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?)
Yet, it seems to me that at the same time, Merkin's memoir reveals her own hard-won recognition of how unrealistic, infantile, romantic or magical expectations about what psychotherapy is and is not, can and cannot do, tend to undermine the process when not explicitly addressed during treatment. To begin with, I believe Ms. Merkin may underestimate what she has learned cumulatively from psychotherapy all these many years. First, that the fantasy of finding the "perfect therapeutic match" is, like looking for the perfect mate, just, that, a fantasy. Second, yes, it is entirely possible to "stay in therapy forever without much real progress." Which is why both unsuccessful and successful psychotherapy must inevitably end at some point. (See my prior post on "The Power and Terror of Termination.") Thirdly, that, inescapably, in therapy, "the weight of responsibility is borne almost entirely by the patient. . . . " Fourth, is the recognition that constantly searching for growth, transcendence, "self-transformation" or "character change" may be a means of refusing to accept oneself for who and what one truly is. Fifth, that "insight" is not enough in and of itself to bring about behavioral or characterological change. Sixth, there is "no magic to be had, that a therapist's insights weren't worth anything unless you made them your own and that nothing that had happened to me already could be undone, no matter how many times I went over it." No amount of therapy can change the past. Seventh, that psychotherapy is, or should be "a place to say out loud all that we have grown accustomed to keeping silent, in the hope that we might better understand ourselves and our missteps, . . . to sort through the contents of your own mind . . . in the presence of someone who is trained to make order out of mental chaos." Psychotherapists, despite our real limitations and fallibility, do generally possess certain skills, experience and sometimes even precious wisdom to share with patients caught in the throes of life's confusion, emotional turmoil, and suffering. In fact, well-trained psychodynamic psychotherapists partake of a highly specialized, tried-and-true tradition of cumulative clinical wisdom with which to assist their struggling patients or clients. Eighth, that sometimes it is the psychotherapist's responsibility--regardless of theoretical orientation--to intervene actively rather than remaining rigidly neutral and passive, which might include at times offering a suggestion, discouraging certain self-destructive or therapy-subverting behaviors, appropriately expressing some personal feelings toward the patient, and, on rare occasions, even giving paternalistic, maternalistic, expert or friendly advice.
And last but not least, ninth, her profound perception, albeit disillusioning, that behind every all-powerful "Wizard of Oz" she and others so desperately seek and project onto a physician or psychotherapist, there is always "just another little man behind a velvet curtain." Or little woman. Another imperfect, only human, flawed fellow pilgrim plodding through life as productively as they can.There are no perfectly analyzed analysts. No totally enlightened teachers or mentors. (See my prior post "Do You Believe in Magic?") Psychotherapists, no matter what their orientation, are not omniscient, omnipotent nor superhuman, much as we might wish them to be.
What can psychotherapy not do? This is as critical a question as what it can do. For, like all paths to health, spirituality and wholeness, psychotherapy has real limitations. It cannot "cure" all of our symptoms. It cannot alleviate all of our suffering. It cannot resolve all of our problems. It cannot exorcise all of our demons. It cannot transform us into something we are fundamentally not. Nor can it alter or eradicate the past, and all that has or has not happened to us. Psychotherapy cannot extirpate life's inevitable tragic aspects, what Freud meant by that which causes "common unhappiness." It cannot change the existential facts of life, the immutable laws of nature to which we are all ineluctably subject. It cannot relieve us of our responsibility for our lives, choices and actions. Or our existential guilt for failing to find the courage to be true to ourselves or for behaving badly. Nor can it eliminate our anxiety about having to constantly make choices and decisions, even when the outcome of doing so is in doubt. Psychotherapy cannot make us perpetually happy, blissful or content. To expect such spectacular miracles from psychotherapy would be both frustrating and unrealistic. What psychotherapy can, but unfortunately typically fails to do today, as Merkin painfully found, is help patients accept the world, reality, themselves, their past, their rage, their limitations and those of psychotherapy, while at the same time discovering and enthusiastically embracing their own inherently potential freedom, will, creativity and power to meaningfully influence the world for better or worse, good or evil, now and in the future.
To be sure, a few of the psychotherapists she describes seeing sound simply flaky. And some borderline incompetent. But this sadly comes with the territory. Which is why those seeking psychotherapy should do their homework, shop around, be selective, and trust their instincts when it comes to choosing to enter into--or discontinue--such a significant relationship. One thing that appears never to have happened, at least by Ms. Merkin's account, is a satisfactory analysis of her transference reactions, both positive and negative, to various analysts and analysis itself, as well as how--due to her evidently deep-seated fears of abandonment and feelings of inferiority, insecurity and unloveability--she may have been avoiding true intimacy in therapy (and elsewhere) by running from one relationship to the next. This is certainly not to make excuses for the numerous shortcomings and dogmatic rigidities of orthodox psychoanalysis--including the exorbitant expense of 3-5 sessions per week--which her story makes all too clear.
Another issue never apparently adequately confronted by any of her analysts was, I surmise, the chronically repressed anger or rage at the root of her depression, probably originating in traumatic narcissistic wounding during infancy and early childhood. This is one of the central sticking points in psychotherapy of all sorts: How to constructively address this typically unconscious and well-disguised wrath against reality. (See my prior posts.) The recounting of the evidently hyperrational, intellectualized and overly cognitive kind of treatment she received recalls the vital importance of former Freudian disciple Otto Rank's remark that what the patient really needs is not a rational explanation regarding his or her defense mechanisms, but an emotional experience. For example, Merkin describes a close therapeutic alliance she developed with one middle-aged psychiatrist "who paid close attention to my innermost being: I felt fully recognized by him, felt that he saw me as I was and that I could thus trust him with the bad as well as the good about myself." This certainly sounds like a promising, empathetic atmosphere of what humanistic psychologist Carl Rogers called "unconditional positive regard," in which to work on oneself, face one's sadness, grief, anxiety or rage, receive the benefits of what psychoanalyst Franz Alexander called a "corrective emotional experience," and sort out the underlying transference issues. Unfortunately, this therapist terminated their relationship abruptly due to ill health, and soon died. Bad luck. But that's part of life too. Perhaps this and other losses of or abandonments by prior therapists taught her something terribly important: Life is transitory. We all die. No one, not even your psychotherapist, is immune. So, ultimately, we are all on our own. Alone. And we cannot remain childishly dependent on others forever--be they parents, spouses or psychotherapists--for our basic sense of security, self-esteem and well-being.
Finally, Ms. Merkin found the courage--empowered partly by the anger legitimately engendered during her last effort to find "my perfect therapist"-- to try letting go of her extreme emotional dependency on, her self-confessed "almost-addictive attachment" to, psychotherapy, and to venture out alone in life, standing, albeit tentatively, on her own two feet for the very first time, an experience she describes as "feeling liberated and scared at the same time." I call it "flying solo." This kind of ambivalence is typical when patients leave the supportive, protective womb of psychotherapy, even when things have gone well. (Again, see my prior post "Can Therapy Be Addictive?") And she seemingly took with her some very valuable insights and skills: "I recognized that therapy served me well in some ways, providing me with a habit of mind that enabled me to look at myself with a third eye and take some distance on my own repetitive patterns and compulsions." Being able to observe oneself and behavior with some objectivity, insight and detachment is prerequisite to becoming an independent, conscious and responsible adult. "I sharpened my perceptions about myself and came to a deeper understanding of the persistent claim of early, unmet desires in all of us." Being mindful and more aware of how we are all influenced, subtly and not-so-subtly, by our unconscious complexes or demons is another crucial step toward self-determination and individuation. "Above all," writes Merkin, " it provided a space for interior examination, an education in disillusioned realism that existed nowhere else on this cacophonous, frantic planet." An education in disillusioned realism indeed! Acceptance of reality, both past and present, as it is and on its own terms, rather than as we desire it to be. Of ourselves as we are. Of finitude, fate and destiny; the tragic existential facts of life. Of harsh (but also beautiful and mysterious) reality without excessive sugar-coating, buffering, sedation or anesthesia. This is a powerful lesson her antidepressants apparently never provided. Painful, expensive, frustrating, imperfect and time-consuming as it may be, any psychotherapeutic treatment that provides a good "education in disillusioned realism" can't be all bad.
But, if and when Ms. Merkin ever chooses to give therapy another chance--and I would, as a psychologist, encourage her to do so if she feels the need or desire--perhaps it's time to take a different tack, to try a Jungian (rather than Freudian) analysis or existential psychotherapy, or possibly even a cognitive-behavioral approach rather than further perpetuating what Freud himself called a "repetition compulsion": the futile yet repeated return to the same frustrating and dissatisfying situation or relationship in hopes of someday changing the outcome. Here we find one last helpful lesson from psychotherapy for Ms. Merkin to carefully consider. As the Japanese proverb reminds us, you can't get water from the moon.
All citations taken from "My Life in Therapy," by Daphne Merkin, as published in The New York Times magazine (August 4, 2010).