Why Therapy?

People come to therapy either because:

• 1. Bad things have happened to them,
• 2. They are unhappy with themselves,
• 3. Or both. 

BAD THINGS HAVE HAPPENED:

Some people seek therapy because something fateful has happened in their lives: they’ve lost a spouse or a job, they’ve gotten in trouble with the authorities, they’ve failed at something they were trying to do, they’ve been given an ultimatum by someone who matters to them, a child has crashed and burned, someone they loved has died.

What they want from therapy is support and guidance, some comfort, help getting back on their feet. They aren’t interested in examining their childhoods -- the crisis is now and they want relief. Totally understandable.

If the problem is really not of their making, if the fates dealt them a bad hand, they may get back on their feet quickly with just a little help. A therapist may be able to help reassemble the pieces in short order. Sometimes therapies really can accomplish their goals in just a few sessions, sometimes in just a matter of months. Therapist and patient need to keep their focus.

But it’s more complicated if the problem really isn’t external – if the job was lost, or the coursework failed, or the relationship sabotaged, because stuff inside was keeping the person from functioning well. The therapist may have to start by helping his patient understand that the disaster wasn’t just a matter of bad luck or chance or the unkindness of strangers. If the patient and therapist can get there, then the hard work begins.

LIFE DOESN'T GO EASY:

Others come for treatment because they’re unhappy with how they are functioning or feeling. They may be painfully depressed, or anxious, or guilty, or alone, or sad all the time. They may have difficulty managing relationships, or they may keep getting in trouble at work, or be unable to study, or be blocked in creative pursuits, or have trouble coping with a chronic illness, or be unable to have sex comfortably.

Problems of this sort have usually been going on for a time. They may have gotten worse recently, which has prompted thoughts of seeing a therapist. Medication may be very helpful, but it’s usually not enough by itself. Talking helps. It’s a very common experience for patients to feel, when therapy goes well, that the therapist is the first person that they’ve really been able to open up to, fully, and that that it’s the first time they’ve really felt understood.

How Does Psychotherapy Work?

This depends on who you ask. Let me tell you what, for me, a good therapy session is like:

First and foremost, it’s an open and honest conversation, a good talk. I feel it’s been a useful hour if we’ve been able to say the things worth saying to each other. And it’s not so easy to do that – we’re used to keeping our guard up for compelling reasons, because of our experiences of being hurt and used and misunderstood in the past. So it takes a while, and sometimes a substantial while, for us to build trust, to negotiate ways in which we can be really candid with each other.

Our past experiences shape us, and sometimes they take their toll. But it’s a great misunderstanding about therapy that the work is all about rummaging through the attic of our past. Therapists are only interested in the past as it is alive and kicking in the present. The ways of negotiating the world that we learned in childhood often became addictive. For better and for worse we connect in the ways that worked for us as children, even at great price to ourselves. That’s because the opposite of being loved isn’t being hated – it’s being treated as nonexistent – and so we accepted connection on the terms we could find. Therapy is about putting in question the roadmaps we’ve followed without hesitation and taken as set in stone.

In a good-enough therapy, more than anything else, we come to know ourselves better. Which can be extraordinarily useful. We don’t become different people, but we can develop second opinions about things we’ve taken for granted. (An example: It’s not just that I’m afraid of being embarrassed if I speak up. It’s also that I’m afraid of hurting you, and losing you.) Being able to entertain a second possibility offers us a measure of freedom, the chance to make a different choice. At least some of the time.

I think that my patients usually finish treatment with a different understanding of themselves, a different take on who they are and what’s made them that way, a fresh accounting in some regards, a self seen anew by virtue of having been refracted in our relationship.

I should add that I have had a few patients whom I have seen for many years of whom it might be said that they haven’t changed at all in that time, and yet for them the experience of being able to have a meaningful conversation each week has made their lives richer, the therapy session being an oasis in the desert, a pause in the deadened ritual, an hour of freedom.

What's the Difference between Psychoterapy and Psychoanalysis?

The real difference is how often we meet. Conventionally, being in psychoanalysis means having sessions four or five times a week, and being in psychotherapy means coming less often. Once-a-week treatment runs the risk of becoming the “news of the week in review.” By meeting more frequently, we can move beyond surface concerns and work at the underlying problems which interfere with loving, working, being expressive and creative, feeling better. It becomes safer to reveal yourself when you know that we can pick up the conversation tomorrow.

There’s a popular notion that more frequent treatment is for those who are more disturbed, that coming often must mean you’re “really sick.” But it’s actually the other way around. It takes a measure of personal strength to engage in a substantial treatment. Most of the people I’ve seen in psychoanalysis have been students or professionals with substantial personal lives. For stubborn inner problems, which have been years or decades in the fashioning, it may be that nothing less than an intensive treatment will make a difference. A maladaptive way of negotiating the world fashioned over a lifetime can’t be shifted quickly or easily.

“So am I signing on to do this for the next ten years?” I might be asked at this point. “Am I surrendering my life? Am I another perpetual patient like Woody Allen?” might be the private thought. (My first thought is: But think of all the great movies he’s made during those years of treatment.) What I’d say is this. You’re not signing on for life, you’re going to give it a try. If it doesn’t seem useful you’ll move on and try something else. And if it does feel helpful, it folds into your life like other useful activities which take time (working out at the gym, practicing at the piano, participating at the church, and so forth). Analysis makes heavy demands in time and money, and you’ll only stay with it if you sense that it’s become worth doing.

Freud and the Provision of Care

Pop culture has given Freud and his followers a bad rap, either declaring them passé or just dead wrong. The movement in clinical practice has been toward medication, short term treatment, cognitive-behavioral therapy, goal-focused work, and the like. Health insurance companies, facing spiraling overall medical costs, have seen psychiatric treatment as a place they can save money (even though psychiatric costs are at best a couple percent of the total national health bill). They can do this because psychiatric patients, valuing their privacy, are less likely to complain. So quick fixes fit their bill, and they implicitly blame patients for failing to recover.

The problem is that when wounds have been decades in the making, they can’t be patched up overnight, and these bandages don’t cure anything.

The real heart of Freud’s psychology isn’t his ideas about infantile sexuality, penis envy, the analyst as blank screen, his thoughts about gender, and the like. The core Freudian ideas, which are at the heart of most modern psychotherapeutic work, are these:

• We do things for a reason, our actions aren’t random.
• The reasons that especially get us in trouble are the ones we’re not aware of.
• Our unawareness isn’t a matter of being oblivious – it comes from our need to keep our motives hidden from ourselves because they’re unacceptable or shameful.
• “The past isn’t dead,” as William Faulkner famously said, “It isn’t even past.” We are powerfully shaped by our early experiences, and those ways of coping control our lives, even as they’ve outlived their relevance or usefulness.
• We are at war within ourselves, pulled in opposing directions. We want to make contact, for example, but we also want to protect ourselves from being hurt again.
• However we are leading our lives, however ineffective that might seem to be from an objective perspective, is the way that we truly believe is safest for us. (The abusive marriage, for example, feels less terrifying than being alone. The consequences of drinking are more tolerable than the pain the drinking covers. And so on.)

This is what’s at the center of a Freudian approach: discovering the compelling reasons for acting the ways we do, and thus creating the possibility of choice. And this takes time. Psychoanalysis is not really about the couch or the analyst’s caricatured vow of silence. I’ve thought that the single greatest value of a sustained treatment is not the confessions made, the feeling of having been understood, the experience of having been loved, the life events reconstructed, the enactments deconstructed, the interpretations made – although all of these can be useful. The greatest value, I now think, is the experience of an intense unforgiving struggle with another person toward meaning. That seems far more important to me than the particular theoretical framework that the analyst favors. It’s what Roger Angell said about baseball, that baseball is all about dailyness, picking up your glove and bat yet again and going out to give it your all, on days when you feel great and on days when you’re hung over, knowing that the difference between the guy hitting .330 and the guy batting .230 is just one more hit out of every ten at-bats, and going out and doing your best anyway. Doing analysis is dailyness for two.

Couple Therapy

Couples usually come for help when they’ve reached a crisis point in their relationship. Often the problems have been long-standing, but now matters have taken a turn for the worse. If both members of the couple want to try to work things out, treatment helps. It’s usually possible to restore the relationship to the level at which it was functioning before the crisis (the affair, the loss of the job, the death of a parent, and so forth) in reasonably short order, a few weeks to a few months. To create a shift in the couple’s underlying long-term dynamics is much harder, and may take months or even years of work. But if both partners are motivated to change the relationship, there are prospects that therapy will improve things.

But some couples come for treatment with one partner dragging the other in tow. Sometimes the reluctant partner can be successfully engaged, and the treatment moves forward. At other times, that person has simply come in an act of angry compliance, and having paid his or her dues by doing so, doesn’t return. And occasionally one partner is towing in a spouse just to shame the person, and neither party really wants a stranger’s help. Rarely, one partner has actually signed off on the relationship; I’ve never seen such a person change course. It doesn’t necessarily mean that the marriage is over – some people need to be in a relationship with a person they can despise. But on the rare occasions when I’ve encountered this (perhaps a half-dozen times in the five hundred or so couples I’ve seen over the years), being in couple therapy is pointless (and I’ve said this).

For the considerable number of couples who I think I can help, my goal is to help each person understand why the partner thinks and feels the way he or she does, based on the partner’s own life experience. A few years ago, I presented my thinking about what makes marriage work to an audience, and here’s what I said:

Here’s a modest proposal. When you find your spouse taking a truly outrageous position, try to imagine, using all that you know about him, how he got there. You don’t need to agree with your spouse’s point of view, you can even continue to think that it’s ridiculous. But if you can understand that, for example, his upbringing gave him good reason to be totally paranoid when confronted with the request you just made, you make him human in your mind. And that goes a long way. Because in our fights we regularly dehumanize each other, make each other into a cardboard enemy, a stereotype. The most common complaint I hear from couples is “We don’t communicate.” But typically that isn’t true – they’ve been quite emphatic with each other. What the person actually means is: my partner doesn’t see it my way. I have met people who are deeply convinced that if their partner doesn’t agree with them, the partner just doesn’t understand the situation and needs to have it more clearly explained. And relentless explaining ensues. Actually, I don’t think that agreeing is all that important for having a workable marriage; it’s generally quite sufficient just to understand what the other is thinking and how he or she got there, even if how he or she got there involves major league distortions. I discovered that the word “empathy” has two definitions in the dictionary. And they’re opposites. The first definition is “the imaginative projection of a subjective state into an object so that the object appears to be infused with it.” Put more simply, I imagine that you feel the way I would feel if I were in your shoes. I think that this is unfortunately what, in practice, people usually mean when they say in a situation, “I was very empathetic.” The other person, of course, doesn’t feel understood at all. The second definition is “…vicariously experiencing the feelings, thoughts, and experience of another [without having it directly communicated].” In this definition I actually try to put myself in your shoes and imagine your experience. It’s the heart of what we do as therapists. And the mutual ability to be empathic in this sense is the single best criterion for a workable marriage. Being empathic doesn’t mean having the same point of view. Partners can disagree absolutely. What it means is having respect, taking the other seriously.

Couple therapy can also be quite useful in two other situations. Occasionally I’ve seen a couple who are contemplating either marriage or moving in to live together, who want to take stock of their situation before making a commitment. Meeting for a few sessions or a few months, they may be able to sort this out in a helpful way. And I’ve also seen couples who have decided to separate who want to find a way to work together to make the parting less acrimonious, or to help with planning for their children’s futures. Couple work can be vitally helpful in this regard.

In any event, a couple therapy is always a trial intervention. Some of the time individual work will be the best course for one or both partners to pursue, sometimes in concert with joint work and sometimes not. In the initial evaluation we try to sort out the question of which course of action offers the best prospects.

Most often couple therapy proceeds on a once-a-week basis, but some couples have found it useful to meet regularly for double sessions to have time enough to really have a chance to open up to each other. And I’ve occasionally seen couples more frequently, on one occasion actually meeting usefully three times a week for several years.

Family Therapy

The first principle of family therapy is that everyone should be on equal footing and everyone’s ideas should be taken seriously. Sometimes parents see family therapy as a means for the therapist to help them manage their child, who is presented as the focus of the treatment. The child then sees the therapist as another adult in league with the parents to control the child’s behaviors. Enterprises of this sort are always unsuccessful.

But if the parents can genuinely view the treatment as a chance for all the family members to talk openly with one another, and to listen to each other, the experience can be eye-opening and constructive for all concerned. It’s usually best if all the people residing under the shared roof can come to the sessions, and sometimes it makes sense to include older children who live outside the home. When everyone takes part, there’s less scapegoating.

Over the years I’ve found it remarkable how open children can be in family sessions; parents may hear their children speak frankly with them about highly charged matters for the first time. I’ve heard children as young as three or four express themselves in ways that shed light for everybody. Sometimes in just a few sessions of this sort the family’s feeling about itself dramatically changes.

Medications

Medication can be quite helpful in alleviating conditions such as chronic anxiety, depression, insomnia, and attentional difficulties, among others. In some areas, most notably in the treatment of depression, the newer medications have substantially better side-effect profiles than those used in years past, which makes them much more tolerable to take. I’ve seen a wide variety in patients’ responses to medications, with some people getting dramatic relief and others not so much help. That being so, I’m up for giving drugs a try if my patient is of similar mind. Perhaps a third of my current patients are using medications.

On the other hand, medication is rarely sufficient as a treatment in itself. Talking is important too, and actually usually helps more. We need someone to sort out our thoughts and feelings with, to make sense of what’s going on in our lives, so that we can find ways to make things go better for us. That’s where dialogue makes a difference. Sometimes medications provide the sort of relief that actually helps the person to make better use of psychotherapy, and that can be worth consideration. And some of my patients have been opposed to using drugs, for a variety of reasons, and this can be a totally reasonable choice. We need to think about the alternatives together.

Initial Consultation

In our initial meeting, our goal is to get a sense of why you’ve come for help. Sometimes that’s obvious – a partner left, a parent died, a job was lost, and so forth. But often it’s less clear: perhaps you’ve been feeling anxious for years but have decided to seek help just now. We try to get a sense of the forces at play in your life which might be responsible for the downturn, or for the sense of urgency. “What’s the problem,” and “Why now?” are two questions I have in mind in the first hour as I listen. I also want to get your sense of what sort of help you want, whether you just want assistance with thinking through a current crisis, or whether you’re looking for more extensive help with ongoing difficulties. I’ll be trying to figure out whether I can be of use to you, and you’ll be sorting out whether I seem to be someone you can feel comfortable talking with. We’ll also think about what the most useful form of treatment might be – should you take medication, how often should we meet, might couple or family therapy make more sense, should you have a consultation with a specialist in some other area, and the like. Usually this can be sorted out in the first meeting, although sometimes it will make sense to us to spend a bit more time together before deciding whether and how to proceed. And if you just decide that you don’t feel comfortable with me, there’s no charge for the session.