Towards a Psychodynamic-Relational Theory of Psychotherapy

Certain ways of my own being have proven to move therapy into a more genuine, open and emotional experience for my patients and myself. The more that people feel that they can let themselves go and be vulnerable with another person yet still feel safe, the better their overall emotional and relational functioning outside of therapy.

Inevitably, for better or worse, my intuition has ultimately been a guiding force in my therapeutic decision-making and practice. Another major contributor to change, which is not independent of any other factor, is my own desire for therapy to be meaningful or my own emotional connection to the patient. Extant clinical experience and empirical research substantiate the notion that when the therapist really cares about the patient and has a warm, caring attitude towards them, the patient shows a lot of improvement from therapy. The converse is also true, i.e., if the patient is detached and disinterested, the therapy will likely be a challenge.

Therapy Goals

It seems likely that when most people think of therapeutic change, they think of a reduction of psychiatric symptoms, improved internal representations of self, other, and relationships. They may also think of healthier and more satisfying interpersonal and romantic relationships as well as better emotional functioning and perhaps greater self-awareness and insight.

Knowledge of self can equip one to better deal with the problems of everyday life. Spinoza long foreshadowed psychoanalysis when he highlighted the power of insight when writing his book, Ethics: “Emotion, which is suffering, ceases to be suffering as soon as we form a clear and precise picture of it.”

All of these domains of change are interrelated and therefore it is not necessary to consider differential theory and technique for each domain, unless one specific area of the patient’s functioning is impaired and affecting the patient’s life overall or if there are presenting psychiatric symptoms that require immediate attention. In these latter cases, specific interventions should be utilized to address the patient’s immediate treatment needs.

Other Considerations

It is also important to point out that sometimes people get worse before they get better in therapy and this has implications for any theory of therapeutic change. Sometimes when a patient acts out, it can be indicative of progress on one level but problematic in some other area. It is difficult to know if short-term or immediate therapeutic gains are genuine and will translate into long term gains or if the gains mean something different for the patient, therapist, and progress of therapy, respectively.

It is conceivable that based on a patient’s past experiences, personality, and life history, the appearance of improvement may be a negative prognostic indicator. All of these complexities need to be considered for a theory of therapeutic change.

Factors Contributing to Therapeutic Change

In my view, there is no one size fits all model of therapeutic change factors (and there should not be). Every patient-therapist dyad is unique and influenced by who the therapist is as a person just as much as who the patient is as a person as well as the nature of their relationship.

Furthermore, patients have their own needs and weaknesses that require unique therapeutic approaches to address their unique struggles in the context of their past experiences and prior relationships. Mahoney (1989) sums it up beautifully: “Human helping is an abstractly principled interpersonal process that is highly individualized and infinitely unique.”

Based on my clinical experience, five primary mechanisms of change in therapy are:

1. the transference-countertransference matrix,
2. emotional experiencing/affect expression and tolerance,
3. internalization/learning of adaptive coping strategies and skills,
4. holding environment/new relational experience is corrective, and
5. insight.

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Prior research has found a set of factors that contribute to positive therapeutic change regardless of the particular type of therapy. I discussed some of these common factors at the beginning of this piece by highlighting the importance of building a warm, supportive therapeutic alliance as well as the importance of therapist beliefs (also patient expectations) that the therapy will work. In sum, important common factors include:

1. the therapeutic relationship, namely how the patient feels about the therapist and how the therapist feels about the patient (transference – countertransference),
2. who the therapist is as a person, namely their capacity to sit with and tolerate intense emotional experience, including sadness,
3. skillful use of specific techniques, and
4. empathy.

While the common factors just described are not identical to the five factors contributing to therapeutic change, I elucidated just prior, they hopefully overlap. A broadly-based psychodynamic-relational perspective is a good way to describe my approach and theory of factors of therapeutic change in the context of the need for the field of psychotherapy to label everything.

Stay tuned for future articles that elaborate and clarify my theory of factors contributing to therapeutic change as well as possibly illustrative case examples.