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Comparing Basic Assumptions of Different Approaches to Psychotherapy

When we look at different approaches to psychotherapy, we are actually not looking at interchangeable strategies, techniques, or interventions. Each approach has its own set of theoretical, ethical, relational, and structural assumptions. And each set of assumptions leads to and even dictates the role of the therapist and the nature of the relationship between the therapist and the client. First, let’s look at the basic premise of some common approaches – Gestalt therapy, Psychoanalysis, Behavior therapy, Cognitive Behavioral therapy, and EMDR. We need to consider what is their way of looking at what people are, what their view of health is, and what their view of the nature of problems is: GT: Gestalt therapists see the field as constantly emergent, as are people. That means that people are not static, but are constantly developing, needing, responding. The Self is the purely emergent expression of the person/organism. But self and organism do not exist without an on-going contact with the field (the world around us). Problems come to exist when the fluid contact between the person and the “field” is interrupted in a chronic and unaware manner. PA: In classical psychoanalysis, people are seen as being a function of their past, and are determined by a history that they do not remember as they experienced it. Painful experiences and forbidden aspects of the person are repressed and exiled to the “unconscious” mind, where they control the person’s feelings and behavior. Symptoms and neurosis therefore result from excessive deposits in that repository. BT: Behavior therapy sees people as largely a complex set of stimulus/response circuits. Some are set improperly, and need to be re-set. The “reasons” that they were set improperly (e.g. bad learning, trauma, neglect, etc) are not given great importance in the treatment. Rather, the correcting, and unlearning of maladaptive associative/behavioral patterns are given focus. CBT: Cognitive behavior therapy holds much the same premise as BT, but with the intermediating element of cognition or thought. Problems exist when the circuits have been set improperly based on or resulting in faulty cognition. These circuits need to be re-set, utilizing thoughts: maladaptive or irrational thoughts are found and adaptive, reasonable thoughts are substituted. EMDR: EMDR is actually a branch of BT – problems exist when trauma screws up the circuitry in the brain. Circuits need to be re-set. The premise leads to the method and the role of the therapist: GT: Gestalt therapy utilizes a phenomenological exploration of the contact style of the person, looking at what is emergent (what needs and interests are pressing for awareness and satisfaction), and the interruption of the emergence. Gestalt therapists are interested in “what gets in the way” of the healthy process of need emergence, effective action, and satisfaction, and look to see how that happens in the therapy room. Since GT looks at the whole person and the field relationships (the person’s involvement or lack of involvement with h/her environment), any aspect of emergence or non-emergence may become figural (e.g. body sensation, cognition, emotion, fantasy, fixed gestalts, etc.). The role of the therapist is to be an emotionally transparent, engaged part of the field, helping the client to become aware of what elements of self/world are included in contacting, and what elements are dis-included. The therapist can only do this by including an awareness of his/her own experience of contacting. Since the therapy sees healthy functioning in terms of a fluid, non-interrupted emergence and engagement, the therapy is process oriented rather than focusing on a pre-determined goal. PA: In classical psychoanalysis, the method focuses on an exploration of history and fantasies (which are related back to history). The goal is to produce the previously exiled memories into consciousness, and to provide a (well timed) interpretation or explanation of how the memories came to be repressed. This cognitive and emotional understanding is seen as lessening the extent to which the self is exiled to “the unconscious”. With the past more incorporated, the person is less split off, and therefore less symptomatic or neurotic. Attention, however, is not given to present oriented “consciousness” or “unconsciousness”. The role of the therapist is to be emotionally and personally opaque. This is in order to allow the patient to project his unconscious material onto the “blank screen”. The resulting “transference” is seen as the patient’s unconscious material, and is therefore available for interpretation. Modern (interpersonal/intersubjective) analysis tends to be more focused on the emergent affect of the patient, although the various approaches differ with regard to the inclusion of the therapist-as-person as part of the field. This is to say that in some interpersonal approaches, the therapist only reflects the patients’ experience, while in others the therapist is more transparent about h/her own experiences (as is held by Gestalt therapists). BT: The method is one of identifying undesirable behaviors, affects, etc, and setting up a regimen focused on “extinguishing” these elements. The role of the therapist is one of helping the patient to identify “that which is to be extinguished”, and utilizing methods to extinguish those elements. CBT: The method identifies thought as the causative factor in dysfunctional or undesireable behaviors and affects. Little or no focus is brought to the genesis of these “dysfunctional” thoughts. Rather, the “fact” of the existence of these thoughts, and the role of the thoughts’ maladaptive function is the focus. The role of the therapist is one of identifying dysfunctional, outmoded, or irrational thought processes and substituting more adaptive thought patterns. The process of developing new, on-goingly emergent schemas, “road maps”, or world views is not attended to. The focus is on identifying and correcting old, dysfunctional schemas. The Therapeutic Relationship: GT: The relationship is based on authenticity in the contact. The therapist is a real person, who is open to disclosing how s/he is affected in the relationship with the patient (in a manner which is digestible for the patient and in the service of the patient’s growth). This means that the therapist’s charge is to utilize his/her transparency with awareness of and sensitivity to the patient’s needs and capabilities. PA: The relationship is based on the withholding of the real person of the therapist, looking instead for the patient’s imaginings and projections about the therapist. In interpersonal/relational PA, there is variation, with some schools excluding the person of the therapist, and instead focusing on an empathic mirroring; while some other schools include the therapist’s “subjectivity”. BT & CBT: The relationship is one of a (friendly) expert, who is there to focus on the identified problems of the patient. (“Good Relationship” here is not meant to be one of horizontality or transparency, but one of friendliness and expertise, much like a helpful relationship with an Internist or an auto mechanic).