Addressing a patient as a psychotherapist is a very complex thing. On how we do it, that is, on what setting or collection of parameters we establish as the frame for a treatment, hinges a great deal of the therapeutic work. These elements can be grouped in three different levels: the universal, the particular and the individual.
Some features of the treatment can be considered universal and applied equally to all patients, although they can still vary depending on the therapist, his circumstances and his theoretical background. Thus, for a psychoanalyst in a private practice all patients can be expected to talk freely following more or less loosely the rule of free association (we can see exceptions to this when we focus on the particular characteristics of some patients). Also, the analyst will apply the rule of abstinence (refraining from satisfying the demands of the patient), will determine a fixed duration of the sessions (unless he is a Lacanian using the scansion), will charge the patient for the work, etc.
On the other hand, the same analyst under different circumstances will use an alternative set of universal rules. Thus, in a public setting he will not charge the patient directly for the sessions and might alter other characteristics of the work. Other therapists with different theoretical approaches might establish their own distinct treatment frames.
The psychotherapy brands, each based on their identifying universal rules, conduct research trying to prove their absolute efficacy or their relative power in relation to other approaches.
At a different level, the particular deals with the work with specific groups of patients who, with their shared characteristics, require common adaptations of the technique. Groups of patients can be defined by different features, being their diagnosis a common one.
The work with psychotic patients is a classic example of the need to adapt the treatment technique for a particular group. Freud considered that his procedure, which we may call classical psychoanalysis, was not suitable for the psychotic. Later authors have proposed technical modifications to treat psychotic patients from a psychoanalytic approach. Many people with a psychosis are unable to free associate and their work resembles an ordinary conversation, with their therapist not working primarily on the content of what they say, but focusing more in supporting their capacity to keep talking.
Children or people from different cultural backgrounds might also need technical adaptations. In this respect, I am struggling to find a set of particular adaptations that allow for a containing setting in group psychotherapy with Spanish adolescents who suffer from severe mental disorders. These patients have a tendency to meet outside the group and link up in whatsapp groups in a way that challenges the traditional Foulkesian technique. Other characteristics of groups of patients might require different technical adaptations that need to be considered.
Technical adaptations, whether psychoanalytic or not, can be tested for their effectiveness in particular groups of patients, provided it can be clearly defined who belongs to that particular group and who doesn´t. There are many studies approaching the effectiveness of different therapeutic techniques in patients with the same diagnosis, which assume that those who have received that diagnosis are more similar among themselves than to anyone with a different diagnosis.
At a third level, each patient is unique and will require individual adaptations of the treatment technique. Since language is geared to express generalizations, it´s difficult to describe with it what is truly individual, but some patients might benefit from an assertive stance while others require a more tactful approach; some delve in direct abstract expressions while others flourish among metaphors and images, etc.
Science addresses general categories and is unable to enter the realm of the individual. Here is where the art component of the therapy necessarily takes over the more objective, scientific aspects of the task.
Approaching a patient in therapy requires the consideration of the three levels, the universal, the particular and the individual. Thus, in each treatment, one works on a melting pot where a specific frame is produced so that the therapy of that unique person can develop. Science and art both contribute to this process.
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