Clients change during psychotherapy for many reasons, where many therapeutic and pharmacologic studies demonstrate a “time effect”. The factors contributing to this effect fall into three further categories:
- Spontaneous Remission (outside of the therapeutic relationship)
- Placebo Response (positive expectancies within the therapeutic relationship)
- Construct Effects of Interventions
The latter two contain the “tools” of therapy, and address the question “how does psychotherapy work?” (Lambert and Bergin, 1994). The primary tools of psychotherapists are:
- Relationship Skills: Formative, careful management of the therapeutic alliance, i.e. non-judgmental acceptance, trust respect, warmth, etc. This is a strong predictor of outcome (Horvath and Greenberg, 1994).
- Activation of Client’s Observing Self: Activating client’s capacity to self-observe, which often leads to insight, creates choices, regulates emotion, and fosters behavior change. In service of this meta-level self-awareness, therapists may use empathic reflections, cognitive homework, affective exercises, interpretations, behavioral instructions, analysis of dynamics, plus a wide array of other interventions to initiate and maintain changes (Deikman, 1982).
- Knowledge of basic developmental psychological difficulties. Therapists implement theoretical patterns/themes of understanding in order to conceptualize clients’ struggles/symptoms. These vary widely, i.e. anxiety, depression, addictions, phobias, grief, traumatic memories, interpersonal strife, etc; many issues reflect prevailing cultural currents, as we are psychosocial beings.
- Inductive Reasoning: Therapists use disparate bits of information presented by the client to generalize about explicit, enduring patterns of functioning. This information is gathered directly, i.e. questioning, clarifying, confronting, etc., and indirectly, i.e. observations, therapist reactions to client, homework assignments, data from significant others.
- Persuasion: This is not in the traditional sense of the word, but more as therapists encourage clients to increase emotional awareness, modify cognitions, and change behavior, re-defining the “self” in relation to others. These strategies guide clients to face their fears, changing their narratives of the past, experience of the present, and anticipation of the future. In so doing, clients are re-designing their role-relationship schematas and scripts (Frank, 1991).