Therapists, Therapies, or Both?

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When I was learning fly casting a number of years ago, I turned to a number of experts to teach me. Throughout small successes in getting the heavy and whiplike line to carry the tiny artificial fly toward the fish were many, many failures through which the line wrapped around me or became entangled in trees or bushes. Many of my instructors were good anglers who could break down a complex skill like fly fishing into tens or even hundreds of little steps.

Several competent and qualified teachers worked with me but I was a slow learner. Out fishing one day, I learned that one companion was considered by all to be a true expert, so I sheepishly asked if he could give me a tip or two. I was surprised when he told me to just keep fishing and he watched me with attentiveness for about fifteen minutes.

Finally, he walked over and stood alongside me, asking me to cast. This I did, and just after I snapped the rod back to retrieve the line, it flew over our heads. Suddenly and gently, my teacher stopped my arm from going back. I felt the rod pull (this is known as loading), and he guided me in a gentle snap. With speed, the line went out farther than I had ever cast or ever had imagined I could. We did it two more times, and I have been fine at casting ever since.

The pioneers in psychotherapy, and I include names such as Freud, Jung, Rogers, Minuchin, and Stefan de Schill, recognized the importance of the training and skill of the therapist. To become a psychoanalyst, one needed years of training, not only through classes and theories, but through an apprenticeship with a master. Carl Rogers wrote a classic book, On Becoming a Therapist, about this lifelong process. This training helped the therapist know how to approach and help a particular patient.

Since the 1980s, shorter therapies with specific objectives have gained favor, and have documented their effectiveness with empirical studies. Proponents of these therapies point out that classic therapies taking many years have not scientifically been proved to be effective. Those practicing long-term therapy responded that the shorter therapies could indeed be effective with limited objectives, such as “substituting a hopeful thought rather than catastrophizing over an event,” or “exercising 30 minutes a day to improve mood.” These therapists suggest that the brief therapies were not effective in helping with some of the deeper questions brought to therapy: “What do I want to do with my life?” or “How can I best love others and myself?”

The discussions and debates continue, and sadly these sometimes degenerate into feuds that take on a Hatfields-and-McCoys flavor. Therapists of different ideologies face off, and there is rarely a compromise.

For those with the short-term approach, it is often the protocol of goals for a particular problem that is most important. A young therapist with the right protocol might always be preferred to an older and more experienced therapist from a different school of therapy. Sadly, the wisdom of a therapist of 30 years experience may be rejected by an insurer because that therapist has not broken down therapy into small steps wherein a few can be deemed reached over seven or eight meetings.

Perhaps my fishing story is too simplified, but I think we in the mental-health field today are running the risk of losing the great skill that an experienced therapist in some of the older approaches can bring to clients. This is sad when a philosophy of “my way or the highway” prevails, especially when this is given higher status through insurance reimbursement or professional ideologies. Breaking therapy down into hundreds of goals or tiny steps can be helpful in many cases. But not all.

I am delighted when I come across the right articles and books, or therapists that work to combine the best of classical and modern approaches, as in the type of therapy being developed, cognitive psychoanalysis, or when psychoanalysts realize that their patients can sometimes benefit from 12-step approaches like AA.

Let us hope that there will be more intelligent and creative amalgamations of the best of the old and the new in the years ahead.

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