Three Fundamental Layers of Therapeutic Vision

Rollo May (1981) wrote, “The purpose of psychotherapy is to set people free” (p. 19). When suffering occurs psychologically or relationally, how do therapists act to facilitate a movement toward change and healing, toward the kind of freedom described by May? I conceptualize my role in therapy as the work of encouraging healing changes.

This guiding vision for the therapeutic encounter applies whether working with individuals, couples, or family clusters, whether navigating depression, anxiety, grief, marriage dissatisfaction, parenting struggles, or child and adolescent issues, whether “presenting problems” are related to behavior, identity development, anger, stress, fear, addictions, spiritual growth, or life transitions.

Entering into a therapeutic relationship begins by joining together in the midst of distress and the possibility of new hope. Then, almost unexpectedly, therapy begins. Over the course of therapy, clients should be respected and valued for who they are but not left to remain as they were. Therapy is a kind of entrenched battle, presenting vigorous challenges to dynamics of power, jolts to affective experiencing, urgings toward creative self-renewal, and cleansing and reimagining of unnecessary or even toxic belief structures.

Sometimes, therapy can be very effective in the short term, and sometimes therapy must necessarily trudge along for a while. I have written how, for instance, “when transformative changes do occur, they often come in subtle ways and bring with them simple joys, almost unexpectedly,” rather than a clear and linear shift from the undesirable causes of distress to their perfect resolution.

In many cases, factors outside of therapy—known as extratherapeutic factors—play significant roles in the stops and starts of change. For instance, Lambert (1992) described “hope, expectancy, and placebo” as factors not directly corresponding to the content of therapy sessions themselves and, in fact, unrelated to therapeutic technique, yet factors powerfully and nearly inexplicably linked to therapeutic outcome. Miller, Duncan, and Hubble (1997) wrote, “Research shows that merely expecting therapy to help goes a long way toward counteracting demoralization, mobilizing hope, and advancing improvement” (p. 30).

We certainly believe that there are elements of good therapy, as well as warning signs for questionable therapeutic methods. Yet, what makes the difference between healthy therapeutic momentum versus stagnation?

There are many helpful therapeutic lenses that therapists may employ in the course of their work, typically reflective of a chosen methodology. Whatever lenses may aid therapeutic focus and drive in-session activity, the most effective artisans of change embody a reverence for human dignity, engage in an intentional therapeutic optimism, and establish a clear and consolidated set of goals.

To me, these therapeutic values act as three fundamental layers of therapeutic vision providing lenses by which to bend and focus perspective and experience during the course of therapy. In my view, effective therapists must see and engage all three layers to effectively instigate the sort of healing changes that I have described, changes that effectively instigate transformation.

The antepenultimate (short of completion by two) of therapeutic vision is the “person-centered” focus, a humanistic value, a la Carl Rogers, who taught us that therapists are not effective experts at all without proper acknowledgement of and submission to the experience of relationship between two human beings taking place in the therapy room.

Weckowicz (1981) described Rogers’ clinical reasoning: “Any psychotherapeutic technique remains a technique and can only be made more human by an awareness of the existential dimension in the relationship of the two parties in the psychotherapeutic enterprise” (p. 66). Rogers sought to “join” with a client not as a technique but as an overarching way of being, necessary to all good therapy.

Rogers (1961) wrote, “The paradoxical aspect of my experience is that the more I am simply willing to be myself, in all this complexity of life, and the more I am willing to understand and accept the realities in myself and in the other person, the more change seems to be stirred up” (p. 22). Rogers was a therapist willing to also be a human, sitting across from another human. A dangerous proposition!

Viktor Frankl (1988) wrote, “A purely technological approach to psychotherapy may block its therapeutic effect” (p. 6). If therapists are too lifeless or their technique too technical, clients’ participation in therapy may be worthless. Therapy, in this case, does not engage the healing power of the relationship encounter, and what remains is, perhaps, little more than a kind of scientific experimentation. This human element in therapy must first be acknowledged and managed—nay, revered—before and beyond all else.

The penultimate (short of completion by one) of therapeutic vision is the “change-centered” focus, a motivational value.

Back in the late 1980s, Wallace Gingerich, Steve de Shazer, and Michele Weiner-Davis conducted fascinating research which indicated a strong correspondence between a therapist’s use of what was referred to as “change talk” and positive treatment outcomes. For instance, when therapists stated in terms of “when” and “will” rather than “if” and “would” as they engaged their clients in “change talk,” clients became focused on their own personal successes and, in many cases, went on to actualize those successes.

We have learned as a professional field that therapists must come to believe in our clients if we expect them to be successful. Isn’t that incredibly appropriate? Somehow, if we train ourselves to talk about constructive changes, constructive changes begin to follow in some form or another, more often than not. More importantly, as we talk about change, we engage language and co-create a narrative in an ongoing dialogue with clients, and we cautiously aid in bringing the language to life.

The ultimate (final resolving layer) of therapeutic vision is the “goal-centered” focus, a directional value.

The most cliché encapsulation of this value is to be found in that modern proverb, “Failing to plan is planning to fail.” I have a friend who once painted professionally and told me one day what makes the difference in outcome between a professional paint job and an amateur paint job. Quite simply, he said, it’s that a professional painter is willing to spend a good 50% of the time on the job taping everything off perfectly so that what results are perfectly crisp paint lines that, in the end, were well worth the effort. Amateurs often go at the task with little patience for assessing, planning, and taping, and often end up with a splattered mess.

Zig Ziglar said, “When you aim at nothing, you will hit it every time.” When therapists and clients in therapy do not take the time to assess with therapeutic goals in mind, they may enjoy therapeutic experience and even constructive therapeutic progress, yet it is difficult to say whether meaningful successes will occur in a therapeutic relationship with no consolidated agenda.

Watzlawick, Weakland, and Fisch (1974) underscored, “Change can be implemented effectively by focusing on minimal, concrete goals, going slowly, and proceeding step by step, rather than strongly promoting vast and vague targets with whose desirability nobody would take issue, but whose attainability is a different question altogether” (p. 159).

Most of this is common sense, and yet substantive outcome research over decades has served to solidify the legitimacy of such fundamental therapeutic values and vision. Genuine care and concern (person focus), alongside a change-centric approach in the here and now (change focus), and an optimistic monitoring of the work left to be done (goal focus) make for good therapy.

“Good therapists” tend to embody qualities that you would look for, perhaps, in a mentor: They believe in you and in the possibility of things going well for you, they want to hear what you have to say, and they redirect you from cynicism to hope and expectancy.

References:

1. Frankl, V. E. (1988). The will to meaning: Foundations and applications of logotherapy. New York: Penguin Books.
2. Gingerich, W., de Shazer, S., & Weiner-Davis, M. (1988). Constructing change: A research view of interviewing. In E. Lipchik (Ed.), Interviewing (pp. 21-31). Rockville, MD: Aspen.
3. Lambert, M.J. (1992). Implications of outcome research for psychotherapy integration. In J.C. Norcross & M.R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books.
4. May, R. (1981). Freedom and destiny. New York: Dell Publishing Company.
5. Miller, S. D., Duncan, B. L., & Hubble, M. A. (1997). Escape from Babel. New York: W.W. Norton & Company.
6. Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. Boston: Houghton Mifflin Company.
7. Watzlawick, P., Weakland, J, & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York: W.W. Norton & Company, Inc.
8. Weckowicz, T.E. (1981). Perception of reinforcement and psychomotor retardation in depressed patients. Canadian Journal of Behavioural Science, 13 (2), 129-143.

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