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

Comments
  • Karin Lugna

    Hello and thank you for the above article, I have just read it and could not agree more that in order to make any improvement on one's personal situation, no matter what it may be, one needs to have the opportunity to have a two way conversation with a therapist who is real and open about their own thoughts too.

    I too have sought help in desperation. So unable to speak to my family, friends or anyone about the confusion in my mind. Then being referred to several therapists who look at you blankly and simply nod or tell you they understand that you are sad.

    Medication is the only option I have been given. And though it has helped me to numb out somewhat and not feel so 'needy'. The questions and sense of desperation remain lurking in the background of your mind, and you know you are not coping or living, just existing.

    I have been to see a therapist and all we did was bring up the past. I would cry and feel all that shocking pain all over again. Then after you've opened up your gut and are at your most vulnerable the guy looks at his watch and says. okee dokey, well I'll see you next week then?

    Back out in the hallway, feeling shell -shocked, totally foolish and ashamed for the secrets you have exposed, you fumble for your keys and head back to your car, where you cry and cry and you don't know why. the session hasn't done you any good, but only allowed issues to resurface to such an extent that it takes you days to get over it and feel 'safe' again.

    What I feel one needs most is a therapist who has the courage to say it like it is. Some one who can put the situation/feelings into some perspective and help you to work on how to deal with the memories and thoughts that continue to debilitate you.

    Acknowledge the experiences of the past but not to constantly go back there and allocate blame. We need to have a way to cope with today. We don't know how to cope that's way we seek help.

    All of us have a past with some pain. Some of us just instinctively know how to cope well and move on and learn, and be grateful and happy anyway.

    A lot of us have no idea how to manage the haunting of obsessive thoughts that are a part of our everyday struggle.

    If a therapist could start with a simple small plan that is specific to the client's needs and put it forward in a such way that the client feels empowered to DO something, then it would be so so positive and helpful.

    A passive therapist is a cheat, I feel. Sitting there with nothing possitive to offer. Just a great paycheck at the end of the month. (oops that was a bit harsh, no offence) But if you wish to be in the helping Profession, then please realise just listening is not enough. Help us to actively address our issues and learn coping skills and see a different reality to the one we are trapped in.

    P.s and let us bring in our dog so we have some support during sessions, it's scarey opening up to a stranger!

    Kindest regards, Karin - Australia

    Kind regards,

    Karin.

  • Cathy

    I agree with you on this for the most part and you can probably guess that my thoughts about psychotherapy are...... The thing is, just as in any other venue, especially including the medical field, some people are good, very few with the rest being marginal. The word "therapist" itself can be misleading. Here, the therapists are substance abuse counselors - that is what everyone gets unless they are diagnosed with a mental illness. Pretty much since a substance abuse counselor can't do much with someone who doesn't have that problem, they medicate them (these are the people that see the children here with problems)- problem solved, not. So many of those titled "therapists" have little training so maybe it is better if they just sit there quietly, less damage. I do see that therapy has become a way of life for some. Most of the people really need coping skills, positive ones - you don't really change you, anybody else or anything - you learn to cope in a positive way.

  • Beth

    I very much agree that having a real human connection with a human being during therapy greatly aids the process. It was in the very moment I connected with my therapist on a human level that I was then able to open up and show him my own anxieties, fears and weaknesses. In the end, it was the relationship that was most healing to me. The memory of this is something I hold and keep with me today as I fully embrace life. I will never forget him or the brief time we shared together as therapist and client.

  • sedsed

    i have been in counseling before and particularly did not like the person who i had they listened a nodded occasionally letting me know they were still alive but they never really said much i felt more like an annoyance then anything. In a way i think it was like you said in your article in so many words having an artificial therapist or at least one who does not seem attentive. But this experience did not give me insight it was plainly an autobiography to her about myself and truly accomplished nothing.

  • Roberta

    Well, said, Karin. I have been trying to see a therapist for a long time. Now I have insurance, but they tell me that I can only see a theripist once every six weeks. When I saw one before she listened, but did not give any advice. Then my next two appointments were cancelled on the day I was to see one, and that was two more months long. I got fustrated and asked for another therepist. Finally I got one recently, and she let me talk again, too much, and I came away feeling not satisfied. She asked me how she can help me. Now I will come with a written paper about how I feel that she might help me. I will be prepared for my next visti. I came away feeling that she has a wall between us, and that her input is limited. I don't want that. I want to interract and to be asked questions about my thinking and feelings that seem to keep me trapped. Do they really want to know?? It feels impersonal, and that is not what I want. I am coming because I want someone on my side, because I really don't have anyone on my side in my personal life. They keep referring me out to join other group classes, which talks about depression, ect., and I am doing that. But i can't help but feel that I am always being referred out to get help on my own.