapy works and can be transformative in a person’s life, and thereby in the lives of a family, worksite and community. When empathy, genuineness, warmth, active listening, positive regard, and trust are sustained in therapy and when two people live by their respective responsibilities to the work of therapy a remarkable process unfolds. When that happens a life can be rebuilt with love, purpose and the deep pleasures those produce.
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Dr. Lloyd Sederer is Medical Director for the NYS Office of Mental Health, Adjunct Professor at the Columbia/Mailman School of Public Health and Medical Editor for Mental Health for The Huffington Post/AOL.
His very recent books include The Family Guide to Mental Health Care and The Diagnostic Manual of Mishegas (with Jay Neugeboren and Michael Friedman).
www.askdrlloyd.com