levels of psychotherapy
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Psychotherapy can be seen to target one or more "levels" of the personality, or psyche. By “levels” of therapy I refer to the ontological depth of the mental representations targeted by the clinical intervention. The levels of psychotherapy elaborate relatively higher-order versus relatively lower-order representational harmonics. For convenience, I have categorized four levels of psychotherapy, with the lower numbers assigned to therapies engaging lower order mental representations and the higher numbers targeting the higher order representations. In this way, “Level 1” therapies represent approaches that deal with the3 more unconscious and ineffable content of the lower harmonics, and “Level 4” therapies target specific behaviors or are designed to develop certain skills or other cognitive or behavioral capacities. I will make the argument that categorizing psychotherapies this way is helpful in several ways. As we shall see, different levels of psychotherapy carry different sets of boundaries and methodological considerations, the careful observance of which will contribute to the curative power of the psychotherapeutic alliance. Additionally, it is helpful to the psychotherapist to be aware of the boundary lines of the “neighboring” levels, not necessarily to avoid crossing them, but to realize when one is crossing them and to take clinical responsibility for this fact. For example, it is useful for a therapist to be able to sense when her normally cognitive-behavioral style of identifying and modifying inaccurate beliefs and perceptions (Level 3) has recently succumbed to straightforward advice-giving (Level 4), or on the other hand, when she has discovered with the client an affectively-charged complex of memories and associations which requires more explicit tracking of affect (Level 2). There is nothing inherently wrong with crossing from one level to another….unless, of course, it happens willy-nilly in an unconscious or impulsive way, or it happens because of the therapist’s own needs or built-in predilections rather than based on recognition of the clinical situation and its boundaries.
Another benefit of recognizing levels of therapy is simply as a conscious-building exercise for those who provide and receive psychotherapy. For even the most insular and rigid of theoretical partisans, the recognition of different levels of therapy serves as a reminder that there are other ways to do things. If this book achieves no other purpose, reader, I hope it helps convince you that the healing art of talk therapy is as multifaceted as the complex psyches of the people it is designed to help, and that the therapist cannot afford to ignore any aspect of the natural psychological heritage of humanity. Even as we operate in the relatively narrow band of thoughts, feelings, relationships, or behaviors we have become accustomed as therapists to address, we should acknowledge with respectful reverence the soul, the heart, and the deeds of our charges, even those aspects which pass beyond our awareness of competence. Such an attitude is not only technically correct, but it encourages a respectful and inclusive tolerance of the impressive breadth of the human experience…a tolerance which we do well as therapists to model.
My own classification scheme for levels of therapy (See Fig. 1) illustrates that psychotherapy targeting certain harmonics of the psyche show certain characteristics, including discrete sets of boundary considerations as well as clinical methodologies. Level 4 addresses primarily harmonic 6 (self representations), and therefore deals most closely with issues of goodness-of-fit between the individual and the vicissitudes of consensual reality, including explicit assessment and modification of behavior patterns. When I say that Level 4 therapies focus on the self harmonic, I mean to say that the self is taken as an orthogonal unit of intervention (“you do this,” or “you don’t do that”), and is not typically itself the target of analysis, elaboration, interpretation, or subdivision. Level 4 encompasses the more pure behavioral approaches, as well as specific targeted counseling modalities (differentiated from psychotherapy below) and direct interventions such as skills training, job coaching, socialization, and other programmatic approaches that focus explicitly on the individual’s behavior in the environment. These approaches include a broad range of interventions, from token economies to toilet training to social skills groups in psychiatric hospitals, none of which range in any significant way to “deeper” concerns such as underlying perceptions, emotional experiences, defense mechanisms, or other more unconscious dynamics.
Level 3 interventions target harmonic 5 (schema representations) and therefore treats with more complex underlying patterns of understanding, perception, and thinking. With level 3, the object of psychotherapy begins to “look under the hood” rather than take the individual as a behavioral unit to be trained, and the question “why” begins to creep in. Level 3 therapies address increasingly complex issues of underlying motivation and patterns of perception and understanding, including cyclical maladaptive patterns and overvalued ideas. This level includes such models of psychotherapy as rational emotive techniques, cognitive-behavioral therapy, motivational interviewing, dialectical behavior therapy (DBT) and 12-step style chemical dependency treatment.
LEVEL ONE
Focus:
Consensual reality / Behavior
Areas of Functioning Addressed:
Behaviors. Things you do and say. Formal relations with others. Codes of conduct and behavior. Morals and mores.
Examples of Therapy:
- Behavior therapy
- Counseling
- Skills training
- Socialization
LEVEL TWO
Focus:
Relationships / Thoughts / Perceptions
Areas of Functioning Addressed:
Motivations. Means of perceiving and understanding. What you mean when you say something. Tendencies and patterns in relationships. Confronting denial. Cognitions / ideas / thoughts.
Examples of Therapy:
- Rational Emotive Therapy (RET)
- Motivational Interviewing
- Cognitive Behavioral Therapy (CBT)
- Dialectical Behavior Therapy (DBT)
LEVEL THREE
Focus:
Feelings / Identities / Defenses
Areas of Functioning Addressed:
Confronting the deeply unconscious. Interpreting deeper defense mechanisms. Tracking affect.
Examples of Therapy:
- Psychoanalysis
- Depth psychotherapy
LEVEL FOUR
Focus:
Meaning Systems / Archetypal / Psychoid
Areas of Functioning Addressed:
Free symbolic expression. Imagery techniques. Irrational, spiritual, or mythic content.
Examples of Therapy:
- Art therapy
- Dream work
- Sand tray work
- Active imagination
Cawley elaborated a 4-tiered system of classifying psychotherapies which has actually made its way into bureaucratic classification systems for psychotherapeutic intervention. It appears to have been more broadly accepted and implemented in Europe, perhaps partly because its origins are grounded in psychoanalytic sensibilities. This system is based not on target levels of functioning but on clinician skills and capacities, and is therefore used most often in the service of psychotherapy training design. Type 1 reflects basic skills anyone in a doctor-patient kind of relationship should have, with a modicum of awareness about the patient’s presenting situation and explicit attention paid towards maintaining a therapeutic professional relationship. Type 2 becomes more explicitly psychotherapeutic in that aspects of individual psychology play a more central role in the content. Type 3 reflects the methodologies of formal systems of psychotherapy, including use of the therapeutic alliance as a vehicle for change, interpretation of unconscious content, and explicit focus on primary process and “regressive” content.
1 Outer (support and counseling)
1 Value placed on listening sympathetically
2 Supportive relationship designed to encourage expression
2 Intermediate
3 Non-judgmental exploration of presenting problems
4 Elaborating the nature and origins of presenting problems, within the context of a deepening relationship
5 Awareness and confrontation of defense mechanisms
3 Deeper (exploration and analysis)
6 Interpreting unconscious material and transference
7 Reconstruction of the personal past
8 Controlled regression and access with primary process thinking
9 Use of the therapeutic relationship as a vehicle of change
Clinical considerations of the levels of therapy
Generally speaking, the higher levels imply increasingly intimate relationships between therapist and patient. Dual relationships, while to be avoided with any psychotherapeutic relationship, become increasingly corrosive at the deeper levels. We will discuss the issue of boundaries in greater detail below; in the meantime let us reflect that the levels of psychotherapy are appropriate to different types of clinical tasks. Level 1 work often involves non-verbal techniques which allow therapist and client to gain access to deeper content which is hard or impossible to talk about. Art therapy and sand tray work are particularly useful for patients with trauma sequelae, for example, because these techniques help transcend the powerful built-in reluctance to face the toxic, walled-off affect associated with trauma scenes. Naturally, the reasons that Level 1 techniques are useful for deeply repressed emotional issues are the same reasons the same techniques require particularly stringent boundaries. Sexually abused clients, for example, who have seen so many important boundaries crossed to such extremely damaging consequences, have difficulty letting anyone “in” to the deeper levels, and are particularly alert to signs of rejection, misunderstanding, empathic breaks, and particularly, boundary violations.
A therapist must generally “earn passage” to the deeper levels of psychotherapy. Human nature is such that the outer layers must be successfully navigated prior to explicitly talking of deeper thing.. Sometimes the passage to deeper levels happens relatively sooner or relatively later. At the very least, even the most deeply probing analytical psychoanalysis must begin with such Level 4, Consensual Reality concerns as fees, scheduling of appointments, service agreements, and so on. Even in contexts where there is an explicit goal to “go deep” and interpret dreams or do active imagination, there is a definite process of alliance building, at which time the therapist must demonstrate the constancy requires to serve as a “good object” for the patient. We will discuss these concerns a bit more, below.
The founders of psychoanalysis emphasized working with the patient on a daily basis, four or five times per week, largely because they recognized the necessity of moving beyond the inevitable preambles generated by everyday life. Patients who come in once per week generally spend some significant portion of time talking about what happened over the past week (consensual reality, Level 4), which isn’t a problem unless the material is being used defensively to prevent going deeper. Seeing a patient daily forces a qualitative change in the therapeutic relationship; the patient literally runs out of small-talk. Often healthier patients will “hit a wall” after an initial phase of discussing the original stuff they originally counted on talking about, and find themselves at a loss for words as they enter uncharted waters.
One of the factors that should determine the adoption of this or that level of treatment is the patient’s capacity for tolerating the “climactic conditions” of that level. In this sense, moving among the levels of psychotherapy…and navigating the various harmonics of personality…resembles an airplane climbing through different layers of the atmosphere. Commercial air traffic generally sticks to a zone of the atmosphere which is most quiet, but there are certainly zones of turbulence. In particular, moving into level 3 is often a somewhat jarring experience for clients, especially when the client in question is not conversant with his or her own affect and internal emotional climate. For this and other reasons, the psychotherapist always does well to keep a weather eye on the next level down, just like a defensive driver who occasionally checks the shoulder of the highway in case there is a sudden need to pull off onto it. In fact, generally speaking, the art of psychotherapy is the art of staying at least a step ahead of the patient, on the growing-edge of the horizon line where growth is possible and in any case some sort of change is happening.
This business of staying “a step ahead” of the client recalls technical considerations implied by the sphere model. For a therapy client who is relatively unconscious and has a low representational horizon, there is little point in operating in levels of therapy which will be quite beyond her ability to operate comfortably. A patient who is relatively unaware of different ways of perceiving and thinking beyond her own preferred patterns will generally prove unable to access the affectively charged psychological content which those patterns leave unaddressed. Therefore, from a levels-of-processing perspective, the primary task of psychotherapy will remain in Level 3 until the patient is able to perceive and identify inaccuracies and rigid patterns in her own thinking and perception. Moving from Level 3 to Level 2 would include beginning the work of identifying the deeper antecedents for the Level 3 ideas and perceptions; i.e., the underlying defenses and the affects against which the defenses have been arrayed. In this and other ways, the patient must be taken where the patient is at. It is the therapist’s job to move things along ultimately to fundamentally different ways of perceiving, thinking, feeling, and being.
To complicate matters, the therapist is not always in control of what levels will emerge in the treatment process. Jungian art therapists determined to plumb the depths of a client’s deepest psychological trenches may find themselves foiled in this aim by persistent difficulties in the sphere of Consensual Reality (the so-called real world). A behaviorist operating in a structured agency setting trying to use a cookbook-style manualized treatment regime with a young woman with sexual trauma may, on the other hand, may discover that the patient is a talented dissociative open to unexpected depths of symbolic communication which were not anticipated in the treatment manuals. Treatment modality should be adjusted to the presenting clinical situation, not the other way around. Therapists who absolutely cannot cross the boundary from one level to another should take responsibility of this limitation, and prevent the limitation from harming the client by making appropriate referrals at the appropriate time. Sticking to a manualized treatment with a client who needs something deeper in order to recover is inhumane, no matter how much “empirical validation” the particular cookbook has received. Insisting on talking about the alchemy of archetypes with a woman who is being daily beaten by her husband is equally irresponsible. As therapists, we are obliged to prove at least as adept at addressing the various exigencies of life at all its levels as our patients.
During my years of service working for county mental health agencies, it once fell to me to design a pre-doctoral internship in clinical psychology for the agency. In planning the didactic content of the program I happened to add a seminar on sand tray therapy somewhere towards the end of the year. A psychologist in the Children’s Division with a cognitive behavioral orientation strongly objected to the presence of the presence of a seminar on sand tray, stating that interns would not be allowed to do such things with clients, and that they instead must restrict themselves to cognitive behavioral, “empirically validated” approaches. I was surprised, nonplussed, and bemused by this objection from the representative of a department which routinely employs play therapy and art therapy, which in my mind are just additional examples of Level 4 expressive therapy, particularly useful to eliciting nonverbal content with trauma victims. I believe that such illogical areas of resistance are the result of theoretical bias. It is the Jungian origins of the sand tray technique which disturbed this psychologist; other nearly identical techniques which have been founded within or successfully digested by the cognitive behavioral school do not raise such objections. The Zen Buddhist tradition calls this disorder “word-drunkenness,” which suggests a state of becoming excessively narrowly focused on the word-labels of things while remaining close-minded to its dynamic content.
The difficulty of predicting the most likely level of therapy aside, it is supposed to be part of the professional psychotherapist’s expertise and training to make the best educated guess possible regarding the topic. Fools rush in, it is said, where angels fear to tread. I would draw back from using the cosmologically-freighted meta-language of Jungian psychotherapy, with its emphasis on archetypes in the form of chthonic imagoes and gods and goddesses, with a psychotic patient. Talk therapy with psychotic individuals requires a secure sense of open-mindedness to the more disturbing depths of the human psyche, but it also requires a fidelity to reality orientation and a bright trail of breadcrumbs leading back to the edge of the forest and the settled townlands beyond called Consensual Reality. The task is to render consensual reality less frightening, not to render the metaphysics of the subconscious more alluring. In general, the psychotherapist should observe the following rule: don’t go deeper than the ego can safely return from.
I will not go much further in describing the types of therapies characterizing the four levels. They are well documented and described elsewhere, and to discuss all their relative merits and where each is strongest is beyond the scope of this book. At the very least, I am hoping that an explicit awareness of the presence of these levels of psychotherapy will remind the practicing clinician of the context in which they work, and will provide a context in which to guide treatment planning. Most episodes of talk therapy are “founded” in one of the levels in particular, but it is not uncommon for the work to shuttle back and forth, to some extent, across the levels. Indeed, a psychotherapist increases in power and efficacy when she is able to comfortably navigate all the levels, and to understand the ground rules of each.
Levels of therapy: implications for clinical boundaries
Boundaries make psychotherapy possible. Boundaries create the safe place in which treatment can occur. Most contemporary theorists and clinicians have retreated from the “blank slate” ideal espoused by early psychoanalysts, who wanted to minimize any external influences on the patient so that transference reactions could be analyzed in their “pure” state. Remaining carefully neutral in therapy was meant to help ensure that any ideas the patient developed about the analyst was based more or less exclusively on the patient’s own fantasy and projection. Although this approach rightly recognizes that aspects of the relationship itself between analyst and patient will ultimately prove therapeutic, the blank-slate approaches incur a high cost. These approaches tend to detract from the clinician’s ability to establish trust and other vital ingredients of an effective working alliance. So-called therapist neutrality also often ends up hobbling the therapist when it becomes necessary to adjust his or her stance in response to the personality organization of the client. And furthermore, truly blank slate presentations are not humanly possible.
Operating in each of the four layers implies its own set of boundaries. Personally, I don’t like to get in a car with anyone working with me at level 3 or lower, and I don’t like to trade emails with anyone at level 2 or lower. Trading emails, and excessive telephone calls where the usual modality is face-to-face, runs the risk of opening multiple channels of communication simultaneously, all of which have their own sets of rules. This happens anyway in psychotherapy, to some extent…as you move into and out of crisis intervention, for example, or when you start doing Sand Tray techniques after verbal interaction (to say nothing of the constant flux of forces and shuttling among levels that characterizes any intimate relationship like psychotherapy)…but the point is always to maintain as much of a constant frame as possible, and speaking over multiple channels of communication simultaneously simply makes this goal harder to achieve. Along the same lines, when therapist and patient become too “friendly” or “chatty,” the result can be enhanced inhibitions on the part of the patient against broaching painful material.
I want to stress that working at a particular level subsumes the work at that level and higher. Many therapeutic errors are born of ignorance of this principle. For example, doing Level-3 psychoanalysis, one of the hallmarks of which is tracking affect in therapy, does not free the therapist or patient from coming to terms with issues to do with consensual reality, or relationships, or thoughts or cognitions, even though the therapist is conducting a level-3 intervention.
In my experience, threats to appropriate boundaries often have their origins in the mix of personality style between the therapist and the client. Nancy McWilliams, who writes as articulately about the process of psychotherapy as any writer ever has, comments on the subtle effects of the depressive personality so common among people who choose careers in psychotherapy:
When patients of a depressively organized person complain in various ways of not getting enough, the therapist is temperamentally inclined to try to provide more. It is easy to project one’s need, longing for closeness, and inhibition about asking for care on to the patient, who is then seen as hungry, lonely, and subjectively undeserving. From such a perception it is a natural leap to try to extend oneself to provide what is needed.
Other “classes” of boundary issues seem associated with certain models of psychotherapy. I have noticed with dismay that Jungian-oriented therapists seem to be a particularly schizoid and avoidant lot; they like to talk about mythic symbols in dreams but often run scared from clients with hostile, externalizing interpersonal styles or elevated risk factors such as suicide threats. Even more broadly, it sometimes seems to me that Jungians disdain any work above level 1, a situation that frustrates me as much as behaviorists who can’t see below level 3 or 4. I have put the work I have into this book not least to attempt to demonstrate that the methodology and characteristics of Jung’s analytical psychology exists on a clinical continuum with other systematic approaches. It’s hard to overestimate the importance of empathy with a patient’s presenting style: a Jungian’s vague, misty-eyed gaze and sloppy pseudo-spiritual pronouncements can amount to a deal-breaking empathic failure with a client whose life doesn’t resemble the inspirational slogans printed on the therapist’s posters of fuzzy kittens. It is my hope that awareness of the levels of therapy can remind the Jungian therapist doing dream-work with high-functioning professionals of the gritty realities facing the mental health counselor holding together a substance abuse treatment center for inner-city teens….and vice versa. A clinically grounded therapist, although tending to work generally in one or two of the levels of therapy, is aware of, if not conversant with, the prevailing conditions on the other side of the tracks, as it were.
Psychotherapy vs. counseling
Whether to take therapy inwards or outwards depends on the purpose and setting of treatment, the training of the therapist, the desires of the patient, and other factors. One of the most important outcomes of the decision to move inwards or outwards is establishment of the basic modality of treatment as either psychotherapy or counseling. This is a vital distinction lost on too many counselors and therapists. Counseling and psychotherapy are different tasks with different operating assumptions, boundaries, and methodologies. For a while during my graduate training, which, as I have admitted elsewhere, proceeded under the supervision of a conservative psychoanalytically trained psychologist, I felt bewildered disapproval of some of the things I saw counselors doing. Counselors would drive their clients to apartments, or help the client write a resume, or go into the bathroom with a client to do a urinalysis drug screen, or give advice about accepting this new job or that. To a nascent young psychodynamic psychotherapist like myself, trained in psychotherapy (as opposed to counseling), these things look like a string of terrible boundary violations. My supervisor wouldn’t even offer a patient his hand to shake as part of an injunction against touching patients, and here were people driving their clients around! As I became more aware of the spectrum of talk therapies, however, I came to see that the rules and boundaries surrounding counseling are different, and sometimes allow such things and more. The difference, again, is in the stance of therapist and client: in counseling the two partners stand shoulder to shoulder, with their attention on the problem. In true psychotherapy, conversely, the therapist and patient assume a very different stance: they face each other, and the relationship between the two of them actually becomes the stuff of treatment.
It is the difference in stance between psychotherapy and counseling which creates the different ground rules, assumptions, and procedures between them. In drug and alcohol counseling, it is common for counselors to share “war stories” from their own experience, as a way of identifying with and instructing the client. However, identifying with clients and instructing clients are secondary considerations at best in true psychotherapy. If I give a give a patient my advice, I turn away from the psychotherapeutic stance, instead putting my arm around the patient and pointing out a particular direction “out there somewhere.” If I self-disclose by telling a story from my own experience, I pave over the complex interpersonal whorls and eddies dancing in the air between us, instead choosing to give reality a shape of my own choosing. If I give a patient a ride in my car, I magnify the already considerable interpersonal forces between us, coloring the relationship with dependent, or seductive, or aggressive overtones, depending on the context and the character of the patient. If I am a drug and alcohol counselor, I am merely driving a client to a 12-step meeting, just like my counselor did for my back when I was in his shoes.
Study of the distinction between counseling and psychotherapy generates caution against “mixing models” in a heedless way. The context and procedures for exploratory, internal work are different for work that is essentially external. A few paragraphs ago I recalled doing some depth work with a professional who quit his job as a result of an unnecessary dust-up with his boss, necessitating a switch from internal work (characteristic of psychotherapy) to external work (characteristic of counseling). Coming up from the depths to focus on how many job interviews the man had attempted this week was unpleasantly jarring for both of us, and in fact compromised the earlier, exploratory work we had done because I had to abandon the stance I had taken previously. In the exploratory work I had remained an observing presence, modeling the work of an observing ego to a patient who had little of one. I let him generate the material, and gently guided him towards changes in perspective with an occasional interpretation or soft confrontation. In the more externally-oriented work of crisis management, the emphasis was all on what to do next, risking some harder confrontations which leaked away some of my power to act as an observing ego. However, as I formulated the case, I had little choice but to act as I did; when an appendectomy patient goes into cardiac arrest on the operating table, emphasis quickly moves from appendix to heart.
Naturally, in most cases, one approach contains aspects of the other. Even the most pedantic and structured of behavior therapists conducting formal behavior skills training, firmly in the counseling domain, will first find it necessary to establish rapport with the client…and establishing a rapport is internal work, including reflection of affect and alignment of schemas. As with the example above, depth work occasionally requires a resurfacing into external concerns. Risk management and mandatory reporting situations represent a special case belonging to this category. Whether in the midst of depth work or substance abuse counseling, manifestation of suicidal ideation with impulsive behavior will require a safety plan, and an admission of child abuse will require a report to child protective services. For this reason among others, psychotherapy requires considerable skill, thoughtfulness, and energy.
REFERENCES
Cawley R. (1977). 'The teaching of psychotherapy' in Association of University Teachers of Psychiatry Newsletter, January, 19-36. In Bateman, A., Brown, D, and Pedder, J., (2000). Introduction to Psychotherapy: An Outline of Psychodynamic Principles, pp. 83-84. New York: Routledge.
Reps, P. (1957). Zen Flesh, Zen Bones. Boston: Shambhala Publications.
McWilliams, N. (2004). Psychoanalytic Psychotherapy, p. 106. New York: Guilford Press.
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