Psychotherapy Beyond the Books and Manuals

Why Psychotherapy Needs the Art of Conversation

Jay Efran and Mitchell Green

Truly effective psychotherapy interventions can't be fully scripted in advance. The most effective moments are improvisations that arise out of the conversational flow between client and therapist. Indeed, every therapeutic process is unique, involving unexpected twists and turns. These aren't signs of the therapist's lack of clinical skill or treatment failure; they constitute the very heart of the journey.

From this perspective, the growing emphasis on treatment manuals and scientific methods is a step in the wrong direction. Yes, the public needs to be protected from bad therapists, and managed care organizations certainly want some assurance that their money is being spent wisely. In the final analysis, however, the effectiveness of a client-therapist pairing is a function of their collaborative dialogue---a process that resists standardization. Undoubtedly, one can specify general principles and guidelines, and therapy can be anchored in a contract that defines roles and sets boundaries. However, therapy also requires a certain creative ambiguity that can't be reduced to stock exercises or "bottled" like an antidepressant.

Unfortunately, manualized treatment protocols, designed to make treatments replicable, create a false impression of objectivity. For instance, we know many therapists who've worked on manual-driven projects and who report, off the record, that they were only able to adhere to the manual for the first few sessions during the intake phase. After that, the content of their sessions became increasingly variable and idiosyncratic, tailored, as one might have predicted, to the exigencies of the developing client-therapist dialogue. In some of these studies, the therapists dutifully continued to administer the prescribed exercises, but they also felt obliged to slip in side conversations that more directly addressed their client's needs. Such procedural deviations rarely make their way into the published literature. Therefore, readers are left with the false impression that the manualized procedures are easy to implement and reliably produce the desired result. Manuals may not be entirely worthless, but they certainly don't tell the whole story of what transpired between client and therapist.

Several years ago, we watched a manual-driven group treatment from behind a one-way mirror. Time after time, group members were actively discouraged from discussing issues that concerned them because these didn't fit the session's prescribed agenda. The leader kept complaining that the group had to move on because they were "falling behind the schedule." Ironically, it was those forbidden "disgressions" that group members later remembered as the most valuable aspects of the sessions. At a feedback session with an outside evaluator, members were quick to say that they liked being in the group and profited from meeting the other members, but had little use for the leader's heavy-handed attempts to administer "the treatment."

We can trace the current conundrum we're in---over the difficulty of making real therapy fit into a scientific paradigm---to the "slow-acting poison pill" that former American Psychological Association president George Albee says the mental health profession ingested several decades ago. With this pill, we swallowed the deeply flawed medical/psychiatric assumptions about diagnoses and dosages, culminating in the unrealistic expectation that forms of psychotherapy can be administered with the reliability of, let's say, a surgical protocol. The belief that this level of consistency can be obtained derives from a serious confusion of models---what philosopher Gilbert Ryle called "a category mistake." In other words, psychotherapy has been misclassified; it should never have been considered a treatment in the first place. Rather, it's a specialized form of inquiry---more philosophical journey than medical procedure.

Unscripted Therapy in Action

A week ago, a client came in for her first session. She described the frustrations of having engaged in years of self-improvement efforts---meditation classes, body disciplines, empowerment groups---only to find herself as confused as ever about whether to stay in her marriage and if a career shift might bring greater fulfillment. At that moment, I found myself contradicting Socrates, telling her that sometimes the unexamined life is worth living. That statement struck a chord. She lit up, laughed, relaxed into her chair, and said, "Thanks for saying that."

My remark couldn't have been preplanned and wouldn't necessarily have been appropriate for either a different client or even the same client at a different time. Like a thousand other such bits of conversational ingenuity, it worked because of its positioning in the ongoing dialogue--it was exquisitely responsive to the several layers of meaning contained in the client's communication.

It's practically impossible to explain how such comments are generated or exactly what clients make of them, yet the immediate reaction and subsequent discussion in this case made it clear that comments such as these catalyze important shifts in perspective and advance the collaboration inherent in therapy. Such spontaneous remarks aren't learned from manuals and can't be dispensed on demand, yet they're the essence of the therapist's conversational craft.

This blog is excerpted from “The Art of Therapeutic Conversation.” Read the full article here. >>

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Topic: Professional Development

Tags: conversation | meditation | meditation classes | mental health | mental health profession | psychotherapy | talking | TED | therapeutic conversation | therapist | therapists | therapy

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