An Argument Against "Techniques" in Psychotherapy

The American Psychological Association’s (2012) “Resolution on the Recognition of Psychotherapy Effectiveness” summarizing all psychotherapy research emphasized that the therapeutic alliance is more important than any particular “brand” or kind of therapy in achieving desirable outcomes. What are the implications for the day-to-day practice of therapy?

Meanings of "Technique"

Technique has two distinct meanings in the field of psychotherapy. “A technique” is a routine the therapist can implement in the effort to assist the patient, such as cognitive-behavioral therapy’s prescribing homework, Gestalt therapy’s “empty chair,” or solution-focused therapy’s “miracle question.” Manualized treatments consist of a series of such techniques. “Technique,” on the other hand, without a definite or indefinite article, refers to the range of behaviors that the therapist uses to help the patient, behaviors that define the therapy relationship. These might include starting on time, keeping secrets, and avoiding judgments about the patient’s life. You can do a whole therapy without using a single technique in the sense of a subroutine, but you can’t participate in any relationship without some set of skills that qualify as technique in the second sense. Even though technique is ubiquitous, we use the word only for the kinds of relationships that garner advice on how to do them, such as parenting technique, surgical technique, and sexual technique.

Both technique and techniques should be selected because they further the goals of the therapy, whether the goal is amorphous, like “growth,” or more specific, like studying for school or improving social relationships. The problem with techniques (like assignments or packaged ideas) is that they undermine the technique (the kind of relationship) that works best in psychotherapy.

By psychotherapy, I mean a relationship designed to change the patient’s problematic personality patterns. Counseling, guidance, advice, friendship, doctoring, and mentorship are certainly valuable kinds of relationships. However, even before 1895, Freud began noticing that patients don’t follow wise counsel, take good advice, or respond to encouragement. Good therapists working on personality change now know that their technique must be organized around welcoming the hidden parts of the patient’s psychology into the therapy relationship and that these hidden parts must find there not validation, cheerleading, or life hacks, but a nonjudgmental space in which internal conflicts can be resolved.

The first reported therapy conflict between technique and techniques occurred when Anna O. told Freud that his techniques for getting her to reveal her inner self were annoying. She promoted what she called “talk therapy,” and Freud’s genius was that he listened to her and stopped pressing her forehead to get her to reveal her innermost thoughts.

Today, we might say that techniques put the patient in a passive role, whereas an implicit goal in almost all personality-change therapy is to promote the patient’s sense of agency. Techniques are also harmful in that they seek to overcome rather than to resolve patients’ inner conflicts, as if patients’ hesitance to reveal themselves to the therapist or even to change their behavior is nonsense that must be steamrolled. Treating the patient’s resistance as nonsense depicts the therapist as entirely innocent, a wise and benign figure that any sane person would want to reveal themselves to.

In other words, techniques communicate that the therapy is like a visit to the physician, and the medicalization of the person and problem bring their own challenges. This is appealing to both parties because the therapist wants to feel wise and problem-solving, and the patient wants to be told the doctor can solve the problem. (Again, solving problems is great if the problem can be solved, but most depressions, anxieties, and trauma reactions need acceptance and integration of warring parts of the self, not a solution.) The use of techniques also suggests that the therapist is the hero, and the patient plays the roles of damsel in distress. Usually, the patient’s parent or partner or society is cast in the role of villain, and then the therapy becomes a rescue operation rather than an exploration and resolution.

Dehumanizing Patients

Techniques are dehumanizing, because they treat all patients the same. The reason surgical techniques are advisable is because, in important ways, all bodies are alike. The reason parenting techniques are advisable is because, in important ways, all children are alike. But by the time children reach school age, they are different enough from each other to make techniques suspect. And by the time a surgeon develops real expertise, then even routine procedures like appendectomies become guidelines subordinated to the surgeon’s appraisal once the inside of the patient is revealed. Techniques assume that everyone is the same, but the vast majority of anxieties, depressions, and trauma reactions are unique.

Even the technique (in the broad sense) of individual therapy does not pre-exist the patient and therapist understanding the problem and whether it relates to the patient’s personality. A good therapist may never self-disclose autobiographical information, for example, in personality-change individual therapy, but the same therapist doesn’t start the initial consultation already knowing that this kind of therapy will be prescribed.

Because techniques dehumanize the patient, put the patient in a passive role, and define the therapist as heroic and benign rather than a collaborator in exploring and making sense of the patient’s psychology together, patients react to them the way people without power often react to self-righteous authority: patients consciously appreciate and encourage the use of techniques, but they don’t get better. Good therapists know the difference between appreciation and improvement, even if appreciation from patients is more remunerative.