THE LONG AND THE SHORT OF IT: Is therapy forever?

I had planned on writing a post on collaboration, something that has been on my mind quite a lot lately. Then, Sunday morning I woke to a New York Times article that got my blood boiling – In Therapy Forever? Enough Already (click link to view):

http://www.nytimes.com/2012/04/22/opinion/sunday/in-therapy-forever-enough-already.html?_r=1&ref=todayspaper

There are many reasons why it stirred me into action. For one, it begins with descriptions of bad therapeutic behavior, which all of us who practice therapy would agree is unconscionable- yet many things can sound that way when they are taken out of the context in which they occur. But ok, bad behavior is bad behavior and there is no excuse for it. However, the author uses such bad behavior to corroborate his idea that the longer a treatment goes on, the less helpful it is. Really?

Yes really, and this is substantiated by research which while published in scholarly journals, tells us none of the details of the population studied, its size, diagnosis, issues, treatment modality, etc. It just tells us that a whopping 88% of patients got better after one session! Imagine that. I find this insulting to both patients and therapists who spend many hours in dialogue with painful memories, behaviors and issues. One session? Not psychotherapy. Not in my book.

But here is the biggest issue I take with this psychoanalysis/ psychotherapy bashing article: it privileges the therapists’ authority over the patients’. While the author gives lip service to the notion that different therapeutic approaches work differently for different people, and at the same time suggests that there are relatively few “severe” treatment issues which would justify a longer treatment (take schizophrenia, he says, as an example!) – your ‘average’ depression or anxiety can be cured and addressed in one to ten sessions, and here is the kicker: a therapist of his ilk needs to aggressively confront the patient, give his opinion and advice as to what the patient should do, all while proposing a structured action plan for changing his or her life. We clearly have different views about what constitutes therapeutic authority. And therapeutic action. And how transformation and change come about. So here goes.

Almost 15 years ago the brilliant psychoanalyst Stephen Mitchell turned his keen eye to the issue of authority in the treatment setting  (see:  http://www.dspp.com/papers/mitchell4.htm ) attempting to clarify what psychoanalysts’ could legitimately claim expertise of. As one of the founders of Relational Psychoanalysis, Mitchell approached the psychoanalytic encounter as a complex matrix of interpersonal exchanges aimed at arriving at multiple understandings of human experience. Within such a view, psychoanalysts have an expertise in how meaning is made and arrived at, in the process of self-reflection and the ongoing organization and re-organization of experience. This is because the mind is understood as a series of self-interpretive constructions- a complex and dense theater comprised of many voices, events and relationships.

Those of us who work and think relationally, respect the fact that people need a sense of personal history and motivation to “knit their world together”. As psychoanalysts we study the way that those systems of meaning come together and are constructed- we are experts at following narratives, spotting omissions and gaps, and co-constructing such histories into useful and perhaps transforming narratives with our patients. Thus analytic authority is not based on my opinion or advice about something, but on my understanding of my patient, arrived at through numerous mutual, interpersonal exchanges which transmit experience and meaning relationally- through our subjective experiences of each other. My expertise lies in being able to sift through these experiences and put forth questions, ideas and feelings which may lead us to answers and perhaps more questions, but which are lived together through the therapeutic relationship. That is ultimately the way meaning takes shape-relationally.

Contemporary psychoanalysts believe that there is never one truth, but rather many, and in treatment, the issue is more about what becomes entrenched in our narrative(s) of ourselves as the truth. What shuts out other possible versions of truth and meaning and reduces our choices in life. What prevents further truths to be explored. Such analysts are experts at holding many versions of one ‘self’, and alternating between varying selves and self-states. Some would say that this is the art of psychotherapy.

Psychoanalysts can also claim expertise at reading and understanding affect and emotions.  In her research on psychotherapy sessions, and what is curative about the psychoanalytic encounter, Wilma Bucci (http://www.thereferentialprocess.org/theory/emotion-schemas) concludes that psychotherapists have more emotional ‘schemas’ from which they can identify emotion and work with it. The language of affect is a natural part of the therapeutic encounter, and psychoanalysts have expertise in the labeling, containing and understanding of emotions on a wide spectrum of intensity. Often, it is the language of affect that requires words to be processed and understood, and this takes place in ongoing dialogue with one another.

Perhaps the issue of authority is murkiest due to the unbalanced nature of the therapeutic relationship. Often patients’ ascribe greater authority to the therapist than they do to themselves. This is inevitable and even necessary. After all, patients’ come to us because they believe us to be experts in our field, and the analysts’ authority is built into its asymmetrical nature. Yet, if the process is to work at all, it requires a collaborative relationship, which will likely need to be negotiated through many ups and downs, and will always question directives and opinions that shut out possibilities and choices.

The very asymmetry of the psychotherapeutic relationship lends itself to abuses of power such as the one implied in the NY Times article, and presented as  “what patients need”.  Furthermore, while psychotherapists can provide a structured ‘action plan’ I have rarely found this useful except for purposes of insurance and billing, as it reduces the complexity of the clinical hour to a heuristic hypocrisy. Such is not the nature of human beings or human minds. Interpersonal situations are complex actions in which consciousness comes into being through interactions with another and/or through self-reflection on those interactions. This means that events in the patient’s mind are knowable only through an active process of composing and arranging them -which happens in relationship to another.

Acknowledging the inter-subjective nature of the psychotherapeutic situation allows us to maintain a healthy respect for the patient’s autonomy while putting forth our view and experience of them as a co-constructed ‘truth’ that can be examined together. Owning our influence in the therapeutic encounter actually protects the patient’s autonomy and actively invites their participation in self-creation. To use a dance metaphor: patients lead and we analysts follow.

This means that the psychoanalyst’s expertise lies in her understanding of what happens when her patient begins to express himself and reflect on his experience in the presence of a trained listener, within the highly structured context of the analytic situation. The psychoanalytic relationship is one of meaningful engagement in which understanding of the other emerges slowly and over time, and is embedded in the fluid, interpenetrating mix of the encounter and the ongoing impact on each other.

Years ago Mitchell portrayed the analyst as an expert in collaborative, self-authorizing self-reflection. Conducting and protecting the inquiry being one of the major features of maintaining the relationship ‘analytic’: where the analyst attends to his own internal experience and is also mindful of the bigger picture, taking on the responsibility for the navigation of the relational terrain. The context specific intimacy of the analytic relationship highlighting its difference from any other kind of relationship- the constraints that it poses making it possible to open up self-reflection, self-expression and intimacy in a way that cannot happen in other relationships in our lives.

This psychotherapeutic process necessarily takes time because it is built on a healthy respect for the complexity of human experience and the recognition that despite the fact that as psychoanalysts we are experts in many of those complexities, we do not hold the key to health nor are we the arbiters of mental health. My patients are all intelligent, articulate people with complex lives and dilemmas, varying degrees of pain and trauma, severity, crisis, etc. They come to treatment because they have thought of many possible solutions about their issues and yet still struggle. For me to think that I can somehow come up with a better solution for their lives is a total abuse of the power and trust invested in me, and a simplistic and reductionist view of what constitutes growth, transformation and the therapeutic exchange.

Articles such as Jonathan Alpert’s essay in the Sunday NY Times do patients and therapists a great disservice by implying that change can come about without addressing the very fabric of who we are and how we come to be who we are.

Perhaps this post is about collaboration after all.