email page print pageAll Topic Reviews
Maximizing Effectiveness in Dynamic Psychotherapy Self-Compassion in Psychotherapy101 Healing StoriesA Clinician's Guide to Legal Issues in PsychotherapyA Map of the MindA Primer for Beginning PsychotherapyACT With LoveActive Treatment of DepressionAffect Regulation, Mentalization, and the Development of SelfAlready FreeBad TherapyBecoming an Effective PsychotherapistBefore ForgivingBeing a Brain-Wise TherapistBetrayed as BoysBeyond Evidence-Based PsychotherapyBeyond MadnessBeyond PostmodernismBinge No MoreBiofeedback for the BrainBipolar DisorderBody PsychotherapyBoundaries and Boundary Violations in PsychoanalysisBrain Change TherapyBrain Science and Psychological DisordersBrain-Based Therapy with AdultsBrain-Based Therapy with Children and AdolescentsBrief Adolescent Therapy Homework PlannerBrief Child Therapy Homework PlannerBrief Therapy Homework PlannerBuffy the Vampire Slayer and PhilosophyBuilding on BionCare of the PsycheCase Studies in DepressionCaught in the NetChild and Adolescent Treatment for Social Work PracticeChoosing an Online TherapistChronic DepressionClinical Dilemmas in PsychotherapyClinical Handbook of Psychological DisordersClinical Intuition in PsychotherapyClinical Pearls of WisdomCo-Creating ChangeCognitive Therapy for Challenging ProblemsCompassionConfessions of a Former ChildConfidential RelationshipsConfidentiality and Mental HealthConfidingContemplative Psychotherapy EssentialsControlConversations About Psychology and Sexual OrientationCoping with BPDCouch FictionCounseling in GenderlandCounseling with Choice TheoryCouple SkillsCrazy for YouCreating a Life of Meaning and CompassionCreating HysteriaCritical Issues in PsychotherapyCrucial Choices, Crucial ChangesDeafness In MindDecoding the Ethics CodeDeconstructing PsychotherapyDeep Brain StimulationDemystifying TherapyDepression 101Depression in ContextDialogues on DifferenceDissociative ChildrenDo-It-Yourself Eye Movement Techniques for Emotional HealingDoing CBTE-TherapyEarly WarningEncountering the Sacred in PsychotherapyEnergy Psychology InteractiveErrant SelvesEssays on Philosophical CounselingEssentials of Wais-III AssessmentEthically Challenged ProfessionsEthics and Values in PsychotherapyEthics in Plain EnglishEthics in Psychotherapy and CounselingExpectationExploring the Self through PhotographyExpressing EmotionFacing Human SufferingFairbairn's Object Relations Theory in the Clinical SettingFamily TherapyFavorite Counseling and Therapy Homework AssignmentsFear of IntimacyFlourishingFolie a DeuxForms of Intersubjectivity in Infant Reasearch and Adult TreatmentFoundations of Ethical Practice, Research, and Teaching in PsychologyFreud and the Question of PseudoscienceFrom Morality to Mental HealthFundamentals of Psychoanalytic TechniqueGenes on the CouchGod & TherapyHalf Empty, Half FullHandbook of Clinical Psychopharmacology for TherapistsHandbook of Counseling and Psychotherapy with Lesbian, Gay, and Bisexual ClientsHandbook of Evidence-Based Therapies for Children and AdolescentsHealing the Heart and Mind with MindfulnessHeinz KohutHelping Children Cope With Disasters and TerrorismHigh RiskHistory of PsychotherapyHow Clients Make Therapy WorkHow Psychotherapists DevelopHow to Fail As a TherapistHow to Go to TherapyHypnosis for Inner Conflict ResolutionHypnosis for Smoking CessationI Never Promised You a Rose GardenIf Only I Had KnownIn Others' EyesIn SessionIn Therapy We TrustIn Treatment: Season 1Incorporating Spirituality in Counseling and PsychotherapyInside the SessionInside TherapyIs Long-Term Therapy Unethical?Issues in Philosophical CounselingIt's Not as Bad as It SeemsItís Your HourLearning from Our MistakesLearning Supportive PsychotherapyLetters to a Young TherapistLife CoachingLogotherapy and Existential AnalysisLove's ExecutionerMadness and DemocracyMaking the Big LeapMan's Search for MeaningMetaphoria: Metaphor and Guided Metaphor for Psychotherapy and HealingMind GamesMindfulness and AcceptanceMindfulness-Based Cognitive Therapy for DepressionMindworks: An Introduction to NLPMockingbird YearsMoments of EngagementMomma and the Meaning of LifeMotivational Interviewing: Preparing People For ChangeMulticulturalism and the Therapeutic ProcessMultifamily Groups in the Treatment of Severe Psychiatric DisordersNarrative PracticeOn the CouchOne Nation Under TherapyOur Inner WorldOur Last Great IllusionOutsider ArtOvercoming Destructive Beliefs, Feelings, and BehaviorsOverexposedPathways to SpiritualityPersonality and PsychotherapyPhilosophical CounselingPhilosophical Counselling and the UnconsciousPhilosophical Issues in Counseling and PsychotherapyPhilosophical PracticePhilosophy and PsychotherapyPhilosophy for Counselling and PsychotherapyPhilosophy PracticePhilosophy's Role in Counseling and PsychotherapyPillar of SaltPlan BPlato, Not Prozac!Polarities of ExperiencesPower GamesPractical Psychoanalysis for Therapists and PatientsPrinciples and Practice of Sex TherapyPsychologists Defying the CrowdPsychology, Psychotherapy, Psychoanalysis, and the Politics of Human RelationshipsPsychosis in the FamilyPsychotherapyPsychotherapyPsychotherapy and ConfidentialityPsychotherapy As PraxisPsychotherapy for Children and AdolescentsPsychotherapy for Personality DisordersPsychotherapy Is Worth ItPsychotherapy Isn't What You ThinkPsychotherapy with Adolescent Girls and Young WomenPsychotherapy with Children and AdolescentsPsychotherapy without the SelfPsychotherapy, American Culture, and Social PolicyRapid Cognitive TherapyRational Emotive Behavior TherapyRational Emotive Behavior TherapyRationality and the Pursuit of HappinessRebuilding Shattered LivesReclaiming Our ChildrenRecovery OptionsRelationalityRent Two Films and Let's Talk in the MorningSaving the Modern SoulScience and Pseudoscience in Clinical PsychologySecond-order Change in PsychotherapySelf-Compassion in PsychotherapySelf-Determination Theory in the ClinicSelf-Disclosure in Psychotherapy and RecoverySerious ShoppingSex, Therapy, and KidsSexual Orientation and Psychodynamic PsychotherapySigns of SafetySoul Murder RevisitedStaring at the SunStraight to JesusStrangers to OurselvesSubjective Experience and the Logic of the OtherTaking America Off DrugsTales of PsychotherapyTales of UnknowingTalk is Not EnoughTalking Cures and Placebo EffectsTelling SecretsThe Behavioral Medicine Treatment PlannerThe Body in PsychotherapyThe Brief Couples Therapy Homework Planner with DiskThe Case Formulation Approach to Cognitive-Behavior TherapyThe Challenge for Psychoanalysis and PsychotherapyThe Child and Adolescent Psychotherapy Treatment PlannerThe Clinical Child Documentation SourcebookThe Clinical Documentation SourcebookThe Complete Adult Psychotherapy Treatment PlannerThe Couch and the TreeThe Couples Psychotherapy Treatment PlannerThe Crucible of ExperienceThe Cure of SoulsThe Death of PsychotherapyThe Education of Mrs. BemisThe Ethical Treatment of DepressionThe Ethics of PsychoanalysisThe Gay and Lesbian Psychotherapy Treatment PlannerThe Gift of TherapyThe Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work The Healing JourneyThe Heart & Soul of ChangeThe Heroic ClientThe Husbands and Wives ClubThe Love CureThe Making of a TherapistThe Mindful TherapistThe Mirror Crack'dThe Mummy at the Dining Room TableThe Neuroscience of PsychotherapyThe Neuroscience of Psychotherapy: Healing the Social BrainThe New Rational TherapyThe Older Adult Psychotherapy Treatment PlannerThe Other Side of DesireThe Pastoral Counseling Treatment PlannerThe Philosopher's Autobiography The Pornographer's GriefThe Portable CoachThe Portable Ethicist for Mental Health Professionals The Present Moment in Psychotherapy and Everyday LifeThe Problem of EvilThe Problem with Cognitive Behavioural TherapyThe Psychodynamics of Gender and Gender RoleThe Psychotherapy Documentation PrimerThe Psychotherapy Documentation PrimerThe Psychotherapy of HopeThe Real World Guide to Psychotherapy PracticeThe Schopenhauer CureThe Sex Lives of TeenagersThe Talking CureThe Therapeutic "Aha!"The Therapist's Guide to PsychopharmacologyThe Therapist's Guide to Psychopharmacology, Revised EditionThe Therapist's Ultimate Solution BookThe Trauma of Everyday LifeThe UnsayableThe Way of the JournalTheory and Practice of Brief TherapyTherapy with ChildrenTherapy's DelusionsTheraScribe 3.0 for WindowsTheraScribe 4.0Thinking about ThinkingThinking for CliniciansThinking for CliniciansThoughts Without a ThinkerThriveToward a Psychology of AwakeningTracking Mental Health OutcomesTrauma, Truth and ReconciliationTreating Attachment DisordersTreatment for Chronic DepressionTreatment Plans and Interventions for Depression and Anxiety DisordersUnderstanding Child MolestersUnspeakable Truths and Happy EndingsWhat the Buddha FeltWhat Works for Whom?What Works for Whom? Second EditionWhen the Body SpeaksWhispers from the EastWise TherapyWittgenstein and PsychotherapyWorking MindsWoulda, Coulda, ShouldaWriting About PatientsYoga Skills for Therapists:Yoga Therapy
Inside the Session: What Really Happens in Psychotherapy by Paul L. Wachtel makes a bold promise: to take us inside the therapeutic encounter and unveil its mysteries. Hollywood has made similar promises, resulting in depictions of therapy that may satisfy public’s appetite for drama, but rarely seem accurate to clinicians. What is considered one of television’s most realistic portrayals of therapy--Tony’s treatment by Dr. Melfi on the Sopraonos--involves a challenge few therapists’ will ever encounter: curing a murderous gangster.
Though the assumption may be that psychotherapy is full of dramatic revelations and salacious details, much of what goes on in psychotherapy is often banal, and less entertaining than a casual observer might hope. What therapy does involve is attentive listening to often subtle shades of meaning and feeling, which is hard to convey on screen, or even on the page.
As a result, those training to be therapists are often confused about how to enact their role. Things are not any better when professionals attempt to understand what others are doing in the consulting room. As Wachtel notes, case examples in the clinical literature are often carefully constructed to demonstrate successful techniques or theoretical points. There are few opportunities to observe a clinician at work in a realistic context and to understand exactly how the therapist is approaching the material.
Wachtel, a prolific contributor to the literature on therapeutic technique and a founder of the Society for the Exploration of Psychotherapy Integration, attempts to remedy this gap. He presents verbatim transcripts of three clinical sessions, annotated with his observations of what he was thinking at the time and explaining the basis for his understandings and interventions. The result is an illuminating perspective of a master clinician at work.
The project began when Wachtel was invited to demonstrate his work for an American Psychological Association (APA) video series, in which noted therapists interview patients and discuss their work with an interviewer. Wachtel decided to write a book using the transcripts of the video sessions to discuss his treatment approach. An advantage of this book is that the video of one of the sessions Wachtel discusses is available for viewing from APA. So it is possible not only to read the transcript, but see the actual session.
Wachtel filmed three sessions for the series: two with one patient and one with another (only one session is available on video). The transcripts are preceeded by an excellent chapter summarizing Wachtel’s therapeutic approach. Originally steeped in the psychoanalytic tradition, Wachtel, in a courageous sign of open-mindedness, started to study the practice of behavior therapy in the 1970s. He expected to find a superficial approach to treatment without the depth and richness of the psychoanalytic approach, but Wachtel was surprised to find the behavioral therapists he observed were sophisticated and sensitive clinicians whose approach could be quite helpful. The experience sent Wachtel down the path of integrating aspects of other theoretical approaches into his “home” theory of psychoanalysis.
Interestingly, I viewed the tape with several groups of students before the book was available and found Wachtel’s work to be solidly psychoanalytic; in fact, not much different from how I imagined many psychoanalytically oriented therapists would approach a first session. Reading his commentary, though, it became clear the way Wachtel’s immersion in a variety of approaches informs his work. Even in what is meant to be a one-session therapeutic encounter, Wachtel frames his questions and comments in ways to help the patient not only express and understand her experience, and also aims to aid the patient in contemplating ways to interact with others. This emphasis follows from Wachtel’s understanding, based on behavioral approaches, that change can’t occur unless patients take actions so they learn to overcome their fears and practice new skills.
Wachtel’s approach to working with patients’ defenses is also noteworthy. Rather than “interpreting defenses” in ways that may lead the patient to feel she is being criticized for hiding something, Wachtel has developed a number of ways of talking with patients to help them become increasingly comfortable exploring difficult material. (These are explored more fully in Wachtel’s useful book, Therapeutic Communication, now in its second edition.)
The session from the video presents a challenging clinical problem: the patient is in the midst of feud with her in-laws and feels terribly victimized. Wachtel quickly surmises that the patient’s own dismissive and distant stance--which she does not acknowledge--has contributed to the conflict. While empathizing with the patient’s sense of hurt, Wachtel describes his efforts to help the patient observe and accept her contribution to the difficulty. Helping patients aware of their contributions to interpersonal conflict is important for many psychoanalytic therapists, but Wachtel describes in a novel way why this is so important. Unlike other psychoanalytically oriented practitioners, who often see patient’s counterproductive attitudes as stemming from relationship patterns deeply formed in early life, Wachtel sees early experience as starting a process that is maintained by the patient’s current attempts to prevent feeling emotional pain. These attempts, paradoxically, often elicit from others the disappointing reactions they believe they are trying to avoid. These “vicious circles” lead them to create environments which maintain their difficulties. Intervening to bring awareness to actions that are part of these patters is important, but must be done carefully.
“The tone is not one of pointing out to the patient that she is leaving out her own role in the process, which can easily have the feeling and connotation that what happens is her fault,” he writes. “Rather, much of the aim is to enable to see almost the opposite--that is, that it is not her ‘fault’--because it is a consequence of the vicious circle in which she is trapped, an almost inexorable consequence of the very feelings that she is aiming to overcome. At the same time, the inquiry into how she acts with them provides her with a handle that may help her in breaking the cycle (p. 93).”
Wachtel’s description of how he sees this process occurring in the material presented by the patient allows for a particularly instructive in vivo experience of how this therapist works. For that and other reasons, the approach to presenting therapeutic work in this volume is valuable, one I would recommend be adopted regularly by therapists from all approaches. Reading an account of how the therapist sees the material and what he is thinking--including where he’s made mistakes, or wished he said something different--is refreshing and informative.
However, there are problems with the sessions presented in this book. Wachtel is clearly aware of the unusual nature of his encounters with these patients and explains his thinking about how this led him to practice differently than usual. He candidly observes that the situation may have led him to be overly active as he attempted to demonstrate his approach in the short period of time available to him. Still, these sessions are so different from practice as usual that many important questions are left unanswered.Many important issues in the conduct of therapy can’t be addressed in a one or even two-session “treatment.” Wachtel is critical of traditional psychoanalytic approaches that focus too exclusively on what is going on in the room between patient and therapist, but how does he handle transference? Does he allude to it often, or only when it demonstrably interferes with the work? When does he employ techniques, such as behavioral counterconditioning, and how does he make such transitions? How does he monitor the patient’s progress over time and deal with protracted resistances? Wachtel identifies with the Relational approach to psychoanalysis, but does this mean he finds little place for considering sexual or aggressive motivations highlighted by more traditional analysts? Answers to these sorts of questions likely would have emerged if the book focused on more extended, typical psychotherapies.
Nevertheless, Wachtel breaks important ground in presenting an approach to sharing his clinical work that fills an important gap in the psychotherapy literature, which doesn’t give a good sense of how clinicians conceptualize their work in the actual clinical moment. I hope that he and others will make this approach a new tradition and that it will be possible to apply it to more conventional psychotherapies.
© 2012 Robert Cohen
Robert Cohen, Ph.D. is Professor of psychology at Madonna University in Livonia, Michigan, where he also is director of supervision and training for the Masters of Science in Clinical Psychology Program. He is also an associate faculty member at the Michigan Psychoanalytic Institute. Dr. Cohen practices psychotherapy with adults, children and couples in Ann Arbor, Michigan.