“Inside the Session: What Really Happens in Psychotherapy”
By Paul L. Wachtel
American Psychological Association
Washington, D.C., 2011
A unique microscopic view of psychotherapy, ‘warts and all’
Reviewd by Paul Efthim, Ph.D.
This unique book takes us inside the consulting room of master therapist Paul Wachtel, who bravely and generously shares verbatim transcripts of three sessions in their entirety.
The circumstances under which these sessions took place were also unique: Wachtel, a distinguished author, practitioner and teacher of psychodynamic therapy, was invited by the American Psychological Association to make several demonstration videos for their DVD series “Systems of Psychotherapy.” Afterward, Wachtel decided to create the present volume by taking the full session transcripts and adding moment-by-moment descriptions of his thoughts, feelings and reasoning behind his decisions to intervene as he did.
The result is a fascinating fine-grained look at psychotherapy “warts and all” as he puts it, in contrast to the carefully selected vignettes and summary descriptions of process offered in most other published clinical material.
Wachtel breaks the book into three parts, covering theoretical principles, the annotated session transcripts, and reflections on the sessions overall.
The first section, “Grounding Assumptions and Principles,” presents Wachtel at his best. He describes his “integrative relational” approach to psychotherapy, grounded in psychodynamic theory while integrating key concepts from cognitive-behavioral, systemic and experiential models. In the ongoing debates among these competing schools, Wachtel’s voice is a breath of fresh air. He illustrates the many points of agreement between them, demystifying the contemporary practice of psychoanalytic therapy while contributing his own unique ideas on how other theoretical approaches can strengthen his depth-oriented work.
For example, Wachtel argues that working with anxiety is central to the therapeutic enterprise. He seeks to help the patient become less afraid of his feelings, and bring to light feelings that have been hidden from self and others. He draws explicitly on the Cognitive Behavioral Therapy concept of “exposure” in treating anxiety: “In the process of promoting insight, of interpreting (and hence interrupting) defenses that keep the patient out of touch with his experience, a successful psychodynamic therapy brings the patient into closer contact with the experiences that have been warded off. The patient thinks the thoughts and feels the feelings that he has previously avoided – or, put differently, he is exposed to them.” (Emphasis is Wachtel’s in the original text.)
The author goes on to describe the most recent developments in relational psychodynamic theory and notes both convergence and divergence among the different models he seeks to integrate.
The second section presents three full sessions, along with almost excruciatingly detailed commentary. The first two sessions take place with a woman who is struggling with loss and family conflicts, while the third session features a woman who presents concerns about her career choices in the wake of a recent divorce. Notably, Wachtel works with a style that could be described as an appealing combination of staying close to the patient’s experience while also stepping back to offer incisive comments that help both patients feel more emotional clarity. The annotations illuminate his clinical decision-making and make important links to theory. He also acknowledges spots where he admits missteps and muses about how the implicit pressure to make an “interesting” video affected his level of activity and pacing.
In the last section Wachtel compares and contrasts his experiences with the two different patients and offers a number of interesting observations about how psychodynamic practitioners can learn from other models that emphasize acceptance of emotion and experiential perspectives.
This excellent, accessible book should find its rightful place alongside many of Paul Wachtel’s other works (Therapeutic Communication, Action and Insight, Relational Theory and the Practice of Psychotherapy, to name only a few) as an exemplar of a top scholar-practitioner at work.
Paul Efthim, Ph.D. is a licensed psychologist in private practice in Brookline, Mass. and holds a faculty appointment at the Boston Institute for Psychotherapy.
By Paul Efthim PhD