This Is Talk Therapy: What Psychotherapy Is and How It Works
What every therapist and patient should know.
I sat down with Dr. Daniel Carlat of The Carlat Psychiatry Report to discuss psychotherapy, how it works, and how it differs from routine psychiatric care. The interview was first published in The Carlat Psychiatry Report. I am republishing it because the questions about psychotherapy are now more relevant than ever.
Daniel Carlat: For most psychiatrists, evaluating a patient involves coming up with a DSM diagnosis and finding a medication appropriate for that diagnosis. How is the psychotherapeutic approach different?
Jonathan Shedler: For most patients, DSM diagnostic categories are a poor and extraordinarily limiting way of understanding emotional suffering (read my essay about DSM diagnosis). First, most patients don’t come to us packaged in clear-cut diagnostic categories. Second, DSM assumes it is useful to view emotional suffering as a disease, like influenza or ringworm. It fosters the fiction that you can treat emotional pain as an encapsulated illness, separable from the person experiencing the pain. But most of the problems that bring people to treatment are woven into the fabric of their lives. It is less a question of what the patient “has” than who they are—their way of being in the world.
DSM fosters the fiction that you can treat emotional pain as an encapsulated illness, separable from the person experiencing the pain.
DC: So this is a different way of viewing psychiatric disorders—not matching up a patient with a diagnosis, but spending more time understanding the patient as a person.
Shedler: Yes. It is rarely helpful to move from a psychiatric diagnosis to a treatment decision—as many practitioners are now trained to do—without understanding the meaning of the person’s difficulties and their larger psychological context. It would be more helpful to think of depression, for example, not as a disease but as the emotional equivalent of fever. Fever is a nonspecific response to a wide range of underlying conditions, from the common cold to Ebola. Diagnosis does not end with taking the patient’s temperature. Depression is likewise a nonspecific response to a wide range of underlying difficulties. To help our patients, we need to treat the causes of the “fever.”
DC: Can you give us an example of this principle in action?
Shedler: A psychiatric resident and I treated a man in his thirties who had been in psychiatric treatment for 15 years, with little if any benefit. He suffered from chronic depression and came asking for medication changes. We met with him and asked about what was going on in his life, the trajectory that had gotten him where he was, and his thoughts about what might help him to feel better. He said, “I have had psychotherapy before, it doesn’t work for me.” But as we talked further, it became clear that he had never engaged in a meaningful psychotherapy process.
He had been on one medication after another, and he had been through an alphabet soup of brief “evidence-based” therapies (all known by three- or four-letter acronyms). But he couldn’t say anything about what he learned about himself in any of these therapies, nor could he say anything meaningful about his relationship with any therapist.
DC: But this patient thought he had spent years in therapy. So, as psychiatrists, how do we determine whether a person has had a real robust trial of therapy?
Shedler: If a person has had meaningful therapy, he will be able to discuss it in a meaningful way. You can ask the patient, “Tell me about your previous therapy. What was your relationship with your therapist like? What did you learn about yourself?” In this particular case, what was striking was that this intelligent patient had no concept that psychotherapy involved a relationship. He viewed therapists simply as “providers” to dispense techniques and interventions.
If a person has had meaningful therapy, he will be able to discuss it in a meaningful way.
DC: So we should ask: “I see you have had some psychotherapy. What sorts of things do you remember getting out of therapy?”
Shedler: Certainly. We also invited the patient to tell us how he understood his depression—his own view about what was making him so unhappy and making his path through life so painful. No one had ever asked him this. The idea that his depression, his sadness and emptiness, could have meaning, that it was something to reflect on and potentially understand, was completely alien.
He spent about eight months in therapy making small talk and steering around emotionally meaningful topics. After eight months of work—with his doctor repeatedly pointing out how he closed off certain areas of thought and discussion—he began to open up. He revealed that in his private thoughts, he was hypercritical of almost everyone. He’d meet someone, home in on a perceived flaw, then condemn them and write them off.
What next emerged was that he viewed himself through the same hypercritical lens. He was constantly condemning and attacking himself. At that point, we could redefine his depression in a way that made it possible to do some psychological work. His doctor was able to say, “If you treat someone badly—if you berate and abuse them—it hurts. That is also true when the person you mistreat is yourself. The resulting hurt is what you have been calling depression.” That was the turning point in his treatment.
DC: But it took eight months. Most psychiatrists don’t have eight months to do weekly therapy.
