What is psychotherapy? Such a seemingly simple and straightforward question. Something those who have never experienced this secretive, enigmatic, mysterious process are understandably curious about. Perhaps sufficiently curious to be reading this right now. But, oddly enough, it remains a ponderous query even for those that have been psychotherapy patients or clients, either once or multiple times, briefly or for decades and more. And, if truth be told, strange as it may sound, this is still a wide open proposition for providers of psychotherapy: psychologists, psychiatrists, social workers, marriage and family therapists and other mental health professionals who have spent years studying, practicing, teaching and, in many cases, receiving psychotherapy themselves. Indeed, depending upon who you ask, the definition and description of psychotherapy can vary immensely--which is all part of the dark cloud of confusion and controversy still surrounding psychotherapy more than a century after being birthed by psychiatrist Sigmund Freud.
Even now, for most people, the term "psychotherapy" typically brings two simultaneous images to mind: a troubled patient
lying prone on the couch, and interpretations, usually sexual in nature, punctuated with the occasional "And how did that make you feel?" being provided by the analyst or therapist. However, over the last hundred years, much has changed about psychotherapy, for better and worse. And much remains the same. Twenty-first century patients present dramatically different symptoms or syndromes and struggle with different conflicts and issues than those in Freud's Victorian Vienna. Yet, they, like Freud's neurotic patients, still must contend with the complexities and perplexities of the human condition. We live in uncertain times. People are insecure, anxious, frustrated, angry, embittered, discouraged and confused. Some feel spiritually adrift and disillusioned with organized
religion, which traditionally provided solace, succor and direction in the face of life's most difficult and perplexing problems. Others have similar frustration and dissatisfaction with contemporary cognitive-behavioral and pharmacological treatments for mental disorders that did not even exist in Freud's day. Still, ever since Freud formulated the first well-thought out and structured psychological treatment he famously called "psychoanalysis," known colloquially as the "talking cure," psychotherapists have been ministering to such existential,
spiritual and neurotic or psychotic suffering in various ways with some success. In fact, in its twentieth-century heyday, psychotherapy was once touted as "religion for the previously irreligious."
The big secret, for both consumers and providers of psychotherapy, is that there really is no such thing as generic "psychotherapy" per se: only wildly disparate theories and divergent techniques adopted by vastly varied clinicians with dissimilar personality styles, life-experience, training, values, goals, neuroses, complexes and world-views practicing what, only in the broadest possible sense, we have collectively come today to call psychotherapy. When someone says they have been in psychotherapy, or practice psychotherapy, the reality is that his or her experience with therapy may differ radically from another person's. To talk about psychotherapy in general is similar to speaking of ice cream: One can be said to consume ice cream, but all that tells us is he or she eats something sweet, creamy, ice-cold and delicious. Yet we all know that tasting vanilla, chocolate, strawberry or pistachio ice cream are totally different experiences. And that any one flavor does not necessarily suit everyone's taste. So it is with psychotherapy. Psychotherapy is not--and never will be, despite efforts to scientifically systematize, manualize, objectify and make it more formulaic--something consistently or reliably predictable, prescribed and predetermined. Rather, it is, as Rank and Jung understood, an archetypal healing process that is, of necessity, at its best re-invented with each new patient and by each practitioner. No two courses of psychotherapeutic treatment--at least any therapy worth its salt--will ever look exactly the same. Nor should it.
Recently there has been a renewed firestorm raging about psychotherapy and its efficacy--specifically psychoanalysis, psychodynamic therapy or depth psychology--since the August 4, 2010 publication in
The New York Times of chronic psychotherapy
consumer and professional journalist/essayist/novelist Daphne Merkin's memoir. (
See her article.) While I may be a bit late to take up psychodynamic psychotherapy's defense (though not necessarily the type of traditional psychoanalytic treatment she received), noting that several of my PT colleagues have already commented (see, for instance, psychoanalyst
Michael Bader's posting ), I want to offer my own response to Ms. Merkin, readers of her controversial piece, psychotherapy patients, and all those considering psychotherapy.
Ms. Merkin's title, "My Life in Therapy," could be equally well applied to my own professional experience as a provider of psychodynamic psychotherapy for most of my adult life. Indeed, I have had the sacred honor and privilege of being a practicing psychotherapist for almost as long as Ms. Merkin has been a psychotherapy patient. I have also had more than a decade of didactic personal analysis with two (male and female) Jungian training analysts, though my experience was, fortunately, exceedingly different than hers. For those of you that have not had time to read Ms. Merkin's courageous and forthright history of her own personal experience as a patient with "countless" (evidently meaning more than fifteen but less than fifty?) clinicians, most of whom were both medical doctors and psychoanalysts, here is the gist of her journey: Beginning at the age of ten, she apparently saw a consecutive string of psychiatrists (with the exception of one or two non-MD's) without interruption right through her mid-50's, until very recently deciding to stop psychotherapy altogether--at least for now. Her recounting of time, effort, tears and considerable small fortune spent on receiving psychotherapy consistently over four decades contains a certain quality of bitterness, frustration, confusion and sense of futility regarding what, if anything, she ultimately gained from it: "All those years, I thought, all that money, all that unrequited love. Where had the experience taken me and was it worth the long, expensive ride? I couldn't help wondering whether it kept me too cocooned in the past to the detriment of the present, too fixated on an unhappy childhood to make use of the opportunities of adulthood." Here she intuitively expresses one of existential psychotherapy's central critiques of psychoanalysis: its tendency to dwell too much on the past, on infancy and childhood trauma, to the neglect of focusing practically and concretely on the present situation, the here-and-now, and the future. (See my prior posting "What is Existential Psychotherapy?)
Freudian Psychoanalysis
Why even dignify with a comment this incurable patient's narcissistic exhibitionistic rant which nytimes.com should never have published. There are those who are just not analyzable.
For the genuine values of Freudian psychoanalysis, see FreudPs e*Archive with writings by K.R. Eissler, Anna Freud, Freud et al. See also the new book, "Freud Futures" ISBN 0967916178 by Jennifer Arlene Stone.
THE APP on javari
http://javari.com
Reply to FreudPsa e* Archive
In my experience, so-called "unanalyzable" or "difficult" patients (as Merkin sees herself) are those that have frustrated their psychotherapists, perhaps to the point of annoyance, irritation, anger, or even, in some cases, rage. As you know, we call this negative reaction to patients "countertransference." And it is certainly true that some patients do tend to elicit more of this countertransference than others. But, to me, this dismissal of the "difficult" patient by psychotherapists--something we increasingly see happening today with some of the more severe personality disorders, mood disorders and psychotic disorders--says more about the therapy, psychotherapist or analyst than the patient. It demonstrates the failure or limitation of the treatment method more than the patient's failure. Yes, psychotherapy--psychoanalytic or otherwise--can't always help every patient or client. And, of course, the patient, in most situations, must be ready for and committed to treatment. But in Ms. Merkin's case, based on her own self-description in the article, she doesn't sound like such a "difficult" patient to me. Just someone who never quite found what she was looking for from psychotherapy.
Which is more narcissistic-patient or analyst
Or maybe this type of analysis is bunk? I have talked to people going 4 times a week for this type of analysis for years. How does this propagate independence, not dependence. There are those that don't belong in this type of "therapy" at all. They wonder how they are ever going to function without their therapist and feel needy and more unstable than when they started years ago. Now I'm sure there are a lot of people who are helped by this expensive, time consuming, analysis from the dark ages, but sucking at the teet of analysis 3-4 times a week for years would make a strong person dependent. Just my thoughts as a client of therapy...
When a client deigns to
When a client deigns to critique psychotherapy, here comes artillery--labeling the discussion as a "narcissistic rant." This authoritarian, shaming, labeling, invalidating response to criticism just might explain many of the profession's failures.
A new patient's Reaction
I cannot thank you enough for this response to Merkin's NYT article. I am the same age as Merkin and, shortly before the article appeared, I entered therapy for the first time in my life. Merkin read like a horror story, and I was one of its characters.
I have had only a few sessions so far, and I find myself confused, anxious, and obsessed with the process. I have several times changed the conversation to the "real" reason I entered therapy, and revised the question what am I expecting to get out of this when it is "over." Life was so much easier before therapy, I tell myself, when I was in denial that there was anything fundamentally wrong with my life.
While I like my therapist and generally feel more and more comfortable with each session, I have to keep reminding myself that this person I am telling my deepest secrets to is really only the other end of a business relationship. Your list of nine lessons that Merkin underestimates (check your numbers, you have the number six in there twice!) has already become a cheatsheet I intend to keep handy as I assess how the relationship between me and my therapist develops. I highly recommend that you (or someone in your profession) publish something like that in a more formalized way. I certainly didn't see any brochures sitting out in the waiting room.
Dear "New Patient", thank you
Dear "New Patient",
thank you for your post in this matter and thank you to Dr. Diamond for your excellent response to the sad account by Ms Merkin of her experiences in therapy.
May I as an Analyst in faraway Sydney, Australia pick up on your delight in having a "cheatsheet" in Dr. Diamond's list. Please beware!!
A paradox of therapy is that you can't be "told" how to be in therapy. YOU have to discover it for yourself.
Dr. Diamond's forthcoming book with his expanded list of "secrets" may be a poisoned challice.
No amount of brochures in waiting rooms will address this issue.
Reply to Ron in Sydney
Thanks for your kind comments on my article and for your warnings to the new psychotherapy patient about the dangers of trying to learn "how to be in therapy" from external sources. You are right that the psychotherapy process and its meaning must be rediscovered or recreated anew by each individual--though that may sound a bit too esoteric for some. In the article, I was listing some of the lessons Ms. Merkin seems to have learned, perhaps without recognizing their value and importance. I would say that there is a certain archetypal truth and universality to these lessons in general, though each patient must learn them through his or her own personal experience. Just to clarify regarding my not-yet-published book: It does not at all try to tell people how to be in therapy, but rather is a description of some of the most common conundrums and difficulties patients struggle with and how I conceptualize and address these issues and their underlying existential and archetypal themes in treatment. The full title, for those interested, is Thirty-Three Secrets of Psychotherapy: Powerful Wisdom for Dealing With Life's Most Perplexing Problems. I sincerely hope it doesn't turn out to be a "poisoned chalice." But I guess we'll see.
You're right. "Cheatsheet"
You're right. "Cheatsheet" is a bad choice of words. It suggests a list with the right answers printed on it; there are no right answers. But there are definitely wrong answers, and I think Dr. Diamond addresses some of those. Perhaps the lesson is that any layperson who reads Dr. Diamond's list needs to do so recursively -- i.e., his warnings apply to what he says as much as one's own therapist.
Reply to New Patient
Thanks for catching my counting error! I corrected it, and you were right that there are nine lessons there. I am happy to hear you found the article helpful, and hope that your experience in psychotherapy proves to be a satisfying one.
P.S.-- I am in the process of formalizing these lessons in my new book Thirty-Three Secrets of Psychotherapy.
If Merkin had been provided...
Merkin suffered from her therapists unwillingness or blitheness to the importance of treatment plans, as discussed in Zwolinski's THERAPY REVOLUTION.
Without a written treatment plan containing diagnosis, plan of attack, and benchmarks for measuring success, psychotherapy becomes an extremely interesting football game played with a gossamer ball and moving goal lines and goal posts.
Written treatment plans, in my opinion, should be mandatory.
termination
I loved your comment that all psychotherapy, even unsuccessful, nust come to an end, and I would love to read your post "The Power and Terror of Termination" but I got a Not Found message instead.
That said, I would go so far as to say termination defines psychotherapy - of course that may just say something about me, that I limn my life in terms of loss? - but I digress. Termination of therapy is truly a beginning. You call it flying solo and that is an apt metaphor. I loved my therapy, and am SO glad to be done with it at the same time. Maybe I didn't digress at all, the ability to tolerate loss is something that can indeed be gained in therapy, and termination represents the transition from acting out to acting on. I hope Ms Merkin can come to enjoy solo flight.
Reply to anonymous tbnl
If that embedded link wasn't working, it should be now. The posting I referred to is titled "Can Therapy Be Addictive: The Power and Terror of Termination" at http://www.psychologytoday.com/blog/evil-deeds/200912/can-therapy-be-add...
Agree and Disagree and the Cartesian Isolated Mind
An Interesting and thought provoking piece and thank you Dr D. As a practicing clinical psychologist, ten years of a successful affect based analysis' , and a 21 year loving marriage ( which would not have been the case without analysis) the notion of the cartesian isolated mind and aloneness in the world is that antithesis of what i have come to internalize from my experience. Needing and being needed within the transference experience in analysis, transferred over time into life experiences has been liberating , leading to the reduction of isolated shame and the realization that one does not have to fly solo in the world and that we are not alone.
Within the transference experience, focusing on the expansion and making meaning of of both deep affect and mental states resurrected once suppressed in early childhood, the potential threat of trauma repetition experiences in life becomes reduced. Within the transference with the analyst the patient may now move within the world with a more expansive sense of self as a wider broader and deeper sense of selfhood emerges . A healthy self love . Understanding through sustained empathic relating , together making meaning of early crippled isolated states of being that is often the result of a deeply shamed and lonely self , sequestered within protective chaos , appears to be an essential component in the healing of the soul.Dr Diamond notes a comment regarding Ms Merkin recounting . ' Here she intuitively expresses one of existential psychotherapy's central critiques of psychoanalysis: its tendency to dwell too much on the past, on infancy and childhood trauma, to the neglect of focusing practically and concretely on the present situation'. I am curious about the intuitive part of Ms. Merkin regarding her observations on the dwelling on the past. My sense is that intuitively Ms Merkin recognized there was something missing regarding how the past was being addressed within the therapuetic relationship. The key is how past traumas are focused on and addressed in therapy, for focused on they must be. However , rather than address with a practical and concrete approach , Dr Heinz Kohut was an important game changer in the field by showing us that experiences of trauma become further traumatized when a sustained loving and empathic inquiry regarding the event is not experienced. Childhood trauma is the result not necessarily of the experience itself but the lack of loving attunement to the event that provides both emotional safety and makes meaning for a child of their experience of trauma, so that they no longer feel alone. Trauma frequently lies within the experience of emotional neglect an abuse vastly underrated, and one that is often repeated by well meaning therapists. A practical approach while helpful fails to address the necessary underlying affect connection which must be experienced and shared in a corrective way . It is likely that Freudian/ Kleinian approaches fail to address these essential elements thereby setting up a repetitive and disappointing experience for Ms . Merkin and perhaps many others. Creating a ' third' relationship in therapy , one where both therapist and patient together dependent on one another , collaborate to create an expanded world view leading to the emergence of closer and more intimate relationship and in turn life as a result . No longer dependent nor independent but interdependent, where now the memorable lyrics ' People who need people are the luckiest people in the world become more meaningful . Paradoxically the mature path does address the human right to deeply need one another , while at the same time internalizing within the therapeutic experience the ability to becoming a more loving and kind parent to the child within us who can in turn may now give and receive love for one another as well as ourselves each every day .
And as Carl Jung once noted in an interview with John Freedman of the BBC re his refusal to disclose certain information regarding his relationship with Freud. " No ' he affirmed, ' I will not discuss him for these sentiments go beyond this life' . Jung appeared to know more about the longevity and connection regarding relationship than is ' dreamed of in our philosophy.'
Reply to Dr. Wood
Hello. Good hearing from you! And thanks for your comments. Your points regarding relationship, both in therapy and without, are well-taken. As you know, we come from two different perspectives on this matter. I do very much agree that past traumas must be addressed fairly consistently on some level throughout the course of therapy, since childhood experience constantly and unconsciously manifests itself in adult experience, behavior and relationships. That being said, the existential position holds that focusing exclusively on the past is a problem. This is at least part of what Ms. Merkin seems to realize. Your point that the real problem may be that those childhood experiences were poorly processed by her previous psychotherapists is absolutely right. An intellectual, cognitive recognition of what happened or didn't happen in childhood is not sufficient. As I mentioned, this is why Rank said that the patient needs not an explanation but an experience. He meant an emotional experience. Freud understood this when he first discovered psychoanalysis, but it later got lost. As regards the issue of relationship and aloneness, again, from an existential standpoint, we are alone. We enter the world and leave it alone. This aloneness is a difficult, painful existential fact of life that most of us try to avoid at all costs. Relationships, be they with a spouse, friends, family or a psychotherapist, can and do assuage this existential loneliness and aloneness. But they can never eliminate it. Parents die. Friends move on. Lovers leave. Marriages end. Spouses pass away. And psychotherapy terminates. We are always thrown back upon ourselves. When relationships, whether therapeutic or personal, are used, like a drug, to avoid the anxiety of aloneness, they can become part of a neurotic and addictive pattern of avoidance. So "flying solo" means no longer depending on the psychotherapist to avoid the anxiety of being alone in the world. But it doesn't necessarily mean not having relationships. In fact, as you say, successful psychotherapy frees the patient to consciously choose those hopefully healthier relationships, rather than compulsively and avoidantly entering into and remaining in them. But it also frees the patient to choose to say no to relationship, and to accept and embrace his or her existential aloneness. Of course, excessive aloneness or introversion can be a way of avoiding intimacy and relationship. Ideally, some balance between aloneness and relationship can be found.
I wish we could have exit
I wish we could have exit interviews from your clients and talk to them a year or two after termination to see their thoughts on your treatments. It's okay to hear the doctors drone the wonderful ways therapy or analysis can change a persons life-of course this being up to the client in the end-according to your article, but there are a lot of quacks and wacks out there who do more harm than good. I've been in and out of therapy with various people and it took me 10 years to find someone that knew what the hell they were doing. I have a high IQ along with a diagnosis of DID, and expected the person I was dealing with to know their stuff, so to speak. Lots of therapists said they did, only one of eleven actually did. So who knows who this poor woman got stuck with at times, and their level of knowledge. Blaming the patient for their lack of progress is almost automatic, if not in words, in deeds, in the frustration the therapist shows at a lack of progress. I know you put the blame on the therapist if the client gets stuck, but very few therapists I've run into do this, they show frustration, sometimes coming out and actually blaming me when "they" get stuck.
I am a very motivated person.I do the best I can with everything I've learned so far, I study on my own, read helpful books, go to partial hospitalization when needed, (sometimes being the only one there taking notes). So I'm not a sit back and fix me kind of a gal, but the reactions and frustrations I have put up with from therapist's who have no idea how to treat me got old quickly. I finally found someone who knows his stuff, and he was appalled at some of the things I went through in therapy. So I give kudos to the person who put up with this crap for 50? years. I would have given up after nine if I hadn't found one diamond in the rough.
Sorry. I don't buy your
Sorry. I don't buy your defense of the psychotherapy racket.
The lady is right to question investing her emotions, money and time in a
giant scam.
My advice to you is to earn an honest living,
and stop ripping people off.
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