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Following in the footsteps of fellow PT bloggers Drs. Jared DeFife and Judith Beck (Dr. Aaron Beck's daughter), I'd like to offer a response of my own to Dr. Ryan Howes' interesting and revealing series of interviews on the "Seven Questions." My comments are based on my more than thirty years of clinical practice in psychotherapy. I hope this will underscore for readers some of the differences and similarities between Cognitive-Behavioral Therapy (CBT) as discussed by Dr. Beck in her recent response, and an orientation to treatment which I call existential depth psychology: a synthesis of psychoanalytic, Jungian, and existential psychotherapy.
1. How would you respond to a new client who asks: "What should I talk about?"
First session: "What brings you in to see me today?" "How did you find me?" "Why now and not six months ago?"
Second session on: "This is your session. You can talk about whatever you like." "Where are you right now?"
2. What do clients find most difficult about the therapeutic process?
While I agree with Dr. Beck's response that patients struggle with changing or restructuring their "schemata" or "core beliefs" about themselves (e.g., I am unlovable, unworthy of love, bad, stupid, evil, ugly, etc.), I would say that the greater difficulty has to do with accepting reality, past and present, which I refer to as the "bitter pill ": confronting the harsh reality of what happened during childhood, and the reality of evil in life. This is an emotional rather than merely cognitive process of consciously and affectively acknowledging the childhood wounding and dissociated feelings which frequently underlie the presenting problem, symptoms and distorted cognitions. Altering cognitions or providing intellectual insight alone is not enough. These affects--grief, fear, sorrow, anger, rage-- have typically been defended against for years, chronically denied, and are associated with abandonment, betrayal, loss, rejection, neglect or outright cruelty by parents, caretakers, peers, siblings or others. So confronting these socially unacceptable, nasty feelings or impulses in oneself, particularly anger or rage, can be frightening, shameful and painful, and is experienced, to cite Jung, as a "defeat to the ego." Swallowing that bitter pill involves tolerating the anxiety of changing or modifying one‘s self-image, relinquishing the old protective persona (with its outdated or irrational core beliefs) and creating a new, more appropriate perception of oneself and the world. This willing acceptance rather than avoidance of anxiety, the daimonic and the "existential facts of life" is very difficult, requiring courage, commitment, honesty and tenacity. The medicine may be bitter, but therapeutic. Patients also typically struggle with either taking too much or too little responsibility for themselves and their problems. And with recognizing and taking responsibility for loving, disciplining and supervising the inner little boy or girl all adults still have living within themselves.
3. What mistakes do therapists make that hinder the therapeutic process?
They try too hard to relieve the patient's suffering. They want to tone down, dampen or neutralize the daimonic. It is the patient's suffering that brings him or her into treatment. As Jung once said, "Neurosis is always a substitute for legitimate suffering." What he meant is that some suffering in life is inevitable, and must be accepted and tolerated. It is sometimes the refusal to accept natural suffering that leads to psychopathology. Suffering may have meaning. Even value. It may be the primary motivation to change. So rushing to alleviate the patient's suffering is not always necessarily in his or her best interest, since it may play into their already problematical dissociative, escapist or avoidant tendencies. I disagree here with Dr. Beck. Feelings like sadness, grief, anxiety, loneliness, anger, rage, pain, shame need to be accepted and experienced, not necessarily "reduced as soon as possible," as she suggests. (Though this may certainly at times be required, depending on severity and debilitation.)
Therapists (new ones especially) also tend to take on too much responsibility for the patient's healing, which permits the client to continue to slough off their responsibility for helping and healing themselves. So psychotherapists need to strike the right balance between caring and detachment in the Buddhist sense. Psychotherapy is fundamentally a process of self-healing, which is why Dr. Beck is right in emphasizing the importance of equipping patients to help themselves "to solve problems and feel better" between sessions--and, ultimately, beyond therapy. Finally, therapists sometimes fail to adequately address ruptures in the relationship: seemingly minor slights or irritants, which, when ignored, can lead to resentment and premature termination by the patient. Or they allow the patient to remain dependent on therapy (and them) for too long.
4. In your opinion, what is the ultimate goal of therapy?
I believe it is the patient's responsibility to decide the goal of therapy, and how far they wish to go. Ultimately, for me, what I want for the patient is to be able to stand on his or her own two feet in the world, deal constructively or even creatively with reality, and find and fulfill his or her destiny. I grow ever more appreciative of Freud's oft misunderstood remark that the goal of psychotherapy is to transform "neurotic misery into common unhappiness." This, to me, is a deeply spiritual acceptance of life as it is, rather than how we wish it to be. There is no cure for life. Nor does there need to be. My job is to help the patient get to the point where they no longer need to be my patient. Are ready to "fly solo."
5. What is the toughest part of being a therapist?
The toughest part of being a psychotherapist is dealing constructively with what we call "counter -transference," recognizing our own limitations, preconceptions, complexes, biases, and avoiding dogmatism and "burnout." It is hard but rewarding work to wrestle with emotional demons day in and day out, and as Freud observed, no therapist comes away from that task totally unscathed. Doing psychotherapy is, to some extent, staring evil and human suffering in the face each day. This constant exposure to human suffering can take its toll. So it is vitally important for psychotherapists to take especially good care of themselves physically, psychologically and spiritually. Staying somewhat flexible, open and creative in one's approach to treatment is also vital, as opposed to falling into the trap of "Procrusteanism": forcing every patient to conform to the therapist's theoretical or technical orientation and treating every patient identically. When it comes to psychotherapy, one size doesn't fit all.
6. What is the most enjoyable or rewarding part of being a therapist?
To have the high honor and adventure of accompanying patients on their difficult and sometimes extensive journey toward finding and fulfilling their destiny. Even after more than thirty years, I still find this sacred and soul-restoring process intellectually and emotionally stimulating, energizing, inspiring, sometimes even thrilling.
7. What is one pearl of wisdom you would offer clients about therapy?
Don't expect it to be quick or easy. At the same time, don't assume it must take "years," though this is sometimes the case. I agree with Dr. Beck's comment that "all psychotherapy is not the same!" Of course, each patient is different, and demands a treatment approach partially tailored to his or her needs. Therapists should possess some technical flexibility. Psychotherapy depends primarily on the psychotherapist: his or her training, background, orientation, personality, experience, philosophy, creativity, insight, intuition and world-view. And on the human relationship between patient and therapist. So I think that rather than seeking a certain kind of generic psychotherapy, patients would do well to seek instead a specific psychotherapist with whom they feel they can effectively work on their problems. Psychotherapy is not quite like car repair. It is not a primarily mechanical, technical, prescribed, by-the-book process, but rather a dynamic human relationship between a helping professional and patient or client. It is more about chemistry (or alchemy) than technique. Meta-analysis of psychotherapy outcome suggests that no one particular technical approach to psychotherapy is superior to another. But I would say that some approaches work better for certain patients than others. And different therapists have different ways of helping. So I suggest prospective patients consult several competent therapists from different theoretical orientations when seeking assistance to see with whom they feel most comfortable, encouraged and understood. Trust your instincts. If after several sessions or certainly months you feel no sense of progress or encouragement, talk to your therapist about it, and consider trying a different tack.
Dr. Stephen Diamond is a practicing clinical and forensic psychologist in Los Angeles, and is affiliated with the Existential-Humanistic Institute, which provides training in existential psychotherapy. He is the author of Anger, Madness, and the Daimonic (1996) and is working on a new book tentatively titled Restoring the Soul: Thirty-Three Therapeutic Secrets for Emotional and Spiritual Self-Healing.
