Let's psych out the therapists

I.

I am chary of asking other therapists whether they sometimes feel stuck and, after a while, useless with a client (or any number of clients). Three reasons: 𝛹 By asking, we’d be rolling out the red carpet for another therapist to think she’s better than us, and we couldn’t stand that. 𝛹 Since we feel we already know everything that matters (analogous to people’s certainty that they have the right religion, difference being that each therapist becomes his own religion), we don’t really believe we can be taught.* 𝛹 And – just me – I know that the typical therapist isn’t dealing with the dark, subterranean, sometimes intransigent muck anyway, and he will believe his surfacey and mind-massaging “cognitive” approach is making real headway. When it’s not.

So sadly I’m alone with my thoughts, deflatedness, anger at people and human nature, rational­izations. And intra-brainstorming.

S. Levenkron writes about a desired “crisis of healing” where the anorexic girl, having long and stubbornly clung to her “special thinness” identity for dear life, finally crashes the defense and succumbs and regresses to being reparented by the therapist.

But how often does this happen? How often, instead, does nothing help, or unknown factors help, or the therapist sends her to the hospital or a specialty eating disorders clinic? Defense, also known as self-medication, is identity for many people. It is their armor, their fantasy beneath which is the ungrown, unhappened self. When we question defense, we can be asking the person to disappear.

II.

There is a very subjective factor at play in therapy. We know so little of what the client is made of, really, what sits at his formation and what churns deep within him (some of which bubbles up in true or masked form) – far different from what his tongue says – that our assessment of his improvement depends primarily on our own psychology. We may feel he has improved short-term or long-term because we want to or need to feel it. Essentially, our self-esteem determines the phenomenology of his improvement – in inverse ratio.** He may, at moments of clean happiness, feel an undertow of darkness. Have we helped him? She may experience fewer episodes of anger. But is she better, or has she learned mindfulness or forgiving or insight tactics, which require difficult and depersonalizing work to maintain? The young man, age 13, has improved grades. Is he really growing up, or is he just temporarily cushioned by our support?*** The very suicidal woman stays alive after therapy is over, though the feeling is not completely gone. What really have we done?

We try hard, and deserve to feel we have helped.

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* Maybe twice in twenty years have I asked a Cognitive Therapist her take on a client. And in those same twenty years, while many fellow counselors have known I practice a more feeling-centered, regressive approach, not a single one has ever asked me a question about it. Let’s hope we’re very good, because we’re pathetic.

** That is, the lower our self-esteem, the more we need to believe the client has improved or healed; the stronger our self-esteem, the less we need to believe it.

*** Here is an interesting passage in Masterson: “In my own studies with adolescents who are not able to function successfully on their own, I noticed that a few who seemed to improve with treatment while in the hospital reverted to their pathologic behaviors shortly after leaving. The latest follow-up studies indicated that they have never recovered.” “How to explain the fact that they survived childhood without a clinical breakdown, broke down in adolescence, then seemed to repair it in the hospital, but fell apart on discharge? As described in Chapter 2, as the self emerges from the maternal image it internalizes or ‘takes in’ both the image of the mother and the auxiliary functions she had performed for it. These functions (reality perception, impulse control, frustration tolerance, ego boundaries) contribute greatly to the capacity for autonomous self-activation.” “The fact that this image and the associated functions had not been internalized in these patients was disguised during childhood because fate was kind and did not expose these children to excess separation stress and because there is an ‘umbrella of dependency,’ which allows the child to depend on external parental authority to help him function. In other words, the child is not expected to function autonomously. However, adolescence removes the umbrella and exposes the growing child to tasks of emancipation and the need to function autonomously. At this point, his underlying difficulty with self-activation emerges in a clinical syndrome. The teenagers in my study seemed to improve in the hospital because the presence of external authority figures on whom they could be dependent reproduced the earlier childhood environment. They appeared improved, but the changes could not endure when the support of the therapist and the hospital was removed.” (James F. Masterson, M.D., The Search for the Real Self, chapter: “Fear of Abandonment,” pp. 52-53.)