Saturday, October 23, 2010

What's Wrong with Psychotherapy?

by Richard Crews
Half a century ago when I was in my early years of learning to be a psychiatrist, I was in psychoanalysis for a couple of years. Four days a week--on Monday, Tuesday, Thursday, and Friday afternoons--I would ride my motorcycle over to Dr. Ivan Heissler's office and lie on his couch for an hour and say any damn thing that popped into my head. That's called "free association." It's the essence of psychoanalysis--and psychoanalysis is the grand daddy of all Western psychotherapies (the "talking therapies").

I knew a lot about psychoanalysis. I knew that all I had to do was associate freely enough and long enough--with a qualified psychoanalyst listening in (a psychoanalyst is someone who has learned to be very, very patient and to listen quietly no matter what)--and clarifying insights about my tangled mental processes would emerge, and the warm hand of healing would descend on me and my life.

There are several things wrong with that picture. In fact, my experience in psychoanalysis had very little effect on me other than relieving me of hundreds of hours and thousands of dollars that I really couldn't afford.

For one thing, nobody ever told me (and it didn't occur to me at the time) that it would behoove me as I prattled on to talk about things that bothered me, or at least puzzled me in my life. This seems so painfully obvious in retrospect that I am embarrassed to report it now. But the good doctor Heissler, in line with his years of training, never asked me, "What do you want to work on today?" or "So what's been bothering you lately?" Similarly, no friend, relative, or colleague ever inquired, "Whacha workin' on in analysis these days?" And I never thought to ask myself either. Regardless of whether I was discouraged or elated--suicidal or homicidal--as far as I can recall that never entered the analytic sessions.

Secondly, as far as I knew insights would just emerge from the tangled web of my thoughts. I didn't know that you have to hunt them down, puzzle them out, glimpse them hiding in the dark corners protected from scrutiny by every conceivable mental machination and self-deception. And then once glimpsed, once cornered, once grasped, you have to hold onto them with every fiber of the adult, reasonable parts of your brain lest they slip quietly back into the woods and continue their insurgent terrorism on you life. So it isn't enough to realize, "yeah, I guess I overeat to please my mother--so what?" or "whenever I think of homosexuality, I'm still secretly afraid my father will punish me--that's sort of interesting."

Which brings us to the third problem--dissatisfaction with the status quo and motivation to do something about it. This has worked its way into the popular mythology about psychotherapy. You probably recall the old saw, "How many psychotherapists does it take to change a light bulb?" Answer" "Just one, but the light bulb has to want to change."

The fourth way that psychotherapy often breaks down is in providing some mechanism for learning the change. This might be devising some verbal formulations that ring out the old ideas and ring in the new--mottoes and slogans to reshape your life--"eating is not a form of entertainment" or "my father (dead that he is) doesn't care what I do sexually, and never did." Or it might be lifestyle changes--eating a defined diet on a regular schedule; calling the boss by his first name.

The fifth (and final) problem with psychotherapy is perhaps captured by the response of the New York City cop who was asked by a tourist, "How do I get to Carnegie Hall?" The cop answered, "Practice, practice, practice!" Most people don't realize that the hard-won insight and the cleverly devised counter-strategy are only one-tenth of the battle. It is only through careful, attentive, determined, arduous practice of the new, healthy (workable, comfortable) point of view or way of behaving--practice stretching over many weeks, even months or years--that it comes to replace, permanently and automatically, the neurotic patterns we learned as children.