Psychotherapy in Transition

Talk therapy is transitioning. The old Freud-inspired insight- oriented version is being replaced by cognitive-behavioral therapy.

A good thing it is.

The transition is a work in progress. Many patients still cling to expectations that better fit the old model. Some aspects of the new version need to be improved.

All told, therapy is moving in the right direction.

Now, the Huffington Post has run an article by Valerie Ross and Leigh Newman. It purports to tell you what your therapist wishes he could tell you. The concept is a bit misleading, since there is very little in the article that a therapist could not reasonably explain to you. Much of it a good therapist ought to explain to you.

The article serves a better purpose. It allows us to see how far therapy has gotten and how far it still needs to go.

Many patients still expect that therapy will help them to understand why they do what they do. I offered my own views on this issue my website several years. They are still up, and perhaps worth a read.

Modern therapists want to disabuse their patients of the notion that they need to discover why they are the way they are or why they have the problem that they have. They do not want their patients to bring unrealistic expectations to treatment.

The Huffington Post explains:

Most of us come to therapy wanting to know why the heck we are the way we are. It’s important to understand the reasons we do what we do, says Scott Bea, Psy.D. at the renowned Cleveland Clinic. But often, that “why” isn’t enough to help you get past the issue, and there are times when it’s not even necessary. For example, if you have a phobia about elevators, understanding how this fear developed, though interesting, probably won’t help solve the issue. A “why" alone won’t get you on that elevator. “Explanations themselves don’t change the habits the brain has developed,” says Bea. “People have to take on the arduous effort of changing those patterns themselves.”

Psychological difficulties are bad habits. One can certainly fill them with meaning, but that will give you a bunch of meaningful bad habits. Meaning never changed a bad habit.

Cognitive treatment recommends desensitization as a cure for phobias. It allows its patients to be exposed gradually and in controlled circumstances to, for example, elevators or spiders. In that way it teaches them how to manage the negative emotions that have been attached to the objects.

Second, Ross and Newman explain that you should not expect that your weekly one-hour therapy session will suffice to change your habits.

In the old world of psychoanalytically-oriented therapy patients were expected to undergo three or so sessions a week. And they were forced to introspect, thus to withdraw from their lives and to get in touch with their feelings.

Now, the new therapies have simply turned it inside/out, or better outside/in. It is saying that you should not expect a little mental gymnastics, or even insight to improve your condition.

Patients who do the best in the new therapy are the ones who work on changing their behavior, that is, who modify the way they conduct their lives, outside of their sessions.

Ross and Newman summarize:

If you’re depressed and lethargic, you may be asked to follow a schedule that gets you up and out of bed. Therapists might challenge sufferers of social anxiety to have encounters with strangers, such as asking for directions to a bowling alley or farmers’ market. 

Since the new forms of therapy are in transition, they still retain vestiges of the old therapy. For example, they still refuse to give advice.

Of course, there’s advice and there’s advice. If your therapist recommends that you get up and get out of bed or that you encounter strangers, he is offering advice. If he recommends that you begin a workout regimen, he is offering advice.

When therapists say that they cannot offer advice, they are referring to larger, more consequential decisions.

Therapists have found a way to rationalize their failure to offer advice and guidance:

Lots of people go to therapy looking for a fast, tidy solution like “Yes! You should quit your job!” or “No! You absolutely should not quit it!” Therapists, however, don't want to provide us with that response. Here’s why: They don’t have all the information, and so their solution might be the absolute worst thing for you. Instead, they want to guide you to your own solution by asking questions, assisting you through your own thought processes, and helping you identify what’s keeping you from making a decision. For example, if a patient is considering leaving her boyfriend, only she knows what’s really going on. 

In truth, the reason therapists refuse to give advice is that they do not know how. Advice-giving is not taught in therapy school. Therapists who are good at it have learned it through experience, but to do so you need to be offering advice.

Like psychoanalysts before them therapists suggest that their role is to help people find their own solutions or to help them remove the mental blocks that are preventing them from making decisions.

In my view, therapists should get over the notion that patients can find out what to do by consulting their inner guide.

No one gets very far in life without learning how to take advice from other people. There is no special virtue in making your own mistakes.

Therapists who refuse categorically to give advice, on the ground that they are too ignorant to know what is best because they do not have all the information are shortchanging their patients.

You do not have to know everything to offer guidance. No one knows everything, so it is silly to bow down to an unrealistic standard.

No therapist can give advice about all problems and no therapist should imagine that a piece of advice is going to solve everything. That should not prevent him from giving some advice in some circumstances.

Of course, no patient is obliged to take advice. Giving advice is not the same as telling someone what to do. A therapist who knows how to give advice will always couch it in terms that suggest that the patient is being given a choice, between taking the advice or rejecting it.

Moreover, it often happens that when a therapist offers advice, a patient will recall some hitherto unexposed piece of information that makes the advice less valuable. If the therapist did not offer any advice, the patient would not have thought to factor in the new information.