Ten Principles of Psychotherapy: Building Hope

Imagine a mental health professional starting the first session with a new patient. The patient could describe extremely difficult problems to the therapist, or those problems as described by the patient might be just touching the surface and masking extremely difficult issues out of the awareness of the patient.

Problems such as these illustrate that being a psychotherapist is a fantastic responsibility, and requires much education, training, and experience to be successful. Some basic principles make it easier for both professionals and patients.

1. The first principle of psychotherapy: A new patient should not be viewed only from the lens of the personal problems being shared with the therapist, whether or not he hides deeper issues. Rather, each person in psychotherapy should be viewed as a whole person with a unique personality and lifestyle, and living in a particular context. Each patient has personal strengths that the therapist needs to discover and bring out in the patient, even if these strengths are masked by the problems of the patient.
2. The second principle in psychotherapy is that it works best when there is a good match between the patient and the therapist. The therapist needs to have good rapport-building skills and should speak at the level of the patient, keeping in mind that each patient is unique.
3. The common myth is that psychologists can read the minds of people. However, behavior is too complex to be able to quickly and clearly grasp all the reasons underlying it. As mentioned, the real problem facing the patient might be very different than the one described by the patient (for example, one partner could greatly misrepresent the problem in a couple).
4. Fourth, the therapist should assess the readiness to change in each patient. Patients might resist good suggestions, sabotage their progress, not cooperate, and so on. The therapist needs to be attuned when a patient is more open to change and should guide the patient toward it. The therapist should be alert when a patient is not ripe for change.
5. Fifth, the therapist should assume that patients deeply want change, even if there might be resistance to varying degrees. Having hope and wanting to change for the better is the human birthright. The therapist needs to help the patient unlock the power of positive change.
6. Sixth, the patient is the one who has to do the changing. The therapist can only be the facilitator, or provide the scaffold. The therapist can help the patient see new habits, paths, and ways of being, or more positive stories to tell about the self and the future. However, the patient is the one who must choose these new options.
7. An important principle of psychotherapy is that each of us, no matter what age, can grow psychologically. As human beings, each of us is in continual transition to a better path and to a better way of being. We might get stuck at a particular level, or even regress. However, the therapist should work from the principle that problems are solutions waiting to happen. Therefore, the therapist should work from the assumption that each moment is a moment for potential growth. We should never stop believing that our problems can be solved or that our growth cannot continue. By adopting an attitude that living is about transition and transformation, we can get through the most difficult times.
8. Aside from the positive grand narratives that therapists can help patients tell about themselves and the future, therapists can also teach specific techniques and procedures that can help patients. For example, in the behavioral tradition, patients can learn both relaxation exercises and the scheduling of positive events and activities. From the cognitive tradition, they can learn not to think negatively, pessimistically, or catastrophically. Also, they can learn particular social skills, for example, to control anger or, at the other extreme, counteract shyness.
9. The ninth principle: Keep it simple. Much of therapy is putting together techniques and concepts that reflect common sense and folk psychology. Science helps determine what works best, and the therapist needs to keep up with the complex literature. However, the basic principles in psychotherapy can be communicated to patients in simple terms without losing much information. For example, I indicate to patients that I follow the approach of "action and distraction." That is, I describe psychotherapy as learning positive ways of living, or engaging in positive activities. Furthermore, when we are not being active, we should distract ourselves from our stresses, for example, by learning positive ways to relax, reclaim joy, and reduce stressful thoughts and feelings. Another principle that I describe to patients is that of "surrounding the negative with a positive." For example, after telling someone an inappropriately critical comment, one could tag on a more positive statement or a reframed one. After telling someone what to do in a too forceful way, one could add, "Perhaps that is a good idea and what do you think?"
10. Finally, there are overarching or super-ordinate principles that help explain behavior and how to change it when it is problematic. For example, I view behavior and its change as reflections of the principle of "activation/inhibition coordination." Therapeutically, this principle refers to helping patients to activate or initiate more positive actions, thoughts, feelings, ways of living, and stories about the self and the future. In addition, it refers to helping patients to inhibit or interfere with blockages that can get in the way of new habits and lifestyles. Patients need to have hope, as do therapists for them. When psychotherapists understand their patients and how psychotherapy works best from a scientific perspective, it is easier for them to instill hope and have hope.

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