What really happens in psychotherapy? Better yet, what are therapists really thinking? Best yet, what are they really feeling?
Elizabeth Bernstein addresses these questions in an interview with a therapist named Paul Hokemeyer. I had never heard of him before so I assume that he does not write very much or do very much theorizing. As we shall see, it’s a good thing that he doesn’t.
Hokemeyer seems to believe that he has an eclectic approach to therapy. He takes a little of this, adds a little of that, spices it up, feels deep feelings and thinks that he is helping people.
Without going into too much detail, his treatment amounts to psychoanalysis lite, a watered down version of psychoanalysis mixed with more some lip service to cognitive therapy.
In truth, you cannot mix the two forms of treatment. Psychoanalysis is based on the idea that symptoms have a meaning and that they are expressing an unresolved mental conflict. It assumes that once you have gotten to your deeper feelings and learned a new mode of relating, the symptom or the issue will resolve itself. In truth, this never happens, which is why no one does psychoanalysis any more. One suspects that the form of therapy Hokemeyer practices is not very long for this world, either.
The more cognitive approach sees symptoms as bad habits. It wants to replace the bad habits with good habits and sees no real advantage to trying to find a hidden or unconscious meaning. In general, this form of therapy is as effective as medication in treating depression.
Bernstein gives the game away when she says that she wants to know what is going through the therapist’s mind when he is listening to his patients. Thus, she is asking the question that therapists ask themselves. She cannot really ask about what is happening in these patients’ lives while they are undergoing treatment because that is not what the treatment is about. Therapists seem to be more interested in feelings than in the concrete details of anyone’s life.
She does not use this example, but when therapists ask the standard, idiot question-- How did that make you feel?-- they are directing their patients into their minds and away from their real world problems. They want the patient to discover what he really feels. Apparently, this insight will lead him to form a more healthy relationship with his therapist.
Surely, Freud did emphasize the importance of the relationship between patient and therapist. But, since the relationship is completely one-sided, it cannot possibly become a role model for future relationships. So, Freud believed that it was a way for patients to enact their mental conflicts, thus, to take their analysts for someone they are not. If therapists were actually engaging in mutually respectful relationships with their patients there would be no need to write columns about what they really feel.
In Hokemeyer’s words:
My brand of psychotherapy operates on a number of levels. The first requires me to be hyper-aware of the physical and emotional feelings the patient brings up in me. How do I feel in their presence? Am I anxious, bored, entertained, manipulated?
Then I focus on what they are saying, verbally and non-verbally. Do I feel the heaviness that comes from depression, yet the patient is saying everything is fine or trying to distract me with superficial details?
Hokemeyer says that he is listening for feelings, for emotional feelings and for physical feelings. Like I said, the man is not a theoretical wiz.
Note well that he does not at first want to hear what the patient has to say. He does not want to know the details of the patient’s problems. He withdraws into himself to explore his feelings. In the world of advanced psychoanalysis this is called countertransference analysis. I will not bore you with the details.
He would have done well to understand, as Ludwig Mies van der Rohe said, that God is in the details. No one is saying that a therapist should not examine emotion, but if you do not know the details, if you dismiss the details as superficial, you will never know whether an emotion is appropriate or inappropriate to a situation. And if you do not know the situation that the patient is trying to manage, you will never be able to help him to manage it. You might imagine that the patient is simply enacting his unresolved neurosis in all of his dealings with real people in the real world. But, even if this oversimplification has a kernel of truth, the world does contain many other people and many different types of relationships. Reducing them all to one giant neurotic mental conflict is simpleminded and useless.
According to Hokemeyer, patients get better by having a reparative relationship with their therapists. This is a variation on the theory of transference. It was invented by an analyst named Franz Alexander decades ago.
First, examine Alexander’s definition of what he dubbed the corrective emotional experience:
The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.
The goal is for the patient to internalize the reparative relationship with their clinician. This means that they hear their therapist’s voice and anticipate what their therapist would say when they are confronted with a real-life situation.
I love when patients make a confession about falling down on a commitment and tell me: “I know exactly what you’re going to say…” That means they are internalizing a nurturing, affirming voice.
In the old days Freud called the internal punishing voice the superego. Replacing the superego with a more nurturing, affirming voice has long since been a goal of therapy. In so doing therapists have shifted focus from the harsh paternal superego to a more nurturing and motherly figure. Apparently, this markets the treatment more effectively to women, but as women become more involved in all aspects of life outside of the home, why do they need to be drawn away from real situations in order to get into their minds and to get in touch with their feelings.
Hokemeyer sounds like he mothers his patients. One understands why the profession is attracting more women than men and also why fewer and fewer people of either sex are engaging in it.
I focus on the immediate, my feelings, thoughts, what the patient is saying, then step back and put it in a global context. Is what they are saying congruent with what I’m feeling? What patterns are emerging?
Given his emphasis on “emotional feelings” Hokemeyer is unanchored. He is prone to get bored. His mind tends to wander:
Most of the time it wanders back to the session I had with the last patient and what I should have done differently.
It can also wander if the patient is avoiding connecting and filling the time with superfluous details. I’ll start to think about the dry cleaning or what I can have for dinner. This is important clinical data as it lets me know that just as I’m not feeling connected to the patient, the patient isn't connected to me because they don’t feel safe enough to share the intimate details of their life.
Hokemeyer believes that his treatment offers patients a new way to relate. Perhaps he does not know it, but you cannot help a person manage relationships if you do not recognize that different relationships call for different ways of relating. You cannot help a person get control of his or her life if you are dismissing the details, wallowing in compassion and focusing on vulnerabilities.
In Hokemeyer’s words:
I dislike traits my patients display, but my job isn't to like or dislike my patients. It is to give them a new way of relating.
My awareness of myself and my own issues enables me to relate to and feel compassion toward the vulnerability of being human. It is the thing we share and it gives us a strong foundation to build upon.
It’s not a strong foundation. It’s quicksand.