Hypothesis and practice
If psychotherapy is a form of social interaction (see above), how much logic and reason are involved? When it succeeds what have been the operative factors? Does the psychotherapist, like a skilled technician, meticulously translate into practice the theoretical basis of his craft, or is his activity more in tune with that of an artist who may represent the contemporary situation in new and unaccustomed terms and cause such an emotional effect on the mind of a receptive viewer as to change the direction of his thought and purpose? The same question can be put in rather different terms. Does the successful therapist adopt a detached and scientific posture, or does he temper aloofness by a sustaining warmth (Greben 1981) which brings the therapeutic relationship to life? In psychotherapy does the theory upon which the practice is based have anything to do with the outcome? Does therapeutic progress depend on verbal communications couched in terms of logic and reason or upon the interplay of non-verbal emotional attitudes? In 1955 I attended the mid-winter meeting of the American Psychoanalytic Association in New York. The subject was the validation of psychoanalytic theory and practice. Imponderables abounded, and the data remain unproven a quarter of a century later. There have been attempts to validate psychodynamic theory and practice by objective research, but its intensely subjective nature' renders sound experimental design and scientific methodology difficult to apply. For this reason there is still no sure knowledge that training and technique are in any sense superior to what might be described as the nonspecific personal influence of the doctor/patient relationship. A personal view
In my experience psychotherapy is a potent and effective form of treatment. It is serious. It is hard work. It is time-consuming. It requires infinite patience and courtesy. It has nothing to do with explanatory chats and encouraging gestures and noises. But it is not, in my opinion, a specific technique based upon a psychodynamic theory, nor are logic and reason and intellectual insight essential requirements. Rather it is concerned on the one hand with the strength of the patient's motivation to change, and on the other with the artistry of the therapist in handling constructively an emotional relationship.
The patient and the therapist sit down in an atmosphere of mutual trust and respect. That is the essence of the relationship. It enables the patient to change. Without this link of trust and respect there can be no substantial therapeutic progress. They focus on recurrent themes and issues of dissatisfaction. The patient is sustained by a sense of security and personal significance generated by the doctor's interest and understanding. The doctor restores the patient's faith in his ability to control his destiny. The patient's mind is directed to his untapped capacity and potential. He becomes aware of a new sense of freedom and independence. His life begins to have some purpose and direction. The doctor combiin%s his sustaining influence with a realism which conveys to the patient the limits of his at'ainable goals.
Whatever the doctor's ideology, whatever his frame of reference, whatever his $iJlls in interpretive intervention - scientifically called cognition in therapy, and translated into simple terms as a guess at what the symptoms mean - the prime mover in psychotherapy in my submission is the non-verbal emotional interaction. This is the critical force which enables change to occur. Three basic factors prevent progress: a discordant 4optor/patient relationship; a tacit collusion between doctor and patient, the purpose of which is to retain the patient's symptoms; and a patient who lacks motivation whatever the cause.
Psychotherapy and immunological mechanisms
There is general agreement that if psychotherapy has any validity, its main target should be those symptoms which arise out of conflicts between personality and circumstance where physical causes do not appear to be operative. But what of psychotherapy's place in the presence of demonstrable physical pathology or the likelihood of its existence? It is certainly applicable to the psychological overlay of physical disease, but has it any more direct influence on the underlying disease? Studies of the possible influence of personality on the incidence of breast cancer and the survival rate are relevant (Morris et al. 1977, 1978, Greer & Morris 1975). If immunological mechanisms are influenced by mind/body interaction, psychotherapy could have a direct effect on the body's defences. In primary depression, for example, are we to think exclusively of an abstract disease, a chemical lesion and rational physical treatment, or are there defensive immunological processes which can be influenced by thought and attitude; in other words, is it conceivable that psychotherapeutic intervention could cause changes which facilitate the pharmacotherapeutic outcome?
Conceivably there has been a disproportionate urge to bring psychotherapy within the bounds of science and a disinclination to accept it as an art. Do science and art represent a unity and not a duality? Do they not spring from the same source and flow by different channels to the same sea?
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