Why psychotherapy? Why not a book? a workshop? a friend? this website?

Put into words, the stuff of psychotherapy can seem hopelessly obvious. One thinks: Of course your depressed friend has nothing to be depressed about; why can't he see it? Why can't you just tell him so, give him some books about depression and how to overcome it, and end the problem that way? Of course the overly timid, cautious, and withdrawn man became that way because he grew up with an intolerant, volatile parent; everyone else who knows the family can see that, and they can see that this man has no reason anymore to be so scared. If they can see all this, why can’t he do the same and get moving with his life? Of course the arrogant, know-it-all only irritates the very people he’s trying so hard to impress? Why can’t he keep quiet a bit, so that he doesn’t end up jobless, friendless, and solitary?

The short answer is that it's too painful. Your depressed friend is stuck in this depression partly because, believe it or not, it is easier to feel depressed than to face what really hurts. It is easier for him to believe that everything about him is worthless, however much this flies in the face of all the data, than it is to cope with whatever else is going on. That is why his depression seems so irrational to us -- because it’s a distraction from something else. Meanwhile we can only drop our jaws in disbelief as this handsome, talented, successful man mopes that he has nothing and is worthless. The bright and attractive woman who attaches herself to one unreliable and dishonest man after another prefers -- at an unconscious level -- to cry or rage over the current man's behavior rather than to feel and acknowledge more pervasive and unweildy dissatisfaction with herself and her life. Even the timid soul finds it more comfortable to flinch his way through life than to face all the rage, despair, and fear involved in questioning his habitual view of himself and the world. [Greg, Ed - II]

Important: These irrational patterns of feeling, perception, and behavior are not chosen or established on a conscious level! Clearly most of us would not engage in such silly behavior on purpose. But these habits develop outside of awareness (and nonverbally) where we can’t get at them. Why this is so, and how it happens, was explained in previous three sections. (See also Ed - II, Bully, Ron]

It is this unconsciousness that is key to understanding "Why psychotherapy" (as opposed to other kinds of help). For just as the problems are established somewhere outside your awareness, so too must the cure reach into this area. Otherwise the treatment won’t work. Learning on an intellectual level is rarely sufficient. Take a look at these case examples [Evan, Ed - II, George, George - II, Ron II, Evan - II] to see the difference between intellectual learning and the kind of personal insight that is the goal, and the great gift, of psychotherapy.

Unfortunately this kind of learning is difficult, which is one reason psychotherapy usually takes more than a few sessions. Put simply, in psychotherapy we resist most strongly the things we most need to learn, once again because they are painful [Greg]. (If after reading the rest of this website you still find this last statement odd, be sure to read the page on resistance.

What’s the cure? What does psychotherapy do?

If my answers here seem arbitrary, I encourage you again to read the earlier pages in this website before looking at this one. (Think of how strange it might be to someone who knows nothing of the human nervous system if you try to explain to him that the pain in his leg -- sciatica -- is caused by disc problems in his back. "My leg hurts, and you want to examine my back? What kind of quack are you?")

The cure for psychological problems is increased awareness of the "other agendas" discussed in Why go. Psychotherapy is the process that accomplishes this. The less aware we are of our motives, feelings, thoughts, actions, perceptions, the more they control us and the more we stay stuck in old patterns that don’t work anymore. Relief from symptoms lies in discovering and incorporating into our constant, every-day consciousness that which is being masked, distracted from, or indirectly "acted out" in symptoms. (Take a look at the characters in Personality for examples of this process.) Virtually all psychotherapies work in this way, by expanding awareness (which is why the term "shrink" is so silly; psychotherapy is supposed to do the opposite). In fact, even when the focus of treatment is not symptom relief, when the goal is a general increase in contentment, power, freedom, happiness -- "self-actualization" it’s sometimes called -- the key is awareness.

Before you say, "But I know what I feel, do, believe": If we were perfectly aware, we would have no symptoms. [Jim, Ed, Ed - II, Evan] We would experience reasonable emotional reactions to the ups and downs of life instead of sinking into incomprehensible panic, anxiety, depression. We would behave rationally, putting our talents, intelligence, and energy towards gratifying ends. We would learn from our mistakes; we would not hurt the ones we love nor be drawn to those who hurt us. Again, if this idea is hard to swallow, take a look at the earlier pages, especially Why Psychotherapy.

Of what exactly do we need to become aware? No, not of some forgotten childhood memory; that’s too glib and rarely is the answer. Rather, we need to recontact the specific experiences -- wholly lived moments of perception and feeling, regardless of where they originated and even if not attached to specific events -- that are being both avoided and indirectly expressed via symptoms. The bully needs to become conscious not of who bullied him (if anyone did), but of his fears of humiliation and powerlessness. Only by such means can he cease the constant compensation for those fears -- the insistence on total control of people and situations, the self-imposed isolation when he isn’t assured of such control, even the phobias and panic attacks that such people can develop when they fear losing that control. The flincher, too, needs to recall that same original horror so he can stop fearing it around every corner. Think what this means: To get over his symptoms, a person must face exactly that which his defenses were created to protect him from; he must face his worst nightmare.

Resistance

As you read the website you'll notice how often this word arises. Resistance is at the core of psychotherapy. It determines the course of treatment and is largely why psychotherapy can take so long. Understanding it, facing it, and working through it are so central that it has been said in my field that 'the analysis of the resistance is the treatment'.

So what is it? Simply put, resistance is what we do to protect ourselves from awareness of that which we fear will overwhelm us. It does not happen consciously. Have a look back at the pages on symptoms and personality (especially "What's a Personality") for discussion of how defenses, personality, and symptoms all develop at the unconscious level.

As an introduction to the topic, look at Greg . As you can see, Greg was most resistant to the very topic he was most interested in exploring, a topic that encompasses or will lead to exploration of the most central concerns of his life. This is true of all of us: We resist most the material we most need to address. Thus Harry in the page on symptoms pushed people away most strongly when he most needed them, resisting awareness of his needs when they were in fact most pressing. And again, we don't do this consciously; if we did, we could stop. But we all do it. Like Greg, we even rewrite history to accommodate it. (Keep an eye out on the blog for a funny example from my own life.)

This is similarly why psychotherapy can take a long time and why other measures may be doomed to fail. It's why self help books on age old subjects keep coming out. These books aren't necessarily bad – well, some are – but they can't adapt and accommodate to your particular style of resistance, to your personality. There are times in our lives when we are open to new ideas that run counter to the demands of our resistance, but when we are not open – when resistance is high – the best self-help book in the world won't reach us. And again, resistance is highest when the issue is most personal and central to us.

Resistance works like friction – in the exact opposite direction that you want to go. And because it is the product of our defenses which are at the core of our personalities, it is very difficult to break through. Everything in our psyches will seem to yank us the other way. A good analogy for this is the way one has to lean down the mountain when turning on a steep ski slope. Every cell in us screams to lean up the hill, away from the steep fall – but when you do, the skis go out from under you and you lose control. By contrast, if you manage to overcome all your instincts and lean down as you turn, it's hard to believe it even while it happens but the skis respond by moving more slowly, and you're in more control as you make the turn; for a while, even after you've experienced the turn, it's hard not to lean up again each time you turn.

Resistance can be very tricky and intricate. Sara resisted by means of the very same defensive style she had come to me to shed, and which she had partially done. She struggled to overcome feelings of intense self-consciousness, to cease the relentless pattern of feeling accused and responding defensively, to relax around people and have some trust in them and in herself. She made some progress in these areas. But she then used the same habits in service of resistance to our continuing. Despite all our work together could not perceive that she was doing so. Instead she sincerely felt – although she could not articulate why – that she could no longer trust me.

Why did Sara do this? Look back at the definition of resistance above – to protect herself from something more painful or frightening than her more familiar if uncomfortable state wherein she feels picked on, denigrated, condescended to, and/or accused. As you see from the link, Sara had made some progress and was feeling much better. Particularly gratifying and relieving to her was the easing of the self-consciousness and obsessing that used to poison most of her encounters with men. She was beginning to date again, and had met someone about whom she began to entertain hopes of building a relationship. This is not something she had done previously.

Although Sarah was more comfortable with casual social encounters and dealing with people professionally, the idea of dating and relationships understandably stirred a lot of her old anxiety and habits of obsessing. Quite simply, she did not want to revisit that part of her. Resuming our exploration of her insecurities – how deep they ran and how they affected her perception of others – brought up too much anxiety; and it simply hurt too much. It was easier to revert back to her defensive posture of focusing on how untrustworthy everyone else is, including me and any romantic prospects, even though that posture still leaves her feeling victimized and inadequate. And don't forget, the process was unconscious. She was not aware of the dynamics I just described; from her point of view, she was simply responding to the facts of the world – I and the people she was thinking of dating are not to be trusted.

People resist without being in therapy. Again, it arises out of our defensive style, our personalities. Like any defense, it protects us from something that hurts. In childhood, of course, things hurt (and please) all the more intensely. Thus it is childhood – the memory of it – that tends to be most strongly resisted.

"But wait", I hear you say, "I remember my childhood". This is tricky. First, think of the blind spot all humans have in our visual fields. (Put two dots on a piece of paper, about 3 inches apart, along a straight horizontal line. Close one eye. Look at one dot and move the paper closer and farther from your eye. At some point the dot you are not directly looking at will disappear. This happens when the image of that second dot hits the part of the retina where the nerves bundle together and head off to the brain; there are no visual receptors there to pick up the image.) We never notice the blind spot because unless we go explicitly checking for it we don't perceive that we're not seeing something. Make sense? Sometimes a therapist or friend may alert you to gaps in your memory but otherwise you may never notice them.

Second, and more to the point in treatment, people resist memory by recalling the facts but not the impact. This is quite common. Gene recounted to me an event from when he was about seven years old in which his father greatly frightened and humiliated him. He began the story almost cheerfully. As he spoke, he became hesitant and then tearful. This is a story, Gene later told me, that he had entertained friends with in bars and other places for years. Clearly he remembered the facts of the event. But the experience – the range of feelings and perceptions surrounding the event – had long ago been shunted out of consciousness. Reconnecting with the totality of what happened when he was seven years old – and other times – eventually freed him from one of the symptoms that brought him into treatment: Prior to therapy, he moved through his life with a great deal of anxiety, particularly focused on anticipated humiliation; he found it very difficult to relax even around close friends, and he was especially guarded and uncomfortable with women.

In treatment, resistance takes many forms. Some become distrusting as Sara did, some become angry, discouraged, supercilious, bored, boring, confused, confusing, dependent,... In future blog entries and in the more extended pages on this topic (see Resistence II ), I will discuss all these types of resistance with case examples and examples from daily life. In any event, patients are sometimes discouraged, sometimes very disappointed in themselves when they break through and realize what they have been doing. This is a completely unwarranted feeling. Resistance is very normal. It is an element of our basic defenses which are so central to our functioning and necessary for our survival. So don't beat yourself up when you catch yourself doing it.

I'm sure you've noticed that this page is much longer than any other in the website. It was also the hardest for me to write. As a colleague pointed out to me, this is because the topic is one of the more difficult to explain. Bowing finally to that fact, I have decided to give resistance its due. I have extended this discussion into a roughly 30 page book chapter which includes much more explanation and many case examples from treatment and from daily life. You can purchase a copy by clicking on the link at the bottom of the index. Also, in the blog I will be posting examples and discussion of resistance and other topics, taken from both therapy sessions and from daily life.

What Cures - II: Why a Psychotherapist?

Treatment is a process of becoming aware of your own particular personality processes, of the parts of you that need or want things that make the rest of you miserable, and of how they all fit together. This is your story, your unique path into and out of psychological difficulty. It will not be the same as anyone else’s. While it will of course have similarities with others’ paths, you can only go so far on someone else’s story. Books, lectures, and other forms of treatment that are not individual to you are generalizations, composed of common elements from many or most people. Valuable as these are, they are like statistics. They tell you what goes on with most people, but in any individual case the answer could be different, even vastly so. [Compare Patrick and Mike.]

Moreover, if you do find your answers, you are likely to resist them (see Why psychotherapy, Greg). We are dealing in therapy with the most inaccessible and heavily guarded aspects of you. That is simply the nature of the beast and it’s why, I believe, there are so many self-help books. It is not that any of them are bad -- well, some are -- but they cannot accomodate to your unique personality style, difficulties, and interests, nor can they usually overcome resistance. At different points in our lives we are open to the ideas in a self help book, but when we are not -- when resistance is high -- they won’t help no matter how good they are.

What is needed, then, is a relationship, even if it’s only for 8 sessions. The bully and the flincher (from Personality) both need to become aware of the same motives and feelings but each will do so in his own way, his own time. The flincher, for example, is probably going to admit sooner that he’s afraid, but he may have a great deal of trouble acknowledging how angry it all makes him; the bully will openly discuss these aspects of himself in probably the opposite order. Treatment will progress for each according to his own comfort level, depending on a lot of environmental and personal factors that may be pressuring them to change, and only in so far as a therapist can help them make contact with this unconscious and highly uncomfortable material. So the therapist has to become someone they trust and who’s point of view is valued. Otherwise it’s too easy for what he says to be dismissed, too easy to fall back into old habits. On the other hand when that relationship is in place, wonderful things can happen. [ John, Jim, Mike, Patrick]

Difficult to define and itemize, some people have never been comfortable with the idea that relationships count in psychotherapy. This point of view is particularly strong in the past 20 years or so. But the fact is that even back in Freud’s circles a century ago, when talking about the "therapeutic relationship" was pretty scandalous, psychoanalysts were admitting that successful treatment depends heavily on the analyst’s charisma and skill in cajoling the patient into trying a new behavior.

Behavior Therapy

This is the one kind of psychotherapy that does not foster awareness. Behavioral treatments came out of laboratory work with animals and involve the principals of learning -- positive and negative reinforcement, conditioned reflexes, and many others. Behaviorists have had success with certain kinds of patients and most therapists incorporate behavioral techniques in their work.

In a therapy that is more purely "behavioral", a variety of exercises may be prescribed for the office and for the patient’s life between sessions. These exercises will hopefully eliminate symptoms in something under 20 sessions or so. They might involve gradual exposure to the thing you are afraid of, relaxation exercises to accompany this work (breathing, contracting and relaxing muscles, visualization, etc.), and various kinds of practice for the real life situation.

Behavioral treatment seems to work best on specific and circumscribed symptoms. By that I mean it can be useful if you really have no symptom other than your elevator phobia. Usually, however, as I have hopefully made clear in other sections of this website , there are many other symptoms, and even the phobia you think you have turns out not to fit the definition. [Ed] So instead of going straight to a "behavior therapist", talk to the best therapist you can find -- behavioral or otherwise -- before you decide what kind of treatment you need.

One problem with behavioral techniques is that they are inconsistently applied in real life, outside the session. This is especially the case when working with children and their families. It can be difficult for parents and schools, with their own styles and busy schedules, to really stick to the reinforcement schedules, limits, and consequences that we specify in session. Still, behavioral techniques, properly applied, can be very useful with some of children’s specific problems such as tantrums, bed wetting, toilet training, and phobias.

When to stop - II

Sometimes the impulse to stop treatment comes out of resistance, from motives in your inner life, rather than from rational, real world considerations. Resistance is unconscious (see Why psychotherapy,Personality, What’s the cure), resistance, but you may have clues that it is happening. This kind of resistance tends to express itself in unpleasant and perplexingly strong emotions. If, for example, after a long period of gratifying and productive work you suddenly find yourself furious with your therapist, bored with him, maybe unable to remember why you ever liked him in the first place and what you ever got out of treatment, these are signs that resistance is at play -- if only because these positions are so frankly irrational. It means that the therapy is beginning to stir up something in you that you are struggling to avoid. It may even be the result of your feeling better and thus beginning to think about the end of treatment; the separation might be scaring you. There are many possiblities. In any case, if you can get to it, therapy will take a jump forward.

But if you cannot, it is time to stop. Even in the worst case of this kind, when you are thoroughly and unreasonably disgusted with your therapist, you can both agree that no progress is being made and that at least a temporary break is in order. [Sara]

The thing to do, then, is to talk about your desire to stop with your therapist. Even if your therapist feels there is more work to do, you should be able to agree on the progress you have made up to that point, the changes that have occurred, and on where you stand currently. That may be exactly where you want to stand for the time being, or it may be as far as you can go at that point in time. Either way, it’s your decision. Whether you are fleeing in resistance or choosing realistically to stop because your therapist isn’t performing up to snuff anymore, it’s time to quit if you can’t move past this dissatisfaction. (For example, in the case of Sara it didn’t matter whether she was making an ogre out of me in an unconscious flight from our work, or was leaving because I really am condescending and judgmental. Whatever its true cause, the discomfort she was feeling came to dominate the sessions and I could not help her out of it. She was therefore quite right to end treatment.)

No matter what the situation, I think you should flee any therapist who can say only "You are resisting" when you disagree or don't understand. Any therapist who cannot help you to to see that resistance is happening, why it is resistance and not some simple difference of opinion, is useless to you, no matter how right he is.

Choosing a Psychotherapist

You will probably want to read the pages on types of psychotherapy before reading this section.

If so many therapists have essentially the same goal and even employ similar approaches to practice despite their seemingly divergent theoretical orientations, how do you pick one? Actually, I already stated the most important answer to this question: You pick a therapist who says things that click for you. But that’s not quite fair to the poor therapist who’s meeting you for the first time. So when should things be clicking? And how do you find one who’s likely to get around to saying things that click sooner rather than later or never?

Psychotherapists have no 1-800-4SHRINK number, thank goodness, and I don’t think such a thing would help you anyway. There are two main reasons for this. As we discussed in "Why go" parts 1 and 2, people enter treatment because they have become lost or stuck, because there are motivations and determinants of their feelings and behavior that are out of awareness and out of control. In short, people usually don’t know what’s wrong with them. How, then, can they know what treatment they need? 

Second, in psychotherapy one must be wary of specialists. For one thing, what does it mean to be a specialist in some disorder? It may mean the therapist took extra courses or conducted research. But such pursuits, especially research, often contribute little or nothing to one’s skills as a therapist. They may help, but if the therapist is not good at doing psychotherapy then no amount of course work or research or scholarly publication will change that. What makes a good therapist most of all is experience and excellent supervision. (It’s kind of like hoping that reading books about singing will make you a good singer; books help, but mainly you have to actually sing and have a teacher listening when you do.)  

Furthermore, what does it really mean to be an expert in some disorder? Does that mean you are not an expert in other kinds of behavior? How can you be an expert in bullies and not be able to help the flinchers? They suffer from the same core issues, as we saw in the sections on personality andsymptoms. And once therapy is truly under way, the details of the acting out -- the symptoms -- usually fade in importance next to the issues and feelings that those symptoms are covering [Ed, Ed - II, Bully,Ron, Jim]. And even though symptom relief is the goal, we often achieve it without even talking symptoms.[Mike, John].

So how do you choose? Start with credentials. For some reason people don’t like to think about this in relation to a therapist. I would encourage you to conquer this resistance, despite the discomfort it may cause, and ask.