Ebook Basics of psychotherapy - A practical guide to improving clinical success: Part 1

BASICS OF
PSYCHOTHERAPY
A practical guide to
improving clinical success

Richard B. Makover, M.D.


Basics

of

PSYCHOTHERAPY

A Practical Guide to

Improving Clinical Success




Basics

of

PSYCHOTHERAPY

A Practical Guide to

Improving Clinical Success

by

Richard B. Makover, M.D.


Note: The authors have worked to ensure that all information in this book is
accurate at the time of publication and consistent with general psychiatric and
medical standards, and that information concerning drug dosages, schedules,
and routes of administration is accurate at the time of publication and consis­
tent with standards set by the U.S. Food and Drug Administration and the gen­
eral medical community. As medical research and practice continue to advance,
however, therapeutic standards may change. Moreover, specific situations may
require a specific therapeutic response not included in this book. For these rea­
sons and because human and mechanical errors sometimes occur, we recom­
mend that readers follow the advice of physicians directly involved in their care
or the care of a member of their family.
Books published by American Psychiatric Association Publishing represent the
findings, conclusions, and views of the individual authors and do not necessar­
ily represent the policies and opinions of American Psychiatric Association Pub­
lishing or the American Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please go to www.appi.org/
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Copyright © 2017 Richard B. Makover, M.D.
ALL RIGHTS RESERVED
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Library of Congress Cataloging-in-Publication Data
Names: Makover, Richard B., author.

Title: Basics of psychotherapy : a practical guide to improving clinical success /

by Richard B. Makover.

Description: First edition. | Arlington, Virginia : American Psychiatric

Association Publishing, [2017] | Includes bibliographical references and
index.
Identifiers: LCCN 2017004882 (print) | LCCN 2017005674 (ebook) | ISBN
9781615370764 (pbk. : alk. paper) | ISBN 9781615371327 (ebook)
Subjects: | MESH: Psychotherapy--methods | Psychological Theory
Classification: LCC RC480 (print) | LCC RC480 (ebook) | NLM WM 420 |
DDC 616.89/14—dc23
LC record available at />British Library Cataloguing in Publication Data
A CIP record is available from the British Library.


To my patients and my supervisors:

I learned from all of them

CONTENTS
Preface - - - - - - - - - - - - - - - - - - - - - - - - - - - - ix
About the Author - - - - - - - - - - - - - - - - - - - - - xi

Chapter One
What Is This Book About? - - - - - - - - - - - - - - - - - - - - 1

Chapter Two
What Is Psychotherapy? - - - - - - - - - - - - - - - - - - - - 29

Chapter Three
What Is the Psychotherapy Relationship? - - - - - - - - - 69

Chapter Four
What Is an Initial Evaluation?- - - - - - - - - - - - - - - - 107

Chapter Five
What Is a Formulation? - - - - - - - - - - - - - - - - - - - - 145

Chapter Six
What Is a Treatment Plan? - - - - - - - - - - - - - - - - - - 183

Chapter Seven
What Is Communication?- - - - - - - - - - - - - - - - - - - 227

Chapter Eight
What Is Collaboration? - - - - - - - - - - - - - - - - - - - - 259

Chapter Nine

What Is an Autodidact?- - - - - - - - - - - - - - - - - - - - 291



Chapter Ten
What Is the Sum and Substance? - - - - - - - - - - - - - 305

Chapter Eleven
Suggested Readings - - - - - - - - - - - - - - - - - - - - - - 309


Index - - - - - - - - - - - - - - - - - - - - - - - - - - - 313



Preface

Over the course of a long career, I have had the opportunity to observe
other professionals practice a variety of psychotherapies. They demon­
strated a wide spectrum of skills. Certain clinicians showed great com­
petence and expertise in their work with patients, and I was fortunate
to learn from them both by their example and by their guidance. Others,
while diligent and conscientious, were not as effective. Some practitio­
ners struggled with certain kinds of cases and succeeded with others.
Some appeared to form strong bonds with their patients, but their re­
sults were disappointing: patients dropped out of treatment or contin­
ued for long periods without significant improvement. Whether these
therapists were new to practice or quite experienced, I observed that
these difficulties often seemed to reflect an incomplete grounding in the
basic principles of psychotherapy.

Doing therapy well is difficult. A strong foundation in the universal
principles of therapeutic practice can improve patient outcomes while
helping to manage inherent challenges such as clinician stress, fatigue,
and burnout. I have found, however, that these core principles may not
be fully covered in the coursework, training, or supervision offered by
many professional programs.
My intent in this book is to provide a practical guide to the essential
postulates and practices that form the foundation of successful treat­
ment. These principles are not specific to any one type of therapy, but
rather form the basis of effective therapeutic work regardless of the spe­
cific methodological approach. This book is addressed to those thera­
pists who are open to reexamining the essential elements of their craft
and applying these elements directly to their everyday work. My belief
ix


x

Basics of Psychotherapy

is that therapists who expand their understanding of these ideas and
practices will gain in confidence and expertise, improve patient out­
comes, and increase their personal satisfaction with the art of psycho­
therapy.


About the Author

R

ichard B. Makover was educated at Yale University and the Albert
Einstein College of Medicine. After a medical internship, he completed
his psychiatric training as chief resident, served two years as a U.S.
Navy psychiatrist, and opened a private psychiatric practice. His knowl­
edge of psychiatry is based on more than 40 years of clinical experience in
office-based, ambulatory, and inpatient settings. Dr. Makover has held
academic positions at Cornell University Medical College and The New
York Medical College. He is a Lecturer at the Yale University School of
Medicine Department of Psychiatry. He was board president of a child
guidance clinic and chairman of a Program Review Committee for the
state Department of Mental Retardation. Dr. Makover served as chair­
man of a hospital psychiatry department, chief of a neuropsychiatry ser­
vice, and clinical director of psychiatry at a large health maintenance
organization. He worked as a consultant in geriatric psychiatry and at
a sleep medicine center. He lives in Connecticut with his wife, Janet.

xi



CHAPTER
ONE

What Is This Book About?

For the art is long and life is short
opportunity fleeting
experiment dangerous
judgment difficult.
Hippocrates

If the world were perfect,
it wouldn’t be.
Yogi Berra

Introduction
Before computers, before airplanes, before gunpowder, before agriculture,
in the unrecorded past of many thousands of years ago, small groups of
Homo sapiens formed into tribes. They were people like us, with large frontal
lobes that allowed them to evaluate, respond to, and modify social be­
havior and to organize themselves into stratified, hierarchical groups.
Our tribal behavior still persists and pervades every culture, even
those aspects we might wish we had left behind. Like those ancient
tribes, we even now
• Selfishly compete for property and prestige (social conflict).
• Regard anyone not a member of our “tribe” with suspicion, loathing,
and fear (xenophobia).
• Kill each other over territory (genocide).
Our genetic makeup, with all its primitive traits and proclivities, has
not evolved throughout those many millennia. Despite our technology
1


2

Basics of Psychotherapy

and our attempts at civil harmony, we remain subject to the same pas­
sions and respond to the same stimuli as our prehistoric ancestors. This
roster of unevolved traits also includes our responses to psychological

factors, both cognitive and emotional, that create both our mental health
and our mental illness and that make us susceptible to psychological
stress and to the forces generated in psychological healing.
Those primitive tribal members must surely have vied for status, en­
gaged in intrigue, practiced deception, warred on their neighbors, formed
alliances, and exhibited the same variety of individual quirks, habits, and
traits that we see today in our contemporaries and in ourselves. Through­
out the sweep of history, in large social groups and small families, in casual
encounters and stable pairs, whether closely bonded or loosely connected,
men and women have always attempted to influence how others thought,
felt, and acted. Much of this effort has involved the mandate of social
groups to strengthen conformity among their members. Much of it has also
taken place in the context of organized religion, and the same struggle
to influence behavior animated those who sought political power or com­
mercial success.
Among those early tribal groups, some individuals were recognized
as designated experts in behavioral change, with enhanced status and
influence as a result of their social position. We can make an educated
guess that at least some of these special individuals exerted their powers
to minister to the ills of the sick and the dysfunctional. These shamans
were designated healers who called on supernatural forces and em­
ployed magic rituals to magnify their efforts. If the history of these heal­
ers traces back to early primitive tribes, then their work places them
among the oldest professions. As shown in Figure 1–1, however, the
healer’s position in the tribe was both communal and separate. She or
he had power just below that of the leader, but the tribe viewed the
healer with both fear and respect and sometimes with awe. That ambiv­
alence gave the healer a high status, but at the same time it kept her or
him apart from the community, as it does to some extent in our contem­
porary society.

Over the last century or so, socially approved healers have offered
their expertise in behavioral change under the heading of psychological
treatment. As successors to those ancient tribal practitioners, we mod­
ern healers promise help to those who want to change behaviors iden­
tified as personally distressful or socially disruptive. At the beginning
of this era of personal assistance, the bulk of these services were con­
sumed by two socioeconomic groups:


3

What Is This Book About?

Leader

Healer
Sons

Tribal Members

FIGURE 1–1.

Status of tribal healer.

• The poor and disadvantaged, who often received this “help” invol­
untarily, and
• The wealthy and privileged, who consumed them as a luxury.
Since the end of World War II, however, more and more people of the
middle classes and of ordinary means have accepted this type of healing
and have taken advantage of the increasing availability of mental health

services.
To meet this rising demand, a separate category of professional healer
has emerged: the psychotherapist. Distinct from purveyors of religion
and practitioners of medicine, the members of this group come from a
number of service professions: medicine, nursing, psychology, social work,
physician assistants, and a variety of counseling occupations. Mostly, we
are certified and licensed, a postgraduate process that solidifies our so­
cial and professional status. Most of our services are compensated (and
therefore regulated) through commercial and governmental “third-party”


4

Basics of Psychotherapy

payment programs. Their financial support has encouraged the growth of
this sector of the service economy. These same third parties, however, be­
cause their primary interest is cost containment and not patient care, have
imposed restrictions and paperwork burdens that have altered clinical
practice for the worse.
We psychotherapists, like tribal healers, are recognized as experts,
although what we are expert in is often loosely construed. Asked for ex­
planations, psychotherapists have been willing to opine on politics, crim­
inology, child-rearing, consumerism, education, the financial markets,
and a variety of contemporary subjects about which, in truth, we know
no more than anyone else. Because we are offered this special expert sta­
tus, and are willing to accept it, we occupy that same mysterious position
in the social organization, half in and half out of the ordinary social hier­
archy, that was enjoyed by the tribal healers of early prehistory. Psycho­
therapists are even today viewed with some mixture of fear, respect, and

awe, the same ambiguity that they aroused in primitive tribes, and that
ambiguity can have both helpful and destructive consequences (as dis­
cussed in Chapter Three, “What Is the Psychotherapy Relationship?”).
Well established as our group of professions may be, the service we
provide, psychotherapy, is a poorly defined, many-headed, disorganized,
and sectarian set of undertakings. Whether you are a newly trained
therapist or a seasoned practitioner, you find yourself in a vast ocean of
•
•
•
•

Contradictory ideas.
Controversial claims.
Conflicting theories.
Confusing practices.

Surrounding this ocean are mountains of psychotherapy research
that present a difficult intellectual task, as published material appears
to continually challenge some ideas, support others, and offer up new
theories. Faced with this unsettled panorama of competing ideologies,
you are naturally inclined to look for a safe harbor in a congenial meth­
odology. Career management is simpler if you select only one modality
and concentrate your energies on its theory and practice. Soon, your ded­
ication and your investment of time and resources might incline you not
only to ignore other promising ideas but also to defend your chosen path
with dogmatic intensity.
At the center of this roiling ocean, however, is an island of common
principles and practices that provide a foundation on which all the sep­
arate ideologies and methodologies can rest (Figure 1–2). This book is fo­

5

What Is This Book About?

Directive

Generic
Principles
and
Practices

Exploratory

FIGURE 1–2.

Experiential

Generic core.

cused on that central core. Its goal is to identify and explain some of the
common ideas and basic concepts that apply to psychotherapy practice
in general. This core includes
• A common therapeutic dynamism shared by all psychotherapies.
• A generic psychotherapy, a sort of foundational system from which
all other types of psychotherapy develop.
• Techniques that are useful in every methodology.
Familiarity with these core concepts can help you understand
• How the psychotherapy relationship provides the foundation for ev­

ery methodology.
• The role of the therapeutic alliance in the healing process.
• The central principles all therapies have in common.
• How to organize and carry out treatment to maximize its chances for
success.
• How to deal with the common problems any therapy will encounter.


6

Basics of Psychotherapy

To keep this book to a manageable length, I have imposed two limi­
tations:
• The book is confined to individual treatment—dyadic or one-to-one
therapy—and does not try to cover group, marital, or family therapy,
although much of the material will apply to those multiperson ser­
vices, mutatis mutandis.
• I do not survey, examine, or evaluate the hundreds of specific psycho­
therapies in use today, except as needed to illustrate a more general
point. Each of these methodologies has its own adherents and a lit­
erature supporting its claims. Tempting as it is, such a detailed task is
beyond the scope of this undertaking. Nevertheless, in Chapter Two,
“What Is Psychotherapy,” I attempt an overview of the three main di­
visions—exploratory, directive, and experiential—each of which in­
cludes a large variety of different methodologies.

First Case
At some point in our training, we all were presented with our first case.
Although preparation for this event may have included some reading

and (maybe) some direct instruction, for most of us this experience was
like learning to swim by jumping into the deep end of the pool.

NORMAN NEOPHYTE
As an example of perhaps a too common experience, we can look over
the shoulder of a new psychotherapist—call him Norman Neophyte—
as he is about to meet Lisa, his first psychotherapy patient. Lisa is a young
woman who was initially evaluated in the outpatient screening clinic of
the local hospital with a complaint of “bad nerves.” Somehow, her com­
plaint got her seen first by a neurologist, with a negative work-up, before
she was referred to the behavioral health service. After three “evalua­
tion” visits at the mental health clinic, she was accepted for psychother­
apy and placed on a waiting list. Five weeks later the clinic contacted
her and set up her initial appointment. In total, then, nearly three months
have elapsed from the time she first applied for help to this first session.
What should we expect after this long delay?
• Lisa must be highly motivated and perhaps in a great deal of emo­
tional distress to accept this bureaucratic postponement. Or maybe
she has had to accept the delay because she cannot afford a private
referral.


What Is This Book About?

7

• Lisa came with a (misunderstood) neurological complaint but appears
to have readily accepted a mental health referral. Or maybe she is
simply following the recommendation of the “experts” in their white
coats.

• Lisa’s problem may have changed over the several weeks she has
waited for help. Or she might even have recovered to some extent, since
many people do improve simply by the anticipation of treatment im­
plied by the waiting-list assignment. Sometimes the enforced delay
allows the precipitating stress to dissipate, reducing the symptoms
that impelled the initial request for help.
• Lisa’s estimate of the importance of this meeting and of the profes­
sional judgment of the clinical team may have been heightened by
the ordeal of several evaluations. Or perhaps she is understandably
frustrated and discouraged by the long delay.
All of these factors must have raised her expectations of this final phase
of the long process. With the cumulative effects of a neurological con­
sultation, a mental health evaluation, the validation of acceptance for
treatment, and the growing anticipation as she awaited her assigned ap­
pointment, Lisa might reasonably expect great results.
In honor of the occasion, Norman has worn a tie. He buttons the collar
of his blue-and-red checked dress shirt and snugs up the knot of the skinny
black knit tie. Before he goes out to the waiting room to greet his new
patient, he pauses to review the referral. On his tablet, he logs in, brings
up the patient record, and reads the evaluation summary (Figure 1–3).
Norman is assigned to one of the offices in the mental health clinic.
The room is about 10 feet by 8 feet, with a desk, a lamp, and two chairs,
and is illuminated by overhead fluorescent strip lights (Figure 1–4). On
the wall hangs a dusty print of Vincent van Gogh’s Sunflowers. The win­
dow is shielded by a Venetian blind, slats closed. The walls are painted
a light institutional green. Norman places his backpack and tablet on the
desk and swings the desk chair to face what has to be the patient’s chair
next to the desk.

Norman and Lisa: First Session

At Norman’s invitation, Lisa comes into the room and takes the chair
next to the desk. She looks at him expectantly. At this point Norman is
thinking
• I don’t like this dreary room. She’s practically sitting in my lap.
• What’s the first thing I should say?


8

Basics of Psychotherapy

University

Hospital


Mental Health Clinic

Intake Service

Lisa XXXXXXXX

Age: 19

Marital Status: married

Employment: homemaker

Insurance: Blue Cross (husband)

January 6, 2017

EVALUATION SUMMARY
Lisa is a 19-year-old white female, married six months, who presents with a chief complaint
of “nerves.” Her husband is a mechanic at an automobile dealership. She is a homemaker. They
married one week afer their high school graduaton. Alone at home she experiences nearly
constant low-level anxiety punctuated by two or three panic atacks per day. She controls these
by rebreathing into a paper bag. Her anxiety subsides when her husband is home. Her sleep and
appette are normal, and she is otherwise in good health. A neurology consultaton found no CNS
abnormalites. Mental status examinaton shows an alert, friendly, but restless young woman with
mildly pressured but goal-directed speech. She is well groomed, with somewhat heavy make-up,
dressed in a paterned blouse and dark slacks. Memory is intact. Judgment is age-appropriate.
Estmated IQ is 110–120. She denies depressed mood and suicidal ideaton. There is no evidence
of impaired reality testng, hallucinatons, or delusions.
Diagnostc impression: Generalized anxiety disorder (300.02)
Plan: Individual psychotherapy
Dispositon: waitng list untl slot available

FIGURE 1–3.

Evaluation summary: Lisa.

• Am I really expected to “talk” this woman into mental health?
• What should I do and how should I do it?
What can we make of these thoughts?
• First, notice the way the room makes Norman uncomfortable.
Chances are Lisa feels the same way. The physical setting is a silent
but important factor that can promote or retard the healing process
(Chapter Three).

FIGURE 1–4.

Norman’s assigned clinic office.

Painting

Lamp

Window

What Is This Book About?
9


10

Basics of Psychotherapy

• Second, Norman is not prepared with his opening remark, although
it may be one of the most important things he says in this first ses­
sion. How he begins is part of the impression he needs to make to
have a positive impact on their relationship and one that starts to
structure this initial evaluation (see Chapter Four, “What Is an Initial
Evaluation?”).
• Next, he lacks confidence that the therapy he will offer will really be
effective. Lisa will likely sense his uncertainty and will, in turn, have
doubts about how useful the therapy will be. (For discussion of the
therapist-patient relationship, see Chapter Three.)
• Finally, he feels uncertain about how to structure and conduct the ther­

apy. In Chapters Four, Five (“What Is a Formulation?”), and Six (“What
Is a Treatment Plan?”), I cover the initial assessment, the resulting
formulation, and how to use a treatment plan to organize the work.
In Chapter Seven (“What Is Communication?”) and Chapter Eight
(“What Is Collaboration?”), I identify some of the general techniques
useful in most therapies.
Meanwhile, we left Norman and his patient in their first therapy
minute.
Norman

(clearing his throat) So, tell me about yourself.
Not a good start. Better would be if
Norman made more of an effort to con­
nect with Lisa and offer his help.

Lisa

( looks taken aback) Don’t you have the report? I saw
that other person three times, and I’ve been waiting
over a month for this appointment!

Norman

Yes. I have the report, but I’d like to hear it in your
own words.
Uh-oh, Norman thinks. My first sentence
and I’m already having a problem.

Lisa sighs and proceeds to give Norman the same history that he has
in the referral report. He asks a few additional questions. The atmosphere

is now somewhat strained, and Lisa looks unhappy. Norman picks up his
tablet and types in a few notes about the session so far, but mostly to
give himself time to think about what to do next. It is not a good idea for
Norman to make notes during the session, creating more distance from
his patient.


What Is This Book About?

11

Norman decides to do a mental status examination and asks Lisa the
date, then plows through the other standard questions. She appears to
have no problems with memory, orientation, cognition, and the rest. The
intake evaluation assigned a diagnosis of generalized anxiety disorder
even though Lisa also has had panic attacks. On the basis of his evaluation
so far, Norman doesn’t disagree. He’s not sure about what kind of ther­
apy he needs to do, but he decides that medication for the anxiety would
be helpful.
Norman

I’d like you to try some medication. It would help
you not to feel so nervous.
This “bottom up” approach and the
problems it creates are discussed in
Chapter Six.

Lisa

I don’t like the idea of taking drugs. I thought you

were supposed to help me with my nerves.

Norman

Of course. We’ll be working on that. But this med­
ication just might make things easier for you.

Lisa

No, I don’t want that.
At least Lisa is forthright in her rejec­
tion of this idea. Other patients might
passively accept a prescription but never
fill it.

Norman

OK, then. Well, I’ll see you next week.
Norman concludes this first meeting
without having made progress, but he
hopes he can do better next time.

Lisa

I’ll have to call back when I know my schedule better.
Since Lisa is a homemaker with no chil­
dren to care for, Norman wonders, how
busy a schedule could she have? He
doubts he will see her again. He feels
discouraged.

Norman’s first foray into psychotherapy has not gone well, and his
patient may not return. Even if she does, Norman does not yet have a
clear idea (or, really, any idea) about what he should do for her. His initial
evaluation has been unfocused and has not produced much useful infor­
mation. He has not constructed a single hypothesis from the history he re­


12

Basics of Psychotherapy

ceived from the assessment clinic or the information he gathered in the
interview. Much of the problem lies in his handling of this first meeting:
• In this barren institutional setting, Norman has not established his
professional bona fides. Although he has worn a tie, little in his self­
presentation says I am a professional, and I can do the job.
• He seats himself and the patient at a desk, which creates an uninvit­
ing, authoritarian relationship.
• He begins with an open-ended request for history he already has and
that the patient assumes he has. That not only annoys her, it wastes
valuable evaluation time.
• He conscientiously performs an unnecessary mental status examina­
tion.
• He offers the patient medication without
1.
2.
3.
4.

Completing his assessment (Chapter Four).
Formulating the case (Chapter Five).
Drafting a treatment plan (Chapter Six).
Reaching an agreement with her on how they will work on her
problems (Chapter Six).


No wonder Lisa is reluctant to schedule another session!


Norman and Lisa: Second Session
Nevertheless, to Norman’s relief, Lisa makes a second appointment. This
time she wears a low-cut blouse and a short skirt. Heavy make-up ac­
centuates her eyes and mouth. Her outfit makes him uncomfortable. He
tries not to notice her cleavage.
Norman

I’m glad you came back. How has the week gone
for you?
Norman invites her to provide a chron­
icle of the interval between sessions, a
precedent that might prove problematic
in future sessions. Because he has no
treatment plan, he has nothing else to
focus on.

Lisa

OK, I guess. I’m still having nerves. (She pauses ) Let
me ask you something. Do you like me?

Lisa voices her concern. Many patients
would not raise it so directly, and it
would remain unaddressed and corrosive.