Whatever Happened to Real Psychotherapy?

This article by Lori Gottlieb makes sobering reading. We have seen how the trend to supposedly evidence based practice has led to cognitive work achieving a special dominance in psychotherapy services and here we see how various forms of coaching are superseding therapy practice. Actually there is nothing wrong with coaching per se. What is more disturbing is the squeezing out of work in depth in favour of targeted problem solving.

The truth is that therapy in depth is actually a form of spiritual transformation and it will only ever be a minority that will under-take it. Buddha did not try to convert the whole world to a mass religion, he tried, rather, to cultivate a cadre of people who could be a leaven in society. There will be a few with but little dust in their eyes.

Perhaps part of the problem is that psychotherapy has tried to be a profession within the frame of a meritocratic society. Get your certificate, join and institute and set up shop is a formula that, on the one hand, makes therapy available as a purchasable commodity, yet, at the same time, and by the same token, makes a matter of the heart into a matter of the pocket.

In the modern world, money is the common measure of worth. Sometimes, therefore, that is the only way of doing things effectively. However, we should not be deceived into thinking that that is the real core of the matter. Therapy is a matter of soul and spirit and such mysteries are not amenable to mass production.

A related problem has been the emphasis on method, as though once one has the right technique it matters not who applies it. The attempt to produce a taxonomy of human problems each with a matching treatment, generally known as the medical model, simply does not accord with reality. The DSM is an fascinating work of fiction and a periodic check on where the story of American psychiatry has got to, but it is not a guide to treatment.

The factors that matter in psychotherapy are what are called the generic ones, like empathy, positive regard and non-judgementalism and these, if they are genuine, are essentially qualities of the person of the therapist, not features of  method technically applied. When a student counsellor comes to supervision and says, "I used empathy in this case"one knows immediately that they have missed the point.

All this, of course, throws up the difficulty of training. How is one to turn a person into a therapist? If there is any relationship between ability to pass examinations in counselling theory and ability to help souls in distress, it appears to be an inverse one. The real teacher is life itself. There is probably more to be learnt from good literature than from most psychology text books.

I hope that at Eleusis, while we will offer workshops and host training programmes, we shall be able to hang onto the basic spirit of education for its own sake, learning that springs from the need of the soul rather than the calculations of career planning or faith in mere technical expertise. In taking this stance one is standing against the current and defying the spirit of our times, but there is, I believe, a greater and less ephemeral spirit that demands no less of us.

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  • Writing can be a way of empathically entering another life and we grow richer in the process.

  • Sometimes I feel like the kind of writing I do, that requires that I set my stuff aside and really listen to what the person is saying, can be a little like psychotherapy for both of us. "Listening is and act of Love"

  • I agree very much with what you say here, especially the last part. Working with people recovering after a psychotic episode, especially if it has been for a time a major part of their life, does require a slightly more didactic approach than working with the "normal" run of neurotic problems. A client of mine once said, "Being psychotic was never dull, but ordinary life is often empty." This was from a patient who had been in hospital m,any times, but in rehab the great triumphant goal was to get her rehoused into a low grade apartment where the most exciting thing that ever happened was that a man called to read the electricity meter once in three months or she took a trip to the supermarket. Again, somebody who has been on powerfully suppressant drugs can have lost touch with what emotion feels like. If they start to feel sad or lonely, there is a tendency to think that they are going mad again. It can help simply to say, "This is normal - this is emotion." To stay "sane" we have to cope with ups and downs. Yes, rest, work, love, and do it one step at a time ~ that is quite a good formula.

  • I’ve never worked on psychiatric ward, so I don’t have much firsthand experience with people in the acute phase of some serious phychotic condition. Ordinarily I meet with them when they have already been through the worst and the problems bringing them into my room are rarely have got much to do directly with the psychotic process itself.
    However, I relatively often work with people who have some kind of delusions that are clearly and squarely grown to psychotic dimensions while not devouring their whole lifes. In these cases either the sense of reality remains intact outside the direct focus of the particular obsession and the craziness becomes compartmentalised, or the person seems to have a unique reflective genius of creating space around his madness even during the most turbulent phase of its. Anyway, the whole mind doesn’t get unhinged entirely, so much so, that the person concerned is frequently able to perform his normal duties. These cases are exciting and interesting especially as going against the widely held portrayal of psychosis, and also because are rather under-represented when it comes to theory building. It’s important not to lose sight of diversity in life. Psychosis may be a much more variegated phenomenon than we usually think. This insight seems to fit the approach of Buddhist psychology that serves with plenty of examples verifying the existence of a continuous spectrum in terms of delusional thought. The world of psychosis and that of normal thought are overlapping.
    Regarding therapy, people with psychotic conditions teach us some precious and homely things that often remain neglected in the ambitious and at times haughty world of mainstream psychotherapies. None of them is spectacular or affords chance for the therapist to show off their gorgeous technical skills, acumen and proficiency. Once again they remind us that the non-specific factors and the quality of presence is of the utmost importance in therapy, and that common-sense will always preserve its place in healing: these patients usually respond well to a practically orientated, no-nonsense approach where the therapist is not afraid to share his knowledge in due time as to the simple tricks of everyday life. One has to be a Mary Pipher to appreciate this aspect of our profession: „For the most part, my solutions to human problems have been simple ones – get more rest, do good work, take things a day at a time, and find some people to love."

  • Thank you for this - very interesting. I like the reference to psychoanalysis as "a Western-style nirodha-practice" which, in principle, is quite right. The problem then lies in the fact that the average therapist is by no means as clean as Buddha, but is in the same position of Yalom: "I, too, crave enchantment." That craving - the counter-transference - leads to the enmeshment of client and therapist and we could say that in many cases the substance of therapy is made up of the flailing attempts to get out of that net.

    The position of the professional is so often one of trying to be Buddha-like for an hour at a time. Yet recently one of my students told me about a case known to him that illustrated another common scenario. The person in question (somebody known to my student but not their client) had a psychotic breakdown with manic and depressive episodes. The poor person was at times completely lost in his self-made fantasy world and behaved in worrying and bizarre ways, thus causing great distress to his family. I will not go further into the details of the case, save to say that the most therapeutic thing that happened for this person lay not in any of the professional interventions, but rather in that during a period of hospitalisation he met a similarly afflicted woman, fell in love with her and they started a family together. This did more to stabilise his condition than any of the therapy or medication prescribed. However, as one might conjecture, it did not constitute a complete cure.

    Sometimes it is better not to be love's executioner, or even madness's. Bringing the rationality of science to bear upon human fantasy is like mixing oil and water. They soon separate again and remain unaffected by each other. Yet within the realm of passion and fantasy there may still be a quite different kind of logic or narrative that has healing potential of a quite different kind.

    Some young psychology students to whom I was lecturing once asked me what they should do in order to advance themselves in their aspiration to become therapists and I caused a good deal of hilarity by telling them to go and live dangerously, have adventures, make mistakes, have some disasters and find out about real life.

  • I don’t like to work with patients who are in love. Perhaps because of envy – I, too, crave enchantment. Perhaps it is because love and psychotherapy are fundamentally incompatible. The good therapist fights darkness and seeks illumination, while romantic love is sustained by mystery and crumbles upon introspection. I hate to be love’s executioner.” (Yalom, 2001)

    If only I could puzzle out how come that Yalom is always able to tell us such a lot about unfathomable themes of our common life in such a deceptively simple language. Here we can hear about love, passion, craving, introspection and illumination, awareness and mystery and, first and foremost, about the inherent ambiguity lurking deep in any healing profession.

    Whether we like the role of executioner or not we regularly have to venture upon transilluminating and dissecting inveterate and wayward passions, so we musn’t be too fastidious and queasy about emotional expression. Freud was a remarkible thinker in more than one branches of science but that might probably not have been enough to predestinate him being one of the founding fathers of our (post)modern self-reflecting, psychologizing culture.

    I don’t think it has been happenstance that the key event leading to the birth of our beloved profession was not other than a sudden eruption of passionate emotions: in an unexpected moment, a young woman patient flung her arms around Freud’s neck and declared her sweeping love in unreserved manner. Just imagine how horrified the middle-aged Victorian professor must have been! It would have been so easy to give free course to his indignation in icy words or turn back on her and run, run nice and far. Like his old friend and mentor, meek-hearted Joseph Breuer had done. What has happened instead, is deeply symbolical: he didn’t give way to rejection (dosha) nor did he indulge in passing fancy with an enticing young girl (lobha). After recovering his balance (sati), he began to inquire into the nature of the experience. By bracketing his instinctual reactions and prejudices, he got down to ask without any bias: what did it mean and what could be the best condition for unravelling it.

    We might as well take it as emblematic: let free expression of passions in a holding environment, in the frame of a healing relationship carefully cleansed from ego-defences and interests and what you get is a Western-style nirodha-practice: psychotherapy, so to speak. Yalom is right: psychotherapy is incompatible with consummation of the passions. But it is impossible without them finding safe expression. Freud teaches: we cannot defeat our enemy (neurotic entanglements) „in effigy”. In other words: „Psychoanalysts know that they are working with the most explosive forces, and that they need to deploy the same care and conscientiousness as the chemist. But when has a chemist ever been banned on account of danger from dealing with the explosive materials whose reactive properties make them indispensable to him?”

    Freud, S. : Observations on Love in Transference

    In. Wild Analysis (2002) Penguin Books

  • Yes, thank you, many good points here. It is certainly true that many people have been sustained psychologically and spiritually by their relationship with an animal such as a dog or cat and none of these animals have got degrees or diplomas.

  • There is a strong and ill-concealed inclination in professional circles to appropriate any authority to reach towards each other therapeutically. The legendary noble and gentle tradition of bartenders and other innate healers hardly arouses anything else these days than condescending smiles and eloquent looks. This probably has much to do with the perpetual legitimacy war psychology has been waging from its start: individually with medical doctors and, as a trade, in the groves of science for recognition.

    Moreover, the news from the front-line of research seems, for the spokemen of the guild, to be pretty upsetting. Not only that formal trainings don't improve efficacy unequivocally, but not rarely they downright look as if spoiling the inborn and burgeoning therapeutic potential, contributing to the fact that so many candidates never start to practice at all. (At least that is the case in Hungary.)

    As I see it therapeuses is a natural property of life that continually manifests itself in every conceivable way. Between even different kinds of being. Just think of how we are able to find not only fleeting solace, but also real remedy in deep relationships with dogs, cats, horses or with any other kinds of living creatures. Or remember that there is no culture without some ancient tradition aiming for harnessing the healing forces of the natural objects or that of the surroundings itself. (My favourite is the Japanese practice of "tree hugging" which means exactly just that.)

    My point is that there is something deeply universal that seems to be working here. Seeing from this perspective the question begins to transform: instead of how do I make it, it may sound: how can I get out of the way?

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