The State of Therapy Today

Given its inherent tendency toward secretiveness psycho therapy does not easily lend itself to evaluation. We do not really know what is happening in most therapy sessions, because therapists cannot share openly. As it happens, some therapists are now sharing their sessions online, but the thought horrifies. Dealing with another human being's problems is not the same thing as playing to the peanut gallery.

If we are looking for raw, albeit anecdotal data, we can examine the letters that therapy patients send to advice columnists. As I have often noted, nothing about these letters inspires confidence. The pseudo-therapeutic advice offered inspires even less.

Of course, we can remark on the prevalence of psychotropic medication and conclude that practitioners of talk therapy are not doing a very good job. Or else, we can remark that of today’s millennials, dubbed the therapy generation, 22% percent report having no friends at all. Seriously, no friends at all. Another triumph for self-actualized, independent, autonomous, self-involved living. Millennials are generation friendless. Yikes.

Today,  however, we find an interesting article in the New York Times. The authors, by names of Juli Fraga and Hilary Jacobs Hendel address some of the issues that therapists discuss when they are talking to each other. 

They present the latest thinking-- if you wish to call it such-- about what therapists call the therapeutic alliance, the relationship between patient and therapist. You will note that they, as do most therapists, define it as something special, something different. It is not the same as a relationship between doctor and patient, between client and lawyer. It is, almost by definition, decidedly unprofessional.

It’s more about emotional manipulation than about working together. As it happens, most therapists these days use their emotions more than their rational faculties to try to treat people. More often than not, this causes problems. 

While Fraga and Hendel do not absolve therapists of all responsibility they lean toward suggesting that if something is wrong with treatment, the patient should address it. If the patient does not address it, does that mean that the patient needs more therapy or does it mean that the therapist has created an atmosphere where such considerations are considered to be out of bounds?

They begin by saying that the therapist’s all-knowing demeanor discourages criticism. The point does not make a great deal of sense. If you are consulting with a lawyer and he offers an opinion, you don't refrain from asking questions because he knows more about the law than you do. Of course, you don’t. Most of us ask questions of our physicians. We are not cowed into silence because they know more than we do about medicine.

Fraga and Hendel open:

As with any relationship, patient and therapist unions aren’t immune to misunderstandings. When conflict appears, addressing it early on can help patients determine if the therapist and the therapy are right for them.

We often think of psychotherapists as “all-knowing,” which can make patients feel that complaining about the therapy or the therapist is not allowed.

As noted, they consider that patient and therapist are having a “relationship.” They fail to consider that it is a professional relationship, not just any old relationship.

They continue to point out a factor that seems to bedevil the therapy profession: premature termination. This tells us that many therapy patients stop coming to treatment, often without announcing it in advance. Evidently, therapists are seriously self-interested when it comes to termination. It's bad for business. The point does not seem to register:

In their 2015 book, “Premature Termination in Psychotherapy: Strategies for Engaging Clients and Improving Outcomes,” the psychologists Joshua K. Swift and Roger Greenberg point out that unrealistic expectations about treatment, compatibility issues with the therapist and fear of facing painful experiences can cause patients to stop therapy prematurely.

Indeed, studies suggest that 20 percent of patients getting mental health care will end therapy too soon — often without telling their therapists why.

Let’s see, patients stop treatment because they do not want to face their problems. Or else, because they expect that treatment will actually help them. Really?

Consider this: would you consider not consulting with a lawyer because you are being indicted for embezzlement, and do not want to face the painful experience. This notion that you would stop therapy because you do not want to face a painful experience hides a more salient difficulty: you might stop because you know that your therapist will not be able to help you to deal with said experience. 

As for alerting your therapist to your intention to stop treatment, why would you do so if you know that your therapist will try to talk you out of it, will treat your decision as a symptom and will show how badly he feels rejected. If the therapist has not created a climate where such issues can be discussed, it’s his problem, not the patient’s.

The authors continue, adding a few problems that therapists themselves might be contributing.

From talking too much or not enough to mislabeling feelings and offering unsolicited advice, therapists may unintentionally upset their patients in various ways. When this happens, broaching the topic by saying, “I’d like to discuss how I feel about coming to therapy,” or “Your recommendations aren’t helpful — here’s why,” are two ways to begin the conversation.

Come now, mislabeling feelings. Whatever are these therapists doing? They apparently have no sense of reality and no real ability to help their patients to navigate the real world situations they find themselves in. As for offering  unsolicited advice, what is wrong with that. Patients have every right not to take the advice, but still, offering it is not a mistake. Looking at reality is not a flaw, except in terms that the insular therapy world has defined. 

As for discussing how the patient feels about coming to therapy, who talks that way? Again, therapy seems to care more about inner space than about the real world. No wonder people do not want to come back and do not want to engage in conversations where they will be required to expose more of their feelings than they wish.

You can tell what therapists care about, what makes them feel comfortable, by considering that they will respond to anything the patient says with the idiot question: How does that make you feel? They are unwilling to ask about the reality of any situation. All they care about is your feelings, because they are incompetent to address any real life situation.

And, let’s note, patients understand that their therapists are decidedly sensitive creatures, easily triggered, unable to accept that they are doing a crappy job. Thus, patients do not raise certain issues because they know that their therapists cannot deal with them:

In one 2016 study, they found that 72.6 percent of psychotherapy patients had lied about their therapy experience. Common lies included pretending to agree with the therapist’s suggestions, pretending to find treatment helpful and masking their opinion of the therapist.

Therapy fails because therapists do not understand how to help patients deal with real relationships and real moral dilemmas. Their bailiwick is emotion and they reduce everything to emotion and to needs and to discomfort and to what unsettles them. The delicate flowers:

In therapy, these white lies can rupture treatment because it means the patient’s needs aren’t being met. This is why it’s crucial for patients to discuss any negative or unsettling feelings that ensue during therapy.

Perhaps the therapist came across as judgmental, started the session late or didn’t provide a structured treatment plan. Whatever the therapist’s mistake, patients can be direct by stating why they are upset.

When giving feedback, it’s common to pad critical comments with compliments. Organizational psychologists warn these positive statements, known as a “feedback sandwich,” can drown out negative messages.

So patients are obliged to expend considerable time and effort protecting the therapist against the sense that he has failed them. There is nothing pathological about this. It is normal human behavior.

The same pattern can play out in therapy. Before sharing their misgivings, patients may feel the need to say something positive, as a way to protect the therapist’s feelings. But while therapists are trained to look out for their client’s well-being, patients need to do the same.

If patients are doing so, that means that they feel the need to do the same. The authors are blind to reality. It’s a symptom of therapy.

To their minds, ignoring real life is acceptable because we are in a realm where therapists are dealing with hurt feelings. This tells us that the therapists are women and that their patients are most often women, or wanna-be women. No man talks this way. I would even suggest that no professional woman, no woman who is participating in the real world of business, sits around whining about hurt feelings:

If a patient feels hurt by the therapist’s words, it’s O.K. to say, “I’m hurt by what you said, and I’d like to discuss it with you.” If the therapist is sharing too much personal information, patients can set a boundary by saying, “I prefer not to hear your personal stories because I’m here to work on myself.”

Naturally, Fraga and Hendel think that the therapist should shower the patient with empathy and with other inchoate emotions:

The therapist should be receptive to feedback. Positive and empathic responses may include apologizing for the misunderstanding, suggesting ways to improve therapy, as well as exploring what it’s like for the patient to speak up and commending their courage for doing so.

The therapists are working to make their patients emotionally dependent on therapy. Incidentally, commending the patient for speaking up is vapid and useless. If the therapist has ignored the patient’s real life, offering him faint praise for getting more emotionally involved with his therapist is not going to change the equation.

As has happened throughout the history of psychoanalysis and psychotherapy therapists want their patients to be entirely committed to treatment. The authors have nothing whatever to say about patients’ real lives:

Therapists viewing the therapeutic relationship as a focal point of treatment, known as client-centered, psychodynamic or attachment-oriented therapy, see feedback as an opportunity to strengthen the patient-therapist alliance.

To do this, they acknowledge the patient’s disappointment, anger and frustration. 

Curious to learn how therapy went off course, these therapists also invite their patients to share more. Because a person’s emotional reaction may offer clues about the nature of their suffering, client-centered therapists might also probe whether the patient’s negative feelings have roots in childhood experiences or traumas. To ease future treatment anxiety, these therapists often say, “If I do or say anything that makes you uncomfortable, I want you to let me know.”

Note the terms: emotional reaction, suffering, negative feelings. All of which will not lead to addressing the patient’s real life, but will lead to an excursion into the patient’s past, whether that involves childhood experiences or traumas. Evidently, this draws the patient out of his life and into the therapist’s web.

While numerous psychological interventions can teach patients how to alter their behaviors and face their fears, according to the researcher and psychologist Dr. Allan Schore, ultimately, it’s the emotional communication between patient and therapist that’s curative.

What feedback offers is an opportunity for realness and deeper intimacy with one’s therapist. When this happens, patients can feel seen and heard, which can be a turning point in treatment, as well as in life.

Again, its all about the emotional communication and a deeper intimacy. Do we really want to encourage patients to seek deeper intimacy with their therapists? Do the authors even understand what that implies? And what is an emotional communication anyway? People communicate with words. They behave as clients and professionals. They deal with real problems, not the vagaries of human emotion.

If your therapist talks like this, find yourself a new therapist.