Psychotherapy: inward and outward directions
Psychotherapy is a purposive endeavor. As with many of the world's great truths, the organizing principles of psychotherapy invite a paradox: its course is spontaneous and unpredictable in fundamental ways, but it is also a carefully organized intervention by a trained clinician, and never truly aimless. Intention and plan separates psychotherapy from advice-giving, “coaching,” and mere helpful conversations. Psychotherapy has been called the “talking cure” because it relies on language arts as a means of moving ideas around. As an application of language arts, the discipline is inexact. The fact that talk therapy cannot be a “hard science” only emphasized the importance of proper context and boundaries, including theoretical considerations and ethical standards.
The purposive nature of psychotherapy demands that nothing should be done unthinkingly, unconsciously, or pointlessly. I am reminded of the essential differences between writing a novel and writing a short story: a novel allows a wide range of extraneous details, descriptions, and atmospherics, whereas a short story requires just about every word to advance the story in some way. It is just so in psychotherapy: every word and deed should advance the story in some way, or at least be intended to do so. Unless doing so provokes undue anxiety, a therapist may wish to imagine himself in audio taped supervision while conducting therapy, as if he may be called upon to explain “Why did you say this, or why did you ask that?” Psychotherapy is deliberate.
There are as many talk therapies as there are individual therapists multiplied by the number of theoretical orientations. Probably the safest common denominator that may be generalized across methodologies is that psychotherapy attempts to effect change in the patient. From this point, the models diverge wildly. What sort of change are we looking for? Behavior change? A change in the internal emotional climate? More satisfying relationships? And different methodologies will also disagree about how to encourage that change to happen. Does the therapist teach new information, or demonstrate certain behaviors as a model, or encourage deeper expression than the patient is used to? In terms of the atmosphere or tone of the therapeutic relationship, does the therapist boldly confront the patient, or quietly bide his time, or guide the patient into increased understanding through Aristotelian questioning? The answer to all these questions is determined by two factors: the intentions (plan of action) of the therapist and the characteristics of the patient. All decisions about psychotherapy, from deciding upon major treatment goals in the treatment plan to each and every word uttered from the doorknob to the "couch", should be founded on some aspect of those two factors.
To the extend that therapy is an unpredictable process of intersecting deeply with another human being, it is best considered a controlled attachment experience, and its primary goal is moving energy around. In this sense, psychotherapy amounts to connecting with the client in very profound, intimate ways...the kind of connection that makes love possible. This aspect of psychotherapy feels like going inward... transcending the concerns of everyday life and contemplating the meaning-making systems of life and what matters most: things like love, power, and identity.
To the extent that therapy is about changing behavior in the world, it is a process of collaborative empiricism: creating space for new ways of being in the world, more realistically and more effectively. This aspect of psychotherapy feels like an outward process.
Psychoanalytic theory in particular supports this idea of two directions of psychological “growth” or development: inward (traditionally called expressive therapy) and outward (traditionally called supportive therapy). Inward growth involves development of and linkage among the internal working models, objects, symbols, and other representations, along with the affects associated with them. This type of growth is the goal of depth psychotherapy and psychoanalysis, along with other more “exploratory” and revelatory (or insight-oriented) disciplines. But inward growth by no means only occurs in the crucible of a therapeutic alliance…fortunately. Artistic expression, intimate and emotionally honest relationships, simple acts of personal courage, and even, I think, a good book can accomplish many of the same things. Internal growth involves the strengthening and flexing of internal resources, the effective and natural “alignment” of psychic content, conscious and unconscious.
External growth, by contrast, involves developing strategies of interfacing effectively with the environment…the outer cosmos of people, events, and things. External growth involves elaboration and development of extra-psychic content, including relationships, work performance, social status, and various behaviors ranging from drinking habits to parenting to public speaking. External growth is more usually the goal of counseling, behavior modification, skills building, and supportive insight-oriented psychotherapy. Once again, there are a host of factors which either assist or obstruct external growth, ranging from the environmental to the psychological.
The internal and external directions are useful guides because they help illustrate an important decisional factor necessary to formulating a treatment plan. I stress the adoption of the inwards or outwards direction as a decision to emphasize the purposiveness of the treatment plan: in psychotherapy, remember, nothing is done willy-nilly; everything must be according to a plan. The therapist decides that she is going inward or outward (or following the patient inward or outward) based on her own understanding of the clinical picture and very practical and strategic knowledge of the larger task at hand. Some answers and interventions will be found within the psyche; others without, in the environment. Psychotics transgress the line between inner and outer spontaneously and impulsively; therapists do not.
The decision to strike this direction or that is vital to the beginning stages of talk therapy. One of my strongest memories as a psychologist-in-training was going into a consulting room for conjoint therapy with a particularly difficult couple: a narcissistic-borderline dyad. My co-therapist, a woman more experienced than I was, paused at the door and asked “So, are we going to dig into this or try to stop the bleeding?” This is an important question, which guides the therapist into the decision to encourage expression or to act to contain the damage. This decision creates a basic strategy upon which the treatment plan will be based, but this decision must be flexibly adapted. Even with an “external” supportive therapy or counseling program there will be opportunities and even demands for moving in the other direction, however briefly. The psychotherapist doing exploratory psychotherapy, digging up painful memories and facing forbidden topics, must be alert for the need to shift this strategy if the situation warrants…if the patient appears unable to respond, for example, or events on the outside require intervention in a matter of basic survival, then this must be done. I was once treating a fellow social services professional who was both bright and imaginative, hungry for the inner work of exploratory, insight-oriented psychotherapy. As a result of personality disorder, the man quit his job in a flap with his supervisor. Suddenly, it seemed, I was exploring long-gone memories and deeply entrenched unconscious dynamics with a man who couldn’t pay rent or feed himself. Time for a change in tack, in the direction of the external.
Let us pause to consider the almost unconscious prejudice that many mental health clinicians, and most researchers, harbor: that internal work is just claptrap, a smoke-and-mirrors sideshow compared to the well-lit scientific world of behavior modification, response prevention, and skills building. In the case described above, I felt compelled to change my strategy not because the internal work wasn’t important…the internal dynamics were, in fact, the reason for the very practical crisis facing that individual, and altering them was of paramount importance. But when your diabetic has a heart attack, you forget about the insulin needle for a time, and slap on the shock paddles.
So, if we can accept both directions – inner and outer – as valid and useful vectors for the treatment process, then we may begin to look at the relative destinations these directions take us. “Counseling” is an outer-oriented talk therapy, aimed specifically at addressing problems “out there” in the world. Examples of this type of talk therapy include substance abuse counseling, couples counseling, behavior modification, and skills training. With all these examples, the ultimate goal is change in a specific behavior pattern: alcohol consumption in an addict, head-banging in a mentally handicapped child, or job performance in a worker. Such counseling does not typically delve deeply into things, such as unconscious determinants of behavior, emotional substrates for thought patterns, except in a very limited way and always in the service of the external goal of behavior change.
