Psychotherapy
1. Introductory remarks
Psychotherapy can be defined as the attempt to change cognitions, emotions, and behaviours in
humans who suffer from maladaptive consequences of their behaviour or have caused suffering in others, by means of scientifically evaluated psychological techniques and interventions.
Central to all kinds of psychotherapy is the assumption that alternative strategies to cope
with interpersonal stress or other adverse stimuli can be accomplished throughout the
human lifespan through learning and experience, albeit with different likelihood of
success depending on age at onset, duration, and severity of the underlying disorder.
It is widely acknowledged among psychotherapists that logic in therapeutic discourse alone
does not suffice to enable a patient to give up maladaptive strategies;rather,it is essential
that the patient feels a difference; perhaps first imaginatively, and later on, as therapy
progresses, as part of his or her 'real life' experience. Even though it becomes increasingly
clear that psychotherapy has the potential to induce long-lasting changes in brain
activation, particularly in the most recently evolved cortical midline structures involved
in the representation of self and others, and in phylogenetically older brain centres
involved in emotion regulation,the fact that any kind of psychotherapy is deeply rooted in the
evolved psychology of our species is more implicitly, rather than explicitly, approved by therapists.
Mental representation of self and others is, however, at the core of interpersonal and intrapersonal conflict, as well as of conflict resolution.
The ability to infer mental states and anticipate future actions of other individuals may
not only have been a major driving force in human brain evolution, but also a major
source of cognitive distortion causing psychological distress (for further details,
see Chapters 2 and 5).
2. Historical developments in psychotherapy
The origins of psychotherapeutic treatment date back to the late 19th century when
Sigmund Freud and Josef Breuer developed what later became known as psychoanalysis
and psychoanalytic psychotherapy. The value of many of Freud's discoveries cannot be
overestimated, although several of his ideas appear scientifically flawed today. Above all,
the fact that most of our mental life is unconscious and only small fragments of mental
processes surface conscious reflection or are accessible to the reflexive self has greatly changed our view of human mentality in pervasive ways. It was also Freud who emphasized the important role of phylogenetic ancient drives and motives for human psychology, and that disintegration of drives and motives with an individual's conscious desires, expectations and self-appraisal has the potential to cause psychological malfunctioning and subjective
distress. Even though Freud recognized evolution as an important scientific concept to
explain human psychology, his conceptualization was strongly influenced by the assumption
of Lamarckian inheritance (inheritance of acquired characters), recapitulation
theory (the repetition of phylogeny in ontogeny), and group selection (as opposed to
individual and kin selection). For reasons that may have lain in his personal history (he
was brought up by a nanny, while his mother remained unattainable for him), Freud
came to overemphasize infantile sexuality and the Oedipal model as central to intrapsychic conflict( although it has been argued that the Oedipal situation may have evolved
as an unconscious 'seductive' strategy of the infant to increase parental investment).
Moreover, he did not recognize that incest avoidance was deeply rooted in biology and
clearly a selected mechanism to avoid accumulation of deleterious mutations,rather
than being part of a universal neurosis that manifested through repression of incestuous
impulses. Today, Freud's drive theory appears simplistic and overly mechanistic, and his
overemphasis of aggressive instincts as driving forces behind human behaviour is no
longer shared by most therapists (although still prevalent in many textbooks).
Freud's colleagues Carl Gustav Jung and Alfred Adler developed their ideas
independent of Freud and took many of the basic psychoanalytic hypotheses further. Both acknowledged the importance of non-conscious information processing and the role of defence mechanisms in coping with intrapersonal conflict. Similar to Freud,they were convinced that much of an individual's non conscious mental life was brought to surface in dreams and by 'free association'. Jung elaborated upon the phylogenetic aspects of human mental life shared by all individuals (called 'collective unconscious')represented in 'archetypes', which Jung conceived of as being much richer and diverse compared to Freud's drive theory.
By contrast, Adler focused on compensation of inherited 'inferiority feelings' as a basic psychological mechanism shaping an individual's life-style. In contrast to Freud, Adler recognized the importance of sociality ('community feeling')for human development and the impact of early rearing conditions and birth order on individual psychological development. Both Jung and
Adler believed that therapeutic success was linked to the quality of the therapeutic
relationship and that a warm, accepting and empathetic alliance with the patient was
vital to psychotherapy, which to some extent differed fundamentally to Freud's more
distant-analytic perspective.
In the 1950, John Bowlby and his pupils began to develop attachment theory by combining insights from psychoanalysis with ethology, and developmental and cognitive psychology. Bowlby came to realize that the quality of an infant's emotional relationship with his or her primary caregiver, including the development of feelings of security and protection, had the potential to bias cognitive processes in terms of expectations and predictions
of future interpersonal relationships in adult life. In other words, personality development
entails the emergence of mental templates or models of self and others representations, which,in part, determine the way an individual unconsciously creates his or her
interpersonal and social environment, based on so-called inner working models. This
focus on early actual relationships was at odds with classic analytic views that a child's
primary motivation to bond with its mother is motivated by the infant's polymorphic
sexual drives. Instead, Bowlby and his co-workers saw human behaviour guided by
innate tendencies to secure survival through establishing close proximity to an
attachment figure, usually the mother. Accordingly,the attachment system is automatically
activated when an infant perceives threat or danger (compare Chapter 3).
If the caregiver is unavailable, unresponsive to the infant's needs or even abusive, hyperactivation or deactivation of the attachment system are secondary strategies to either retain proximity or to distance oneself from others by denying threat to the individual's sense of security. Unlike classic psychoanalysis, attachment theory sees actual interpersonal conflict and internalized models of interpersonal relationships at the core of psychological problems,rather than conflict between
divergent drives, motives, and fantasies.
Behaviourism and cognitive social learning theori
es were originally formulated in diametrical opposition to psychoanalytic theory.
es were originally formulated in diametrical opposition to psychoanalytic theory.
In particular,these theories utterly denied the existence of innate behavioural predispositions. On the contrary, early behaviourists assumed that humans were born as 'blank sheets', and that behaviour was simply the result of learned or conditioned responses, which, in the case of maladaptive behaviour, could simply be unlearned (through extinction).
This perspective greatly neglected the role of biological motives,individual development and defence mechanisms in favour of situational influences on cognition and behaviour.
Conditioning surely contributes to the acquisition of fear and anxiety or pathological habits such as substance dependence and compulsive behaviour.
It needs to be emphasized, however,that learning has a biological basis itself that cannot be separated from an individual's genetic endowment and early environmental contingencies, perhaps even those in one's foetal life.
On the contrary, imprinting-like learning during an individual's foetal and early postnatal period may perhaps be most impervious to therapeutic modification later in life. The role of early
experience is now widely recognized among behaviour therapists, and with regards to the
anxiety disorders, evolutionary ideas have been incorporated into the psychoeducational
part of behaviour therapy. Moreover,the proposition of 'cognitive schemas' by cognitive
behaviour therapy is in many respects akin to the assumption of evolved information
processing biases that are modified through individual experience.
As the sharp distinction between analytic and behavioural concepts of personality
development and psychological problems has increasingly proven impracticable and
scientifically untenable, it is now time to integrate the complex interactions between
early and present experience, genetics, and the evolutionary history of our species. This
complex interplay sets the stage for human interaction,including the patient or
client-therapist relationship. Hence, any form of psychotherapy, whatever 'school' it may
belong to, ought to consider an integrative perspective including the basic needs for
security, protection,respect and empathetic containment, which all humans share as
members of the same species.
3. Patient-therapist or client-therapist relationship
There has been considerable debate over the question what actually helps a patient in
psychotherapy. Although still not entirely clear,there is consensus that the role of the
patient-therapist or client-therapist relationship cannot be overestimated, whereas the
particular therapeutic method is perhaps less important compared to patient and
therapist variables (some professionals favour the term 'client' over 'patient', because the former does not exclusively invoke pathology as source of help seeking; here,the terms are more or less used interchangeably). The differential contributions of relationship and method to therapeutic success vary, however, according to the nature
and complexity of the disorder. In the treatment of complex personality disorders
relationship-associated variables may be more important, whereas in the treatment of
simple phobias the use of a manual-driven approach may prevail over therapist variables.
Among the most important determinants of a successful basis for psychotherapy on the
side of the therapist is the ability to be genuinely empathetic and accepting, and
to create a therapeutic atmosphere that is as egalitarian and reciprocal as possible
to foster trust,feelings of safeness, and protection from further traumatization in the patient.
In some respect,the therapeutic alliance should emulate the safety and stability of a kinship
bond, diminish the dominance hierarchy between patient and therapist, and thus help to avoid distant professionalism. Such a therapeutic stance acknowledges the role of evolved psychological mechanisms involved in the formation of trustful interpersonal
alliances. At the same time, however,the therapist should be able to set clear boundaries
and be straightforward about the prerequisites for a trustful therapeutic alliance.
For example,it should be made clear to the patient that successful therapy requires
abstinence from drug and alcohol consumption, because intoxication leads to distorted
reality perception and may cause inappropriate behaviour. Moreover, some clients may
strive for a deeper relationship than is professionally acceptable or warranted, and
limitations of the therapist's availability ought to be pointed out. To avoid disappointment or
confusion on either side,it may be useful –depending on the nature of the disorder–to
explicitly reach consensus overrules of conduct before formally commencing therapy,
perhaps using a leaflet or information sheet, or even a written contract about rules
of conduct. It can be assumed that all patients benefit from an unambiguous therapeutic
attitude.
Beyond attitude and role models, a therapist's authenticity critically depends on his or her non-
verbal behaviour. Many patients are hypervigilant to deception and may therefore quickly sense if the therapist is not sincerely interested in the patient's needs and emotional distress, or unconsciously signals ambivalent feelings toward the patient. In addition, subtle signs of hierarchizing such as an elevated sitting position or perhaps simply a desk put between the client's and the therapist's chairs, as well as, signs of unconscious rejection like folding one's arms or turning away from the patient ought to be avoided.
Therapists should be able to carefully self-monitor their nonverbal behaviour.
On the other hand,therapists should forestall clients' perception of the therapist as being subordinate, emotionally weak or inconsistent, because such inequality may be equally deleterious to therapeutic progress.
On the patient or client's side, it is important that a patient has the genuine wish for a
change,though some patients initially expect that others change attitudes and behaviour,
rather than they themselves. A useful categorization of a client's willingness to actively
engage in therapy has been put forth by the school of Brief Therapy, according to which a
'visitor' does not see the therapist on a voluntary basis, has no complaints and no
expectations regarding a change of the current situation. In such a case,therapy is impossible.
A 'complainant' is subjectively distressed but expects others to change. Complainants
should be encouraged to consider alternatives to their current(maladaptive) behaviour.
A 'customer' is genuinely motivated to change the situation, and may respond best to
therapeutic interventions that aim at enabling the patient to give up dysfunctional
behaviour and to pursue biosocial goals more effectively. Active support and encouraging
the patient to take a chance for a change may be warranted in patients with pronounced
tendencies of regression.
In addition to determining a client's (unconscious) motivation for therapy,it may be
helpful to explore the client's representation or state of mind of attachment. In adults,
the way past relationships with important attachment figures are represented and verbalized corresponds with the individual's acquired attachment style in infancy. Incoherent verbalization sugges
ts insecure attachment during infancy and childhood.
ts insecure attachment during infancy and childhood.
Insecurely attached individuals may either have difficulties in remembering their childhood or over-idealize parents. They have a dismissing state of mind; as children,they most likely developed an avoidant attachment style.
Others are quickly overwhelmed by adverse memories when asked about their
relationship to parents and have preoccupied states of mind. They may switch from
idealization to anger and rage when recalling aspects of the primary attachment figure.
As children,they usually displayed an ambivalent attachment style. Individuals who as
children experienced abuse or neglect or were otherwise traumatized due to the
unavailability of a primary attachment figure and lack of protection and security often report
childhood memories in a pronounced disorganized way (compare Chapter 3).
The importance of a careful evaluation of attachment representations in adult clients
lies in the fact that past experiences with primary caregivers shape an individual's ability
to represent self and others' mental states. Moreover,it has a profound impact on how
current relationships are formed,including the therapeutic relationship. Hence,the
exploration of the client's current problems along with his or her way to arrange close
relationships may help the therapist to get an impression how the therapeutic alliance
may develop, and how the individual therapeutic process should ideally be tailored
according to the patient's needs.
The apparent paradox here is –contrary to widely held views that parents' emotional
responsiveness and availability bears the risk of 'spoiling' the infant –that securely
attached individuals whose primary caregivers respond to infants' needs, are emotionally
available and provided a safe haven for infants from which they can explore the
environment, and are better able to move to a mature autonomous state. Securely attached
individuals are also better at reflecting upon their own and others' mental states, compared to
individuals whose primary attachment figures are emotionally unavailable or even
abusive. It is the latter who have more difficulties in maintaining trusting interpersonal
relationships, and who chronically over-activate or deactivate their attachment systems.
4. The social brain and psychotherapy
Sociality and proximity to significant others are central to human nature throughout the human
lifespan (and not needs that have to be outgrown).
These basic needs are ultimately linked with human immaturity at birth,long dependence on parental care and other aspects of human life history such as the formation of long-term pair-bonds and investment in offspring of both sexes (compare Chapter 3).
Human psychology is designed by nature to guide the individual in accomplishing biosocial goals, which include care-giving, care-eliciting,forming social bonds and alliances, attaining social status, and mating.
Successful accomplishment of these goals may increase the likelihood of translation into reproductive success, but humans are by no means fitness maximizers in that they are able to (consciously) calculate how to increase their inclusive fitness (compare Chapter1).
Due to the complexity of ancestral human communities with the need to delicately
balance selfish and altruistic behaviour, humans have evolved a set of psychological
mechanisms to evaluate reciprocality and cooperation by means of detecting cheaters,
collectively punishing cheaters, but also to subtly deceive others. These social manoeuvres
have induced a cognitive 'arms race', which has led to sophisticated ways to predict the behaviour of others by inferring their mental states. Competition between selfish motives and altruism may be an important source of intrapersonal conflict.
The emotions of shame and guilt may have specifically
evolved through group-selection and to maintain reciprocal relationships. The induction
of guilt and shame serve manipulative purposes to reinforce the cooperative behaviour of
individuals who under specific circumstances are tempted to behave selfishly. However,
the possibility to act in selfish ways is enhanced by the cognitive ability to conceal one's
real motives before the self,referred to as 'self-deception'. Self-deception may in the first
place have evolved to enhance the ability to deceive others, because if an individual is
unaware of his or her selfish motives,it is easier to send more convincing signals to others
so as to disguise the individual's real intention. This assumption is intriguing because it suggests that natural selection has not favoured cognitive capacities to produce accurate images of the world, but to systematically distort conscious awareness and to block inadvertent access to non-conscious information processing. These mechanisms are active in distinct ways in healthy as well as disordered mental life, and play an important role in psychological problems and disorders requiring psychotherapy.
The primary target of any therapeutic intervention including psychotherapy is the
reduction of mental pain and subjective distress. Mental pain can be seen as an adaptive
signal to alert the individual of impending or actual threats or losses. Psychopathology
often arises if individuals are precluded from achieving biosocial goals and forced to use inappropriate defences as secondary strategies to achieve biosocial goals.
Excessive mental pain and suffering may result from continuing obstruction of biosocial goals, and chronic activation of the physiological stress axis may lead to a vicious circle by producing anger, despair, and more distress.
The difference between adaptive mental pain and pathological mental pain causing suffering and
enduring subjective distress is, however, a matter of degree,rather than category.
Thwarting of biosocial goals may be caused by actual recent adverse or traumatic
experiences, such as loss of job, divorce, or loss of important attachment figures. However,
current problems always meet an individual's personal history and endowment to cope
with stressful life-events. Here, genetic variation, early experiences and relationships with
significant others, as well as gene-environment interaction affect an individual's actual
vulnerability, but also resilience against pathological stress responses.
Both healthy and disordered individuals possess several built-in means to reduce mental pain,to
suppress painful memories, and to conceal unacceptable feelings or desires before the self by
keeping them unconscious. The overarching mechanism through which this is achieved is
commonly referred to as 'repression', a process akin to self-deception.
Generally speaking,repression serves the function to actively distort
cognitive processes to decrease anxiety and keep dysfunctional pain out of conscious
awareness. It may also serve the purpose to inflate one's self-esteem so as to see one's role
in social competition more optimistically. Repression is also ubiquitously involved in
regulating important biosocial goals including sexuality and interpersonal
communication, which underscores that it increases an individual's biological fitness, unless it
become inflexible and pervasive. This can, however, happen in situations in which an
unresol
ved conflict remains active, and resurfaces unintentionally and repetitively in
ved conflict remains active, and resurfaces unintentionally and repetitively in
experience and behaviour.
In its broader meaning,the term 'repression' embraces a set of self-deceptive defence
mechanisms that combine denial of intolerable or unmanageable feelings with different modes of representations of self and others, where the maturity of denial and representation are inversely correlated. Mature defences involve more sophisticated forms of denial, but less difficulties in self-other distinction, whereas immature defences are characterized by the inability to differentiate between own and others' mental states and hence,loosening of ego-boundaries. Accordingly, mature defence mechanisms comprise intellectualization (excessive
use of abstract thinking to conceal unacceptable motives),rationalization (rational
justification of emotionally motivated action), and sublimation (partial satisfaction of
unconscious motives by means of culturally accepted activities), whereas introjection
(internalizing values or characteristics of another person), projection (attribution of
one's own desires to another person, where paranoid ideation is the psychotic extreme of
projection), and projective identification (projection of one's own negative attributes to a
significant other with the tendency to introject the originally projected attributes) are
considered to be more ontogenetically 'primitive' and immature defence mechanisms.
Other,relatively mature defence mechanisms are displacement,isolation, and reaction
formation, with identification with the aggressor, dissociation and fragmentation lying at
the immature end of possible defences.
Since early social relationships with primary caregivers have lasting effects on an
individual's attitudes towards present and future patterns of social interaction, and the way
mentalities of others are appreciated, it is intuitively plausible that patients with early
traumatic experiences have greater difficulties in mental state attribution and hence use
'primitive' defence mechanisms more often than individuals who as children developed secure
attachment and an autonomous state of mind.
However,the activation of mature versus immature defence mechanisms critically depends on the level of psychological distress. In situations associated with extreme real threats or dangers (such as warfare, being taken as hostage, victimization through sexual coercion etc.), perhaps everyone would tend to activate his or her attachment system, use more primitive defence mechanisms, and shut down one's mentalizing system.
In other words,the activation of the attachment
system inhibits mentalization in both normal and abnormal personality development.
For example, healthy individuals who fall in love tend to ignore the less desirable
features of the loved one. In a similar vein, people who have experienced recurrent
trauma during early childhood chronically activate their attachment systems, and
hence shut down their mentalizing systems. Consequently,traumatized individuals
are particularly vulnerable to making use of immature defence mechanisms. Due to
their impaired ability to accurately represent own and other's mental states,they
may have more difficulties in distinguishing inner and outer reality, be more intolerant
of alternative perspectives or tend to construct mental images of the world that no
longer resemble reality. For example, a person with a history of childhood abuse may
as adult tend to identify with an abuser, disavow the abuser's malicious intents,
or even direct negative affect towards the self in the way that he or she 'deserves'
maltreatment.
These examples may illustrate that mentalizing is at the core of evolved human
psychology and individual development. As the costly side of the coin,the mentalizing system may be particularly vulnerable to dysfunction (compare Chapters 3 and 4). However,this does by no means imply therapeutic nihilism. Rather, because the development of mentalizing abilities critically depends on environmental input,this cognitive capacity is one of the most 'open programmes', and therefore flexible enough to be retrained and modulated later in life. Mentalizing is essentially involved in regulating social interaction between individuals and should accordingly be actively encouraged and maintained in psychotherapeutic discourse.
The therapist has the difficult task, however,to find the
appropriate balance between inspiration of mentalizing in the patient and activation of
the patient's attachment system. Treating patients with severe personality disorders
may therefore require a careful examination of the patient's ability to mentalize. Poor
mentalizers tend to focus on external social factors,the physical environment, and
are often preoccupied with social rules and norms. At the same time,they may have
difficulties in expressing anger Wトen norms are violated by others. Poor mentalizers also
tend to generalize and express rigidity or inappropriate certainty about the thoughts
and feelings of others. A possible explanation could be that emotionally unresponsive
or unavailable primary caregivers, who themselves have difficulties in appreciating
their child's mental states, may tend to overly induce shame and guilt in the child to
sanction the child's selfish behaviour. Individuals who were reared in emotionally
unresponsive conditions may then tend to obey to those rules that are acceptable for
the parent, but unconsciously act upon repressed selfish motives, and appreciate
own and others' mental states only in an inflexible one-sided way. As adult patients or
clients,these individuals may perhaps express over-confidence in their mental state
attributions to others and deny objective realities that are not consistent with their
self-interests and preferences.
Mentalizing in psychotherapy entails a process of joint attention focussing on the
patient's mental states. This often requires the therapist to be active in questioning and constructing images of the patient's mental states. The main goal is to help the patient access and explore his or her mental life and to encourage him or her to think about alternative perspectives on interpersonal processes. However, as mentalizing and attachment are inversely related, mentalizing may be discouraged when the patient is overwhelmed with emotions in favour of empathy and support. A patient's ability to accept mentalizing interventions depends on his or her experience of the therapeutic relationship as a 'secure base'.
From such a base, patients may be able to adopt alternative, more trustful models of interpersonal relationships,to give up dysfunctional modes of repression, and to improve emotion regulation.
Focussing on the therapeutic relationship and mentalizing processes emphasizes the
view that psychotherapy in general may benefit from insights of human cognitive and
emotional evolution, and that one of the most recently evolved human capacities may be
actively used to reduce subjective distress and suffering. Most 'schools' of psychotherapy,
not only psychodynamic approaches, acknowledge that the quality of the therapeutic
relationship influences outcome and prognosis of the therapeutic process. Likewise,
working with patients' and therapists' mental states is part of many forms of
psychothera
peutic interventions. Encouraging patients to apprehend their own mental states and
peutic interventions. Encouraging patients to apprehend their own mental states and
those of significant others is certainly a useful tool across psychotherapeutic modalities,
but should be carefully monitored,regardless whether psychodynamic or cognitive-
behavioural intervention techniques are preferred.
5. Sex differences in response to psychotherapy
Differences in the psychology of men and women may influence psychotherapy in many ways. For example, differences between the sexes exist regarding vulnerability to psychosocial stressors. Adverse life events, such as disruption of an emotionally
intense relationship, physical or sexual abuse, usually have greater impact on females.
Conversely, males may be particularly susceptible to develop psychological distress due to
actual or impending loss of social status. These differences may not only account for greater
prevalence rates of depression, anxiety disorders or post-traumatic stress disorder in women,
but also for differences in seeking therapeutic help, and response to treatment. Differences
between men and women are deeply anchored in divergent adaptations of men and women
to problems relating to the need to cooperate,to form close relationships with kin,to
compete for mates, and to successfully reproduce (for details, see Chapter1). Typically, men
are selected to compete intra-sexually for access to women. Women, by contrast, are selected
to invest more heavily in potential offspring, and therefore,to carefully select suitable mates.
Human females are highly cooperative breeders, a mechanism through which humans were
able to shorten inter-birth intervals considerably. Men, in contrast to women, face the
problem of uncertain paternity, which has led to greater sexual jealousy in men (whereas
emotional jealousy can also be intense in women; for details, see Chapters 1 and 16).
In psychotherapy,these divergent behavioural tendencies in men and women may manifest in differences in verbalization of emotional problems, response to emotional and social support, use of submissive behaviours, dysfunctional coping strategies such as drug or alcohol abuse, challenging the value of therapy, and feelings of being stigmatized by therapy. Men,for example, are more likely to conceal emotions,feelings of inferiority or vulnerability, whereas women may 'attach' to the therapist more easily compared to men. So it could be that women, even though they more often suffer severe trauma, including those that transgress important personal boundaries such as physical or sexual abuse,respond better to psychotherapy, because of women's greater openness and superior ability to verbalize and re-integrate negative emotions. In contrast, men may experience psychotherapeutic aid as a threat to social status and independence, which could explain men's greater reluctance to seek therapy.
Taking these differences between the sexes seriously suggests that, depending on the
nature of the disorder or psychological problem, women may be better therapists
for women, and men may be better therapists for men. Acknowledging sex differences in
behaviour may also be useful in special therapeutic settings such as couples therapy and
other systemic approaches.
Afterthought: Are there side-effects of psychotherapy?
The question whether or not psychotherapeutic interventions can have adverse effects
has received little attention. The matter is indeed hard to address empirically, because,
unlike studies into psychopharmacology, double-blind placebo controlled approaches
are impracticable. Anecdotal reports suggest, however, that transgression of therapeutic
rules and norms by the therapist can occur,if counter-transference is poorly controlled
and the therapist fails to maintain therapeutic abstinence. In extreme cases this may
include a sexual relationship between therapist and client. Psychotherapists acting that
way disregard the special vulnerability of patients seeking attachment and a secure base,
or even mistake a client's dysfunctional sexual advances for mature behaviour. Although
no data exist, such violations of rules of conduct in psychotherapy on the side of
the therapist are probably rare. In the strict sense, norm violations in therapy cannot
be considered side-effects, because, by definition, side-effects occur despite proper
application of treatment.
From an evolutionary point of view, which emphasizes the role of nonverbal
communication between client and therapist,the classic settings of psychoanalysis may produce
harmful effects in patients whose disorders require visual contact and exchange of supportive
nonverbal signals or patients whose condition may deteriorate if regressive tendencies
induce overwhelming feelings of helplessness. Thus,in the treatment of patients with
severe depression or personality disorders,for example,techniques such as 'free association'
while the therapist is out of sight of the patient may have deleterious side-effects. Moreover,
patients who are traumatized or have otherwise developed insecure attachment styles
probably do not benefit from therapeutic neutrality. Instead, many patients require active
encouragement, positive motivation,reassurance and empathy (see above).
A disturbing finding is that patients with severe personality disorder may experience a
substantial reduction of symptoms or even remission without therapy, and that
spontaneous recovery rates may even be higher than in patients who have received treatment. One speculative explanation that has been suggested is that patients with severe personality
disorders who have deficits in mentalizing have difficulties in integrating interventions in
insight-oriented psychotherapies,i.e.interpretations of the patient's mental states offered
by the therapist. In other words, dissonance between the patient's inner experience and the
therapist's interpretation thereof may cause emotional turmoil and instability. Thus,
premature explanations of unconscious material should be avoided in such patients.
Conversely, helping patients to understand own and others' mental states may be
harmful if these patients misuse the ability to mentalize for deceptive and exploitative
(selfish) purposes. Individuals with psychopathy usually have highly developed
mentalizing skills, however,they fail to empathize with others. Improving mentalizing in
psychopaths may therefore have a profoundly negative impact on interpersonal
relationships in many ways. For example, skillful psychopathic mentalizers may better be able to
anticipate and predict the behaviour of potential victims. Moreover, violent psychopaths
in forensic custody with good mentalizing qualities may have the potential to convince
therapists of their apparent progress in therapy.
Many more scenarios of possible side-effects of psychotherapy are conceivable. Future
studies may be able to clarify some of the issues raised above. In any event, all
psychotherapeutic tools should be critically evaluated in terms of differential indication and possible contraindications.