Getting Over Therapy

As the old saying goes, better late than never….

Four or so years ago I started a new blog called “Had Enough Therapy?” I meant the blog as a complement to my website. There I explained, in detail, the difference between introspective psychotherapy and life coaching.

Imagine my surprise and my pleasure when I saw that the New York Times had finally caught on. Or, at least, therapist Jonathan Alpert, writing in the Times this morning, has.

Alpert’s op-ed is entitled: “Is Therapy Forever? Enough Already.” To my admittedly biased mind, it sounds like a take-off on the title of this blog.

As concepts go, it isn’t quite as good, but “Had Enough Therapy?” was already taken.

I am confident that Alpert does not read this blog. If he had I’m sure he would have mentioned it. So let’s say that he has come to the same conclusion, independently.

Of course, what Alpert calls “aggressive therapy” I call coaching. Be that as it may, let’s examine his point of view:

Many patients need an aggressive therapist who prods them to face what they find uncomfortable: change. They need a therapist’s opinion, advice and structured action plans. They don’t need to talk endlessly about how they feel or about childhood memories. A recent study by the National Institute for Health and Welfare in Finland found that “active, engaging and extroverted therapists” helped patients more quickly in the short term than “cautious, nonintrusive therapists.”

Opinion, advice, and a structured action plan… sounds like coaching to me.

In truth it doesn’t matter so much what we call it. Alpert is right that most people do not need to spend years talking about how they feel or exploring their childhood memories. Not only is it a waste of time; it avoids the problem at hand.

Alpert is also right in his characterization of therapy. Even though the field is hopefully moving toward a cognitive-behavioral approach, still, when people think of therapy they think of getting in touch with their feelings, and rediscovering their lost past.

Alpert offers us an excellent clinical vignette:

If a patient comes to me and tells me she’s been unhappy with her boyfriend for the past year, I don’t ask, as some might, “How do you feel about that?” I already know how she feels about that. She just told me. She’s unhappy. When she asks me what I think she should do, I don’t respond with a return interrogatory, “What do you think you should do?” If she knew, she wouldn’t ask me for my thoughts.

Of course, once we raise questions about what people should do, we are dealing with issues that are properly within the domain of ethics.

Alpert continues:

Instead I ask what might be missing from her relationship and sketch out possible ways to fill in relationship gaps or, perhaps, to end it in a healthy way. Rather than dwell on the past and hash out stories from childhood, I encourage patients to find the courage to confront an adversary, take risks and embrace change. My aim is to give patients the skills needed to confront their fear of change, rather than to nod my head and ask how they feel.

The truth is, if he had encouraged her to hash out stories from childhood he would have been telling her that her relationship does not need active management, thus, that she need do nothing about it.

He would have been telling her what far too many therapists have been telling far too many patients for far too long: that the problem is all in her mind, and that if she rearranges her mental furniture then her relationship will magically improve.

I would only add one observation here. The culture being what it is, many patients who consult with therapists bring with them an expectation that they will while away their therapy sessions exploring their feelings and rehashing their childhood memories.

Hopefully, Alpert’s column will help change patient expectations.  After all, you can give the best advice or set up the best action plan, but if your patients have been taught that anyone who gives them advice is insulting them, you are going to have your work cut out for you.