In my practice, I systematically track what type of improvements patients have been able to make. If clients are going to make a commitment to psychotherapy, expose their personal wishes and fears, and trust a professional with their vulnerability, I think they deserve to know what to expect in return.
For example, when patients go to orthopedic surgeons with injured knees, they want to know if surgery will just make the pain go away or perhaps whether can they run again. When individuals commit to a place for their religious or spiritual beliefs, they want to know if this commitment will relieve their suffering or possibly help them achieve enlightenment. Psychotherapy seems somewhere in between those.
Much has been written throughout the history of psychiatry about the nature of consciousness, the true nature of the brain versus the mind, and the dualism between strict behaviorism versus the free will of self-reflective thought (Gazzaniga, 2018). But in the trenches of a clinic, with real patients with real, complex problems sitting in the chairs across from therapists, those lofty discussions must be reconciled with what is actually possible.
Based on our tracking of data, outcomes fit into three paths:
Laying blame for all of one’s problems on other people or other circumstances by definition renders individuals incapable of changing themselves. These individuals are unable to self-reflect and use feedback from therapists. The typical diagnosis for these individuals is a personality disorder. While they often feel somewhat better about themselves due to psychotherapy, little permanent change tends to occur. These comprise about 20 percent of clients, although the percentage is likely lower at our clinic than at many other clinics. We try to screen these out because we want to keep therapy slots open for clients whom we are able to help more efficiently.
2. Fixer Uppers
This group comprises about 70 percent of patients. The problems these individuals deal with are relatively narrow in scope and have short-term solutions. These manifest as a variety of subtypes:
- Contemplating Big Life Change: When facing big decisions (e.g., moving, ending a relationship, and picking a job), many individuals just need an unbiased listener who understands human nature to review their plans with them.
- Struggling and Alone: This may be young adults in college who are struggling with career plans or with their sense of identity and belonging in the world. Or, it may be elderly, retired, recently-widowed individuals who have to negotiate a new purpose for their lives.
- Overwhelmed and Confused: After a string of unfortunate stressful experiences, some individuals need time to let the dust settle, and gather their wits about them. They do not need to make major changes to their lives, and often do well with reassurance.
- Big Life Decision Went Sideways: After believing that they had found the right person to marry or found the right career, some individuals discover they made mistakes. Perhaps they had blind spots about the persons they married. Sometimes we find that they had undiagnosed conditions, such as autism spectrum disorder, that made their professions more difficult than they originally thought.
- Anxiety, Depression, or PTSD: Almost all the types of Fixer Uppers mentioned above have underlying disorders of anxiety, depression, or PTSD that are, in part, genetically determined. These disorders typically have been present for many years regardless of any life stressors. Whether these disorders cause problems without concurrent life stressors or with concurrent life stressors (e.g., relationships, college, retirement, marriage, and work), there are short-term, evidence-based treatments for these disorders.
- Untangle a Medical Mystery: Some individuals have illnesses that medical doctors cannot explain and suspect there may be psychological components.
Making the unconscious conscious with psychodynamic therapy causes enormous, life-changing benefits across nearly every activity of living. This occurs, however, only about 10 percent of the time in a general office practice because this outcome is neither the goal of most individuals who seek treatment, nor is it possible.
The mind is cunning, and it does not give up the unconscious easily. Exploration of the unconscious requires a year of weekly psychotherapy, probably several years, extraordinary commitment for self-change, and strong self-reflective capacities.
It may seem surprising that enlightenment about the unconscious is not a more common path, because historically so many writings of the experts have disproportionately focused on the unconscious (e.g., Freud and Jung, etc.), but it is consistent with the notion that individuals mostly want to be happier. Happiness is quite possible, and possibly more likely, while being ignorant of the unconscious. As the poet Thomas Gray famously wrote in 1742 in his poem Ode on a Distant Prospect of Eton College, "Where ignorance is bliss, 'tis folly to be wise.”
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Gazzaniga, MS (2018). The Consciousness Instinct: Unraveling the Mystery of How the Brain Makes the Mind. New York: Farrar, Straus, and Giroux.