Structure Vs. Spontaneity In Psychotherapy

Part of my ongoing responsibilities as a psychologist include participation in continuing education classes. So, Wednesday last found me in an all day seminar at a local hotel listening to another psychologist talk about marital therapy. The presenter was quite a good speaker, and at first I was impressed by her obvious command of the subject matter and her charismatic presentation. However, as the day wore on and I saw more of her style I became less comfortable with what she had to say. This particular doctor, who took as her role model the family systems theorist and psychiatrist Dr. Carl Whitaker, spent a lot of time describing her very active, spontaneous ‘seat of the pants’ approach to interacting with couple clients. Where another therapist might work to impose an active structure or even curriculum onto sessions, she instead described herself as tightly focused on providing her clients with spontaneous interventions designed to give them what they needed at any given moment of her sessions. Psychoeducation was not useful, she proclaimed. What was useful was a client focused approach. If a spouse was not bought into the idea of therapy, she would find a way to ally with him so as to keep him engaged. If a spouse was not taking responsibility for her actions she would get into that spouses face and make sure she did. All of which is fine and good, for certainly it is very important for a therapist – any therapist – to be client focused, to keep clients engaged, and working on important therapy goals as the couple understands them.

But it’s not really all fine and good, as I thought about it. Such a free-form therapy is ultimately a therapy based on art, and not science, relying on the artistry and knowledge and gut-sense of the therapist to provide value to the clients, rather than on a well researched therapy process which is known and verified to offer an actual benefit. Historically, psychotherapy was an art form taught by charismatic master-therapist teachers like Freud and Jung and Rogers and Satir and Whitaker too. These people had their theories which made a lot of sense, and a lot of experience working with clients, and they passed their theories and learnings on to their students, some of whom became charismatic teachers themselves. But there was typically little effort devoted to actual study of whether the theories or the techniques these folks developed actually benefited clients. It was assumed that clients benefited, but most of the evidence for this benefit was anecdotal. This sort of disregard for proof of efficacy of treatments has become unacceptable in medicine, and there is little reason why it should be today acceptable in psychotherapy. Fortunately, a set of empirically-based therapies have come to prominence which are well studied and scientifically shown to be useful. To my way of thinking, it is these empirically based therapies that should be being emphasized today, and not free-form approaches. Not because free-form approaches are without merit; but rather because we don’t really know if they help people!

The major problem with empirically based therapies is that they are by nature structured approaches. They have to be structured, because they have to be consistently repeatable so that they can be offered in the same form to numerous clients so as to demonstrate that they work. And, structured approaches to therapy are too rigid for numerous patients who cannot or will not engage them in their structured form. Some patients don’t want to spend a session working on step 6 of a 14 step empirical therapy protocol; they would rather talk about some painful incident that occurred during the week. This is only human, and of course therapists need to be flexible enough to accommodate this sort of thing. Good therapy ultimately needs to be a dance or dialectic between empirically validated structure on the one hand, and spontaneous therapist attention to client’s needs on the other hand. It seemed irresponsible for this particular psychologist teacher of my seminar to be focusing so much on the flexibility side of things and ignoring the structural side of things, I guess. Anyway, that is how it seemed to me.