September 25th, 2013, marked the second celebration of National Psychotherapy Day. National Psychotherapy Day is the brainchild of PT blogger and clinical psychologist Dr. Ryan Howes, who deserves credit and congratulations for conceiving of, organizing, and getting it off the ground. This annual recognition of the healing value and importance of psychotherapy and of those who provide it has been endorsed by luminaries like Irvin Yalom, David Burns, Judith Beck and others from diverse therapeutic orientations to honor and promote the practice of psychotherapy in general. On this day we stand together, despite our many differences and squabbles within the field, to support psychotherapy, which has been shown by numerous scientific studies to be an effective method for helping people, no matter what particular theoretical orientation is practiced. Research has also demonstrated that psychotherapy can, in many cases, be at least as effective as psychiatric medication alone, often with longer-lasting benefits. And that in most cases potentially benefitting from medication, a combined treatment of psychotherapy plus medication is typically more effective than the use of medications alone. While there are a confusing number of different types of psychotherapy available today, we encourage mental health consumers to do their homework on researching various forms of psychotherapy and finding a psychotherapist with whom they feel comfortable and confident working together.
In honor of National Psychotherapy Day, here is the last of five pieces over the past five days in a series of previously published posts on the theory and practice of psychotherapy, in effect, extending National Psychotherapy Day into National Psychotherapy Week here at Psychology Today. (See my four prior posts in this series.) Hope you enjoyed! If readers care to submit any questions or comments regarding psychotherapy, what it is and how it is practiced today, please feel free to do so. I would also welcome and try to respond to anyone wanting to share his or her personal experience with psychotherapy, pro or con. And remember that National Psychotherapy Day happens again next year, on September 25, 2014. So start planning for it now!
Despite the disappointing experiences with therapy reported by PT blogger Carla Cantor (see her post) and journalist Daphne Merkin (see my first post in this series), psychotherapy has been shown to be effective in most cases. This is especially true when psychotherapy is combined with psychiatric medication for treating more severe and debilitating mental disorders. Having said this, I would remind readers that there is, for me, especially today, really no such thing as "therapy" per se: only differently trained clinicians with different personalities, skills and different degrees and kinds of education and experience, providing what they believe to be the best therapeutic treatment for the patient's problems. While according to some research, no one single theoretical approach to therapy is, in the final analysis, clearly superior to others, not all psychotherapists are created equal. Which is why the consumer of mental health services must be mindful that it is not just a generic matter of "going to therapy" as much as carefully finding the right therapist for you. One area of particular importance in my opinion pertains to how psychotherapists deal (or avoid dealing) with anger or rage, a topic I've posted about frequently. But another equally fundamental matter has to do with how therapists tackle the ticklish process of termination.
Termination is the technical term we therapists use to talk about the ending of treatment. But in reality, termination is more a stage than a particular end point, a crucial and, in my view, inevitable phase in the therapeutic process. Indeed, how the termination phase of treatment is handled (or mishandled) by the therapist can determine success or failure. In his essay "Analysis Terminable and Interminable" (1937), Freud addressed this very issue. Psychotherapy is a process in which a person with a problem or symptom he or she hasn't been able to overcome, either on their own or through previous treatment, seeks professional assistance to do so. A great deal of power and authority is projected onto the person and role of the psychotherapist, not unlike what happens when a patient consults a physician. This is a form of positive transference, to again employ one of Freud's terms. This positive transference is a two-edged sword: It is part of what makes the therapeutic relationship healing. But it can also foster dependency and stand in the way of eventual termination of treatment. This begs the questions: When is therapy over? Who decides? And on what basis? What happens when psychotherapy goes on either too briefly or too long?
Today, most psychotherapy tends to focus on relatively brief, symptom-driven treatment. Who decides on the duration of treatment? Insurance companies commonly place caps on the number of sessions the patient can utilize per year without having to pay out of pocket for therapy. Many clinics offer only a protracted course of therapy to patients or clients, limited to perhaps ten or twenty sessions maximum. Depending on the nature of the presenting problem and how the therapist approaches the case, much can be accomplished even in such a relatively brief therapy. In the right hands, existential, psychodynamic or psychoanalytic principles can be applied to such short-term treatments at least as effectively as cognitive or behavioral approaches. Psychopharmacological interventions can be even more quickly efficacious, kicking in within weeks rather than the several months that even the briefest course of psychotherapy requires. But generally, in either case, some partial symptomatic relief is pretty much all that can be expected. In most cases, today's psychotherapy tends to be too brief, too superficial, and does far too little to psychologically prepare the patient for life after therapy.
When the patient requires a more "open-ended" therapy (I prefer this description to the commonly used and dogmatic conception of "long-term" therapy), the question becomes one of duration: How long is long? I can say from my own thirty-plus years of clinical experience, that for some patients, one year of therapy or less can be quite sufficient; for others, several years is required; and for a minority, five to ten years or even more is not uncommon. Regarding this latter group, one would be right to wonder whether they have become overly dependent on therapy for their daily functioning. Have they become addicted to therapy? Is this a problem? Or does therapy sometimes require a decade or beyond? These are tricky but vital questions.
I believe that therapy addiction—much like other forms of addiction—is quite common. If so, what causes it? And who is to blame? While as a depth-psychologically and existentially-oriented clinician I tend to hold the individual (rather than his or her biology, circumstance or neurology) primarily responsible for addictions and other avoidant or self-destructive behaviors, I see this situation somewhat differently. Therapy addiction is not necessarily the patient or client's fault, but rather the responsibility of the psychotherapist. Psychotherapy, like everything else in life, has limitations. For me, psychotherapy is a process that has a beginning, a middle, and an end. The ending, or termination, is at least as important as what precedes it. When that ending is avoided by either the patient or therapist, or in some cases, by both, therapy has failed insofar as its mission is to help the patient become an independent, self-sufficient adult capable of coping with life's inevitable problems, losses, suffering and stresses more or less on his or her own. Not only has it failed to help the person learn to stand on his or her own two feet, but it has colluded in and contributed to the patient's avoidance of this existential aloneness and personal responsibility. This collusion can be caused by various countertransferential reactions in therapists, including (but not limited to) what has euphemistically been called "unconscious fiscal convenience."
Paradoxically, recognizing and accepting this existential fact of limitation can intensify and deepen the patient's growth and development in therapy. For it is during the "termination phase" of therapy that some of the most important working through is accomplished. This termination phase is the final stage of psychotherapy. But many patients—and therapists—avoid it for as long as possible and thus are never forced to confront it. Termination is a sort of death or loss of a deeply valued, supportive, nurturing and intimate human relationship. But so long as patients remain in this somewhat womb-like, often parent-to-child protective bubble, they, at least at some level, are refusing to grow up and venture out alone into the difficult, cold, cruel world. And by permitting the patient to avoid the anxiety, trepidation and sadness of termination, therapists perpetuate a dependency on therapy every bit as addictive as any drug. Of course, the same may be said of fostering the patient's chronic reliance on psychiatric drugs instead of assisting them to work through their avoidant tendencies. Both psychopharmacology and psychotherapy can unwittingly play into this chronic pattern of avoidance. But ultimately this does a disservice to patients, keeping them infantilized at some fundamental level, and unsure of their ability to face life on their own. They never learn to "fly solo." (Freud, on the other hand, recommended that due to the nature of their work, therapists return to analysis every five years or so for refreshment.)
The termination phase of therapy, once explicitly or implicitly entered into, might last for as much as half the entire treatment time. For example, the latter portion of a ten-week or ten-year course of treatment. Ironically, it typically begins once the patient starts to consistently feel better and less troubled by whatever first brought them into treatment. (If the patient is not responding to treatment after some reasonable time, the clinician has an ethical obligation to either take a different tack or consider referring the patient elsewhere.) The question sooner or later arises: Have I attained my goals for therapy? Can I continue to feel good and remain confident without therapy? What if I stop and begin to backslide? Am I strong enough to handle whatever challenges life brings? These are some of the most crucial questions posed in psychotherapy. And the answers can only be found by accepting and anticipating the inevitability of termination and working through whatever anxieties, abandonment issues, sadness and other feelings this evokes during what is sometimes a prolonged, painful, tumultuous but ultimately liberating and empowering termination process.