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Inside the SessionReview - Inside the Session
What Really Happens in Psychotherapy
by Paul L. Wachtel
American Psychological Association, 2011
Review by Robert Cohen, Ph.D.
Apr 17th 2012 (Volume 16, Issue 16)

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.



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