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 Of course the overly timid, cautious, and withdrawn man became that way because he grew up with an intolerant, volatile parent; everyone else who knows the family can see that, and they can see that this man has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.

When to stop?

The short answer is: When you want to.

Once the symptoms that brought you into treatment have abated, then it’s a matter of choice whether or not you want to continue exploring and improving your life through psychotherapy. Some do, some don’t. [Chris, Ed, Jim] There are only a few other considerations.

Sometimes there is little or no doubt that you should change therapists. If your therapist wants you to have sex with him, wants to borrow money from you, or if he commits some similar breach in the appropriate boundaries of behavior, don’t stop and think; just get out. You do not need to have a beer with your therapist, visit his country house, go to the opera with him, or hear about his personal life. The only time the last would be appropriate is if he is telling about himself to help you understand your own life. The minute you’re bored or lost, speak up.

In general, it is time to move on when you cannot talk about something. Your therapist’s office is the one place where you must be free to talk about anything. That’s what you pay him for. In fact, a major part of his job is to help you talk about difficult subjects. So if you have some discomfort or gripe with your therapist, you should be able to bring it up and reach some resolution and understanding. Of course, you have to make that effort, but if you do and you get no satisfying response, it is time to find another therapist.

Also as a general rule, I think you should be wary of therapists who give advice, particularly early in treatment. The world’s full of advice. One of the reasons you come to therapy is to sort out your own priorities and interests from all the advice around you; the last thing you need when you’re lost or stuck is yet another opinion to weigh. The only exception to this is the case where you are simply not functioning [Patrick].

Be clear on the difference between advice and other kinds of input. If a therapist tells you that your attachment to your current lover sounds to him like it is based on your love of escapism and not of that person, and thus to stop and think before you set the wedding date, that sounds like fair game to me. But no therapist should be telling you flat out who to date, marry, travel with, etc. What you want is for your therapist to help you consider your rationale for those choices, to get you interested in sorting out real world considerations from inner, psychological, motivations in those decisions, not for him to take over for you.

How long does it take?

How long it takes for symptom relief varies with the problem. In my experience gross symptoms -- obsessing, phobias, panic, social and sexual anxieties -- clear up rather quickly, within 15 or 20 sessions. If there is no progress in these areas after a good college try, it’s time to consider another therapist or other treatments [behavior therapy, biofeedback, medication].

In any event, I can always promise patients that within 10 or 15 sessions they will see some change. Maybe not a cure, but a clear difference in how they think, feel, and act, or in how things look to them. This has actually become a rather conservative estimate. Many patients see a change sooner, sometimes a big change.

Other kinds of problems need more time. In general, those that are less circumscribed take longer. That is, something which is part of a general pattern of troublesome behavior and feelings in your life probably won’t evaporate as quickly. This should make some intuitive sense. A behavior that is more embedded in your personality, that reflects your overall way of getting through life, will be more difficult to uproot than one that feels like a thorn in your otherwise comfortable side.  

Be aware that it can take a long time just to tell your story, even if you feel highly motivated to do so. Especially if you’ve never really told the whole truth to someone -- and this is more common than we like to admit -- it can be hard to let another person know your secrets. Meanwhile, it may appear to those outside a session that not much is happening. I think that’s unfair to patient and therapist. Someone with this resistance may be honestly trying to talk, but old habits die hard. Many people consciously and in good faith try to tell their therapist what hurts, but the stories come out incomplete, censored, sanitized, confused. (See the beginning of Ron, and you may want to reread this)

Even when the symptoms that bring you into treatment turn out to be the expression of major problems in your life that might take some time to root out, you can still get rapid symptom relief. Therapy is not an all-or-nothing proposition. You don’t even have to resort to medication, nontraditional psychotherapy, or anything else. You should still see clear change within about 15 to 20 sessions. It is sometimes the case, however, that until you root out those larger problems, you won’t get a lasting change

What should happen in a session?

This is tricky. Relationships, even psychotherapeutic ones, do not follow rigid guidelines. Of course, if you are miserable in the first session, find someone else. Barring that, you and your therapist should agree on some time frame at which point you will discuss whether or not there has been any progress and in general how things are going. If a patient is comfortable with me in the first session and wants to return, I tell him to come 4 times. By then, I tell him, we should have a good idea what we will be discussing and how these discussions will proceed. He should have a sense of what a session feels like and what will happen, and that the conversations are different from what he experiences elsewhere. It is important during this trial period not to obsess over whether it’s working, do you really like the therapist, can the therapist help, etc. It’s too early to know. It’s like going to the gym twice and then checking to see if your muscles are getting bigger.  

Sessions should feel intriguing. They may also be erratic, inconsistent, and fraught with resistance that makes you want to quit, but there should be some sense of the new and interesting happening. You want to find yourself getting curious about what is making you think, feel, and act they way you do and how various aspects and events of your life are related in ways you hadn’t considered. 

You also want to feel that you are getting to the truth of what you feel, how you act, and what you believe. (As one patient put it, "I want you to cut through my bullshit".) If you walk out of all of those first five sessions with no sense of this, you need to bring it up with the therapist. It may be that your resistance is too great for psychotherapy at this point; it may be that this particular therapist in some way puts you on edge, on guard, and you can’t open up; it may be that you feel no connection to the therapist and can’t get interested in the process. In any event, bring it up. If you feel no glimmer of resolution of this issue and things don’t soon change, quit or find another therapist. 

What you want most from a session is the experience of insight. (see Why psychotherapy?, What’s the cure?, and the case examples in those sections.) Insight is psychotherapy. You will know when it happens. It is not like intellectual learning. You will find yourself suddenly feeling clearer, saner, more hopeful, more decisive, more energetic, and your symptoms will clear up. This is the one magic psychotherapy offers. When you feel the things you’ve been trying not to feel, when you become aware of things you’ve avoided, you feel better and you function better. If this isn’t happening, ask yourself what you are getting from the sessions.

Please note: You do not have to talk about your past, nor do you have to blame your mother for everything. In fact one patient was with me for over 3 years, made great progress, became quite a different woman in many ways, yet rarely discussed her past. Despite my personal belief in the importance of childhood experiences, we were never able to explore the subject. When I tried, she would promptly tell me to keep my snoot out of it. And she was right that it was not necessary. She made a great many important and desirable changes in her life without delving into her childhood; by any measure, hers was a very successful treatment.

When we do talk about your mother, the goal is not at all to cast blame. The goal is to understand what happened to you, what effect it had, and how it is still affecting you, so that you can be freed to choose other behaviors and to feel better. If I point out to the bully that in his experiences with his mother it sounds like he felt intimidated, humiliated, powerless, and very anxious, my interest is not in who’s fault that is. It does not really matter if his mother was doing the best she could and was simply sloppy, or was a vicious sadist. What matters is that the bully begin to understand what he lived through, how he understood and tried to cope with it, and how it continues to intrude in his current life. 

Once your sessions are under way, it becomes too personal for me to tell you what will happen. One person's symptom that abates in 15 sessions is another's resistance that hides the real issues until session 20. By about the 10th session Ron was admitting to me, as he did to no one else, the depths of his feelings of fragility, fear, and loneliness. After about a year of this, however, it became clear to both of us that he was now using these admissions as resistance; he had to struggle much harder to acknowledge and express the angry, bitter, vengeful, and even sadistic aspects of his personality. Until he did so, he was stuck in the perception of himself as a hurt, lost soul, while his subtle acts of hostility were endangering his career and his relationship with his girlfriend.

By contrast, Nancy spent the first six months of treatment relating to me as if I was a rival for a man’s affection. She was sure I was trying to cheat her out of session time and she told me only the stories in which she felt either anger or the satisfaction of having gotten her way. It was only after half a year with me that she began to drop this resistance and acknowledge how uncertain and lost she really felt. Her deepest feelings were Ron’s means of resistance, and vice versa. Your own road from lost and stuck to awareness and freedom may be just as unpredictable.

Interviewing and Selecting your Psychotherapist

Even in a first telephone contact you can get some important questions answered. Does the therapist have patients similar to how you describe yourself? Most important, do you feel a sense of comfort from and confidence in the person you are talking to? If not, call someone else. There is no point in seeing a therapist who leaves you cold. You must trust your own response to the therapist, hard as that may be. As therapy progresses, try to keep in mind what I’ve said about data and logic: You should be able to understand why the therapist believes what he does about you, even if it is at first hard to agree. [A note on how psychotherapy works] 

A word about "failed" therapy. Psychotherapy is a relationship and no relationship comes with a guarantee. But if you keep your eyes open -- we will discuss how to do that in subsequent sections -- there is no reason for failure to mean anything more than minimal lost time and money, if even that. This is not brain surgery where one wrong move and there goes all sensation on the left side of your body. If you meet with a therapist for a few sessions and it is not working, you will hopefully have learned something from the experience, if only more precisely what you want in a therapist. If you’ve stayed longer, and you have kept your eyes open, you should have learned something about yourself and even changed a bit.

Finally, it has always seemed curious to me that a patient would expect their therapist to have no problems of his own, that some people find it appalling and inappropriate that a therapist has had to struggle through his own craziness. Why wouldn’t you want such a therapist? Why would someone whose defenses have never failed them, who was able to stay blissfully unaware of any personal turmoil or confusion, be able to help you find your way out of the chaos? How could they help you navigate your own conflicting, confusing, intangible, and half-buried feelings when they have no personal experience with such things?

Isn’t it more likely that the better therapy will come from someone who has had to deal with his own troublesome unconscious? Think for a moment about learning a sport. The natural, who never had to work at it, may have no idea why your golf swing isn’t working. The born klutz, on the other hand, has had to build up his skills step by step, carefully identifying and unlearning his own bad habits. He’s the one I’d want diagnosing my swing. The only thing you don’t want is a therapist who is still acting out his problems, one whose feelings and behavior are out of control. We’ll discuss how to spot such a creature in subsequent sections.

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Finding a Psychotherapist

If you know people who have been or are in psychotherapy, and they are having success, you might ask to see their therapist. If that therapist can’t see you, he might well be able to refer you to someone else he respects. If you have a family doctor you trust, or an attorney or schoolteacher, they might know good therapists; the key is whether you feel those referral sources -- the doctor, lawyer, teacher -- are themselves good eggs. You might also contact the health or guidance office of a school or company you are affiliated with and see who they recommend. Bear in mind, however that if those offices have contracted with E.A.P.s (Employee Assistance Programs), managed care, or other provider lists, then you are not getting a personal recommendation; you are getting the therapist’s name who is on the list and who works for the approved company.

These are the safest ways to look for a psychotherapist. If they lead nowhere, there are other options. You can go to an analytic institute and apply for treatment at a reduced rate. They will interview you and if you are appropriate for their brand of psychotherapy or analysis, you can see one of their trainees. These trainees are studying at the institute and will be receiving supervision on your case. Training institutes also sometimes run outpatient clinics where you can go for psychotherapy, sometimes at reduced rates. Less promising are community mental health centers, which usually work on sliding scale rates. In any of these cases you could get the best help possible or the worst or anything in between. You can find all of these in telephone books. Look under "counseling", "mental health", or "psychologist", etc. in the yellow pages.

Please remember that ads you see in the telephone book or newspaper are simply efforts to solicit business. They should be read with the same skepticism you would bring to any advertisement.

You can also try your insurance company, if you are in one of the managed care programs. If you are short of cash, you will want to see a "network provider" -- someone with whom the insurance company has a contract to see patients. You will have to call the company to get the names of therapists. Your "copayment" -- the portion of the fee that is not covered and which you will have to pay -- will be low, often between 10 and 20 dollars per session. Unfortunately, now you are really taking pot luck; you don’t know how these companies choose their providers. What’s more, it is to the company’s financial advantage to send you to a social worker rather than a psychologist or psychiatrist because they pay social workers a lower fee. So if you want a psychologist or psychiatrist, you will have to insist.

Something else to keep in mind is that managed care rarely authorizes more than about 20 sessions for a patient and some won’t even do that. Some insist after only 12 sessions that the patient be sent to a psychiatrist for medication. Even with "out of network benefits", wherein you can see a therapist of your choice for up to the plan’s maximum number of visits per year, some companies refuse to reimburse for sessions with an in network therapist once authorization runs out. At that point, then, if you want any reimbursement you’ll have to change therapists.

Credentials - Types of Psychotherapists

Isn’t it amazing how the same people who know the contents of every last diploma and certificate on their podiatrist’s wall (and I’ve seen offices with 10 such documents) cannot tell you anything about their therapist beyond a name. They know all about the expert who treats their feet, but nothing about the person who deals with their heads and hearts. You ask if this person, in whom they are entrusting their most private thoughts, is a psychiatrist, psychologist, social worker, or what, and they don’t know. You ask if the therapist is licensed, and if so as what; again they don’t know. You ask if the therapist has had special certification or training in particular areas, and they can’t tell you. In fact at this point they probably tell you to lighten up.

Don’t fall into this trap. Be an educated consumer. I know I said in Choosing a Psychotherapist that one should be wary of experts, but some credentials are meaningful.

The term "psychotherapist" is unlicensed; anyone -- and I mean anyone -- can call himself a psychotherapist. The same applies to the term "therapist". "Psychologist", on the other hand, requires some kind of licensure. The practitioner cannot call himself by this title unless he has met certain state and national requirements. These are usually as follows, in descending order of what fees they usually charge.

Psychiatrist: graduation from medical school, and then graduation from a psychiatric residency program. Many psychiatrists are also "board certified", which requires them to take another competency. Bear in mind, here, that unless the residency specifically focuses on psychotherapy, a psychiatrist can conceivably have no training or experience in it! Most who practice psychotherapy, however, do pursue advanced training. The problem with that is that they very likely received such training at a psychoanalytic institute. Such places vary widely in quality, and they can be rather limited in their orientation. Among the practitioners discussed here, at present only psychiatrists can prescribe medication. There are rumblings in the field of certifying psychologists to do so, but don’t hold your breath.

Psychoanalyst: A psychoanalyst must complete training at an analytic institute. Sounds very advanced but there are some cautions. First, there are institutes and there are institutes. Second, some institutes accept candidates who have little or no prior background in the field. A few institutes will not even consider any applicant other than a medical doctor who, as discussed above, may have no background in psychology. Thus, the analyst’s only training may be in the institute’s possibly narrow view of the field.

Psychologist: Ph.D. psychologists have about 5 years of graduate training in psychology and usually an undergraduate psychology degree as well. Psy.D. psychologists have almost as much training but with less emphasis on the scientific aspects of the field. In order to obtain the license as a "psychologist" most states require a further 1 or 2 years of post-graduate supervised experience in the field. A masters level psychologist cannot licensed as a "psychologist", and has only about 2 years of graduate training.

During Ph.D. training, students spend up to half their time in clinical settings -- mental health centers, psychiatric hospitals, schools, clinics -- and receive one-on-one supervision of their work. Bear in mind that a psychologist who studies rats in graduate school and never sees a human patient can sit for the licensing exam, call himself a psychologist, and set up a practice -- although I’ve never heard of one who did. The thing you may want to ask is whether your psychologist is a "clinical psychologist", meaning did he specialize in diagnosis and treatment of humans.

Social Worker: Usually 2 years of graduate training, perhaps an internship, and a year or two of supervised post-graduate work before obtaining the license. The requirements and titles vary by state. Be aware there are licensed and unlicensed social workers. In New York, the two types of clinical social workers are LCSW (Licensed Clinical Social Worker) and LMSW (Licensed Master Social Worker), but only the first is considered a licensed clinical worker. The LMSW thus cannot practice unless under the supervision of a licensed clinical professional - psychologist, social worker, or psychiatrist.

My own bias is strongly supported by psychoanalysts and even the cognitive behavioral literature. All these sources agree that you should start treatment by consulting a well trained, widely experienced therapist. In that consultation, which could last anywhere from one to five sessions, you will determine what kind of approach will work best for you. There are several reasons for such a consultation. First, as already noted, despite what you may believe people don’t really know what is wrong with them so they are not in a position to choose their own treatment. Second, among the most common errors made by therapists of limited training and experience is that of overlooking alternatives. You would not want to be seeing a narrowly trained, narrowly focused therapist about depression if in truth you were suffering nutritional deficits, sleep deprivation, even neurologic damage, attention deficit, or Obsessive Compulsive Disorder, all of which can mimic depression. I see this danger most commonly in the case of Attention Deficit Disorder. Very often what looks like this disorder is any number of other conditions, including very straightforward interpersonal conflict among family and teachers. Before rushing to the Ritalin, Adderall, or Cylert (commonly prescribed medications for ADD), the condition should be carefully diagnosed and all alternative possibilities ruled out.

Just what are "psychological problems"? What’s a symptom?

I’ve said that symptoms are the expression of one’s being lost or stuck (see "Why go?"). Now why should that be? How do panic, obsession, phobia, depression, etc. express our having lost track of what we feel, believe, perceive, want, need? The answer lies in understanding symptoms and defenses.

We all have at least an intuitive sense of what a defense is. When we tell little Suzie to pick up a strayed toy and she erupts with "I didn’t put it there!", when our school chum, Harry, treats Linda with extra coldness and disinterest while we all know he’s sweet on her, we speak of these behaviors as "defensive". What we mean is that the person is trying, in an especially obvious and graceless manner, to avoid the pain of, and at the same time maximize their control over, their uncomfortable spot. Suzie is feeling accused, put down, even humiliated; Harry fears rejection, humiliation, and a blow to his perhaps already tenuous self-esteem. Rather than acknowledge these unpleasant experiences, the two devote their energy to defense -- to protecting the self and self-esteem.

Now imagine Harry is extra sensitive in this area, maybe because of his past history, maybe because of his inborn temperament, who knows. For whatever reason, he grows up always on the alert for this kind of humiliation. In response, he redoubles his bravado, behaving towards others with ever more disinterest, independence, "cool". The more uncomfortable he is the more aloof he acts. This sets up a vicious cycle, because those uncomfortable moments are precisely when he most needs reassurance -- and that’s just when he’s the least open and approachable. As his discomfort rises, then, he treats more and more people with indifference, even disdain. Perhaps he loses his job and must interview for a new one. With the added pressure and humiliation of needing approval from the people interviewing him, he becomes even more irritable and off-putting. Needless to say, no-one will hire him. He begins to rage inside at all the people who don’t appreciate or help him, ruminating on his anger to the point of losing sleep. To relieve the tension, he retreats nightly to marijuana, alcohol, and watching too much television late into the night. The rest of the time, he begins to suffer back pain and a nasty skin rash. Eventually whoever he lives with, can’t stand it any longer and leaves.

A personality that began as "defensive" has bloomed into one full of symptoms -- depression, drug abuse, various anxieties, insomnia, "personality problems", even paranoia. Under "DSM Diagnosis", his health insurance claim might list Depressive Disorder, Obsessive Compulsive Personality Disorder, Conversion Disorder, Paranoid Personality Disorder (it’s really called that), or several other possibilities.

So a symptom is an outgrowth of a defense. Defenses protect us from unpleasant experiences, such as rejection, humiliation, and other assaults to our self-esteem. When these defenses fail we tend to escalate our efforts. We develop new behaviors (Harry’s drug use), intensify old ones (initially just aloof or "cool", Harry becomes withdrawn and almost paranoid), or fall prey to irrational beliefs and feelings (such as phobias, panic attacks, Harry’s skin rash and back pain). At some point all this becomes sufficiently perplexing or distressing that they are perceived as "symptoms". We might usefully think of symptoms as defenses run amok.

About Psychotherapy

Welcome to About Psychotherapy (or "counseling" if you prefer). My goal in creating this site was to explain psychotherapy in clear and accessible language -- to demystify the whole subject, without trivializing it.

In reading through these pages, you can learn about depression, phobias, anxiety, panic, obsession, attention deficit, learning disability, post traumatic stress, and many other problems including the difficulties we humans seem to have getting along with each other and building relationships; there are also sections on behavior therapy, cognitive therapy, children and adolescents, couples, biofeedback, and many more.

Primarily, though, you will come away understanding psychotherapy: What it is, how it works, why go, why stop (and when), and what should and should not happen there.

Psychology, especially psychotherapy, does not translate well into sound bites. A little background is going to make all of the material much clearer. I urge you, therefore, to resist temptation: Don’t jump straight to "Choosing a therapist", "When to stop", or whatever else catches your eye on the index page. Instead, try going in the order presented, at least through the first 10 or 12 headings.

Also please avail yourself of the many links to case examples and further discussions. Particularly if something seems simplistic, obvious, or vague, these links should be a big help. Some of the case examples are rather long as they illustrate more than one or two points. Don’t feel you have to stay with the case from beginning to end. They will be referred to several times so you’ll find your way back to them when they are relevant. I have of course changed the names and identifying information to protect patients’ confidentiality.

Finally, take your time with the site. There is a lot of material and none of it is advertising. Psychotherapy is sometimes a difficult subject to absorb. You may not understand everything at first reading. But if you let yourself explore, you will find many of your questions answered. After reading the site, you will understand why depression, anxiety, obsessive-compulsive symptoms, phobias, and the many problems and stresses that invade people’s relationships, careers, sexual functioning, family life, parenting – in short many of the problems that come with being human – can be productively understood and eased by a single overriding feature of psychology and psychotherapy. Of course, attention deficit, obsessive behavior, phobias, panic, depression, bipolar disorder, and even problems with anger in relationships may have physiological components as well. Sometimes medication helps. But psychotherapy can effect remarkable change, with or without medication as an adjunct, if only you’re lucky enough to work with someone good at it. The site will help you find that kind of therapist.

This web site will be updated periodically, as your comments and questions come in, so hit me again from time to time. Feel free to email any thoughts or you leave me a confidential message at 212-774-9499. If you have a question, you can click on the "Ask a Question" link at the bottom of the index on the left, and follow the instructions. It will take one to two weeks for me to respond. I've also added a blog elaborating on the material presented in this website. There you can find additional session exerpts, vignettes, updates, and reflections, as they arise in sessions and in daily life.