Thursday, December 25, 2008

The Essence of Psychotherapy

Sigmund Freud introduced the concept of "psychotherapy," which came to mean that by simply talking things through, one could feel and function better. Through his popular, worldwide lectures about his clinical experiences and psychological theories, Freud brought about a paradigm shift in thinking about mental illness and emotional distress. These were no longer seen as mysterious and inexplicable, perhaps as intrusions of devilish forces or the results of structural brain malformations. They came to be thought of as learned maladaptive patterns of mental activity--learned, for the most part, in early childhood so they were not experienced as "add-ons" amenable to change; but with the right kind of intensive psychological "work," they could be "cured."

During the first half of the 20th century as Freud's "psychoanalysis" became widely known (and revered), two practical objections to it emerged. First, it was terribly expensive and prolonged: a course of treatment typically cost many thousands of dollars and took many months if not years to complete. And second, often it turned out to be ineffective therapeutically; it was a wonderful technique for introspective self-study and for elucidating, for educational purposes, the complexities of mental function, but all too often the patient's original symptoms persisted or returned after psychoanalysis was completed.

As a result of these objections, a raft of alternative "psychotherapies" emerged. The Wikipedia lists 150 different kinds of "psychotherapy," over 100 of which are "talking therapies" which rely primarily on verbal interchange--the others use massage, music, dance, acting, aromas, special sounds, various kinds of meditation, etc.

One important branch of psychology, loosely derived from Pavlov's famous work on the bell-triggered salivation of dogs, was called "behavioral psychology." This claimed that emotional reactions were essentially learned, conditioned reflexes. The "behavior therapy" derived from this used, among other techniques, trained relaxation to reduce anxiety while the patient was exposed to increasingly anxiety-provoking stimuli such as pictures of snakes or of intimate social situations. Behavior therapy worked (and works) well in certain clinical situations although suppression and substitution of symptoms were often a problem. (See my essay titled "Where Do Symptoms Go To Die?)

Another branch, the "cognitive therapies," essentially used the power of rational understanding of mental mechanisms and the symptoms they caused (based largely on Freud's theories) to gain mental leverage and release the patient from the grip of uncomfortable psychological symptoms. The so-called "cognitive therapies" also came in a variety of forms and had (and have) some successes.

Some other well-known systems of psychotherapy were Gestalt Therapy, Person-Centered Therapy, and Transactional Analysis. Each of these had powerful, charismatic founders and practitioners, and each had (and has) some successes.

Finally we should note the "group" therapies as part of the phenomenon of "talking" psychotherapies derived, directly or indirectly, from Freud's legacy. These included insight-oriented groups and devastatingly powerful "sensitivity" and "T" (for "training") groups, and such systematized derivatives as the "Square Games Club" of Synanon and the wave of enlightenment seminars such as est, Actualization, and Living Love.

Freud invented psychotherapy, the "talking" therapies, which provided the opportunity and theoretical framework for "insight," that is for understanding why one acted "neurotically" (i.e., foolishly)--and in recurrent (foolish) patterns. But insight alone was not enough to end neurotic symptoms without two additional factors: (1) the motivation to change, for example, due to emotionally painful embarrassment and (2) the hard work of practicing healthy patterns. Some alternate therapies derived from Freud's work provided these factors through charismatic leaders (which Freud would have called "transference"), special techniques (which could be seen as crassly manipulative), or group pressure (since we are all susceptible to the power of the opinions of our peers).

Insight or awareness of the problem; plus motivation to change; plus practice of healthy patterns: those are the three essential ingredients of an effective "psychotherapy." For example, I find myself in a brief, minor social situation; I feel inexplicably enraged; I feel puzzled, helpless, and foolish that this situation should upset me so; I struggle within myself to contain or undo the rage; then I feel anxious and depressed. As I think about this situation, perhaps by talking it through with a therapist, I realize that it is a recurrent pattern in my life. That I have an automatic, competitive reaction even in minor encounters. I discover that I learned this reaction as a young child through oft-repeated interactions with my father in which I felt inadequate and humiliated. I understand, as an adult looking back at this, that my father was trying to teach me to be emotionally strong; it was an expression of his love for me. I decide that whenever this cycle of rage, anxiety, and depression overcomes me in the future, I will remind myself that it is because the situation (and person) in question reminds me of my father's misguided interaction with me and that, in truth, my father acted toward me the way he did because he loved me and was trying to help my emotional resilience, my emotional growth and maturation. I find, as I practice this insightful formulation and revised emotional reaction, that gradually, whenever I encounter a situation which might have enraged me, instead I feel relieved, joyous, and loved.

For another example, I notice that whenever I sit down at an ordinary meal, I overeat. This gradually makes me overweight, and I feel logy and unattractive and, as a result, socially isolated, lonely, anxious, and depressed. In discussing this pattern with a psychotherapist, I discover that when I was a child, my mother urged me to overeat because she felt anxious about my health. I understand, as an adult looking back on this, that my mother, with all her urging and psychological manipulations--including shouting at me and crying tearfully--was, in a warped way, expressing her love for me and her concern for my health. I decide that in the future whenever I am tempted to overeat, I will remind myself that it is because of my mother's absurd urgings which were actually an expression of her love for me, and that I can actually experience her love and concern for my health more if I do not overeat. As I practice this reformulation over a period of time, I come to feel relaxed and to eat healthfully, I attain a more normal weight, and I become more active in life and physically attractive in social situations.

This process of talking through to insight and practice is the essence of psychotherapy. It is the valuable legacy Freud bequeathed us.