A Discussion Of Psychotherapy

Two important articles appeared in the New York Times this week on the topic of psychotherapy. The first article, "What 40 Years of Talking to Psychoanalysts Taught Me," was published in the Times magazine section of Sunday, Sunday, August 8, 2010, beginning on page 28. The second and shorter article appeared this morning, Tuesday, August 10, 2010, in the Tuesday Science section of the Times and is titled, "Lessons from a Wounded Star Pupil." There are important lessons for us to learn from both articles.

The Sunday Magazine article was written by Daphne Merkin and is autobiographical. She describes her 40 year quest for mental health using psychoanalysis as the venue through which she hoped to find less neurosis and find ordinary unhappiness. Basically, psychoanalysis consists of attending therapy sessions three to five times per week with each session lasting 45 to fifty minutes, depending on the particular therapist. Largely, the therapist is quiet while the patient "free associates," or verbalizes everything that comes to mind. This includes a long and ongoing exploration of childhood. In the end, the goal is insight. Insight is presumed to promote mental health.

During her long search for mental healthy, Merkin states that none of the therapists advised her to leave her parents and become more independent. In fact, the makes it clear that none of them advised anything because their job, presumably, was to remain a blank slate for her to project her psyche onto. Later and more recently, she found an analyst who is very confrontational to a degree that was unacceptable to her.

Unless I misread the article, she seems to conclude that the years of psychoanalysis with multiple therapists, achieved very little for her. If anything, it seemed to provide a venue through which she could feel some companionship and an available person to listen to what she had to say.

Today, August 10, Dr. Ronald Pies wrote an article about a very difficult patient he encountered when he was a psychiatric resident. His treatment stands in stark contrast to what Merkin received over her 40 years. Dr. Pies describes how he used his real reactions with the patient. He also applied Albert Ellis's Rational Emotive Behavioral Therapy. REMBT is really the basis of the current Cognitive Behavioral Therapy in which the patient is asked to inspect the irrational nature of some of the thoughts that cause them to get into terrible emotional and interpersonal trouble. Citing the great 20th century psychoanalyst, Frieda Fromm-Reichman, he quotes her as saying, "The patient needs an experience, not an explanation."

The bottom line to all of this is that patients who enter psychotherapy needs the therapist to be a real person rather than someone who sits passively, listens and provides occasional interpretations. Dr. Irvin Yalom, psychiatrist, explores the importance of the therapist being authentic rather than hiding behind a screen of passivity.

I was trained in psychoanalysis and went through the process with two separate analysts. The first was very authentic, warm and active while the second one, during my training, was classical Freudian and, therefore, passive. Frankly, it was the first therapy experience that was most helpful to me.

The interesting thing about "Classical Freudian Psychoanalysis was that Freud himself was not classical. He saw patients six days per week for one year maximum upon which treatment ended. If patients were not making progress of any kind during that year he announced in advance that he would terminate treatment in a few weeks.

My point is that good therapy is comprised of several important ingredients:

1. From the start, patient and therapist set specific short term objectives and long term goals. These need to be concrete and behavioral.

2. The clear statement that therapy is not a way of life. Rather, it is a treatment that has a beginning, middle and end. The end is determined by the achievement of goals.

3. The therapist be a real person and not someone who sits passively and nods their head on occasion and refuses to answer questions.

4. In being genuine, the therapist can work with the patient in planning on such things as, leaving home, attending AA, getting a divorce, separating from an abusive partner, etc. This is done jointly between therapist and patient. Sadly, this was not the experience had by  Merkin despite her 40 years of treatment with a wide variety of therapists.

5. Finally, no one deserves a therapist who is sarcastic, abusive or short tempered. Patients have a right to leave a therapist if any of these things happen.

These three ingredients are important whether the treatment method is psychoanalysis, supportive psychotherapy, cognitive behavioral therapy or group therapy. Again, therapy is not a way of life and is no substitute for living.

I am in agreement with Dr. Pies and with Dr. Reichman, in the patient having a real therapeutic experience with a real therapist.

I would very much like to hear from readers about their experiences with all types of psychotherapy. In discussing experiences, I want to encourage opinions, evaluations, criticisms and observations.

Allan N. Schwartz, PhD