The Future of Individual Psychotherapy, Part 1
When offered the opportunity to address myself to this topic I was given to understand that ‘individual psychotherapy’ was defined as one-to-one, usually regularly scheduled talking sessions whose meanings would be derived from a psychoanalytic or related dynamic theory of personality. Defining ‘future’ was left to me. So were the nature and perils of prediction—one can be a fortune-teller, using whatever skill of divination one has, and lots of nerve, or one can make predictions of an ‘if-then’ kind—that is, if such-and-such happens, I predict one eventuality; if something else happens, I predict another. I suggest that the future is already here in the sense that we are in the midst of a ferment of changes which present fairly clear dimensions for ‘if-then’ predictions.
One can categorize the adumbrating dimensions of such changes as being outside of psychotherapy (changes in society and in the way psychotherapy is thought about and delivered) and within psychotherapy (technique, theory, goals).
Issues from outside of psychotherapy
The future of psychotherapy is best assured by the fact that we have become, as is popularly said, a ‘psychological society’. The family doctor and minister have heavy competition now as the preferred counselors on life’s problems. Explanations that were once cast confidently in physiological or moral terms are now cast in psychological ones. However banal, intellectualized or profound the interchange, we as a culture have finally grasped the idea that two people talking together in terms of self exploration holds the promise of salvation.
A major current of change that has been sweeping through so many of our institutions is relying on groups more than individuals. This trend expresses itself in the arrogation to government of activities that used to be considered the responsibility of the individual. That trend is taken as a matter of course, even as its bizarre excesses have been reduced with the diminished influence of Communism. Centralization can be seen in mergers, cartels, protectionism, mass production and the inclination, when in doubt, to appoint a committee. When once people believed that groups descend to their lowest common denominator, there is an increasing tendency to believe that groups are more efficient than the individual and that checks and balances from many sources make for greater reliability than trusting the individual. Sometimes this trend seems to stem from a quasi-mystical belief in the wisdom of groups. It could also stem from the despair that an individual can make a difference in the increasing complexity of our way of life. As such beliefs and feelings become more influential, individual psychotherapy seems more and more irrelevant, as many group therapists and general systems workers already think it already is.
Individual psychotherapy can be seen as an expression of what is often called in the political arena ‘individual initiative’, often held to be a distinguishing characteristic of capitalism. Thus a person decides for himself on a private practitioner if financially able to do so. Critics of both capitalism and the private practice of individual psychotherapy object to the unfairness and elitism of a handful of people arrogating to themselves a disproportionate amount of mental health time just because they can pay for it. This criticism expresses stark and simplified versions of capitalism and the role of the individual. In principle, individual psychotherapy could be made available in a more socialized system on one or another basis simply because it is believed to be useful. It need not be a perquisite for the rich. But to the extent that it is allowed to be, populist trends will work against it.
For a long time insurance companies helped redress the imbalance between what was available to the rich and the not-so-rich by paying at least part of the psychotherapy fee. They did so on the then prevalent, and usually unquestioned, assumption that psychotherapy was a medical therapy and so was routinely supported as such. As that conception of psychotherapy shifts it provides the insurance companies with a theoretical basis for their financial wish to cut remuneration costs. Increasingly, they are reducing their support for psychotherapy along with all other ‘medical’ activities. The results are manifold. Instead of unregulated and unquestioned support for whatever treatment one wants, with whatever psychotherapist, we have the new or ancillary industry of collectives such as health maintenance and preferred provider organizations.
Many psychotherapists have rushed to get under the umbrella of such organizations, often accepting a lower fee in exchange for being assured a flow of patients. In so doing, however, they give up their sovereignty. They move from a provider-driven to a consumer-driven model. While it used to be that the provider’s expertise (or biases) determined what treatment was given, how often and for how long, now the consumer does so. And the consumer turns out to be the insurance company or its contractual agents, who are in turn beholden to their customers, such as corporations or governmental agencies. What was a healing enterprise administered on the basis of professions is now in danger of being an enterprise powered by financial considerations.
If the centers of such power recognize the financial advantages of prevention of illness, they will take seriously the idea that reducing emotional conflicts can prevent their worsening, and the incidence of physical ones as well (Schlesinger et al. 1983; Mumford et at. 1984). What is more likely, and indeed is already with us, is simply putting a premium on treating with psychotherapy as fast and as little as possible. Thus we can expect an increasing emphasis on brief psychotherapy, behavioral methods, confining treatment to specific symptoms and eschewing psychotherapy in favor of drugs to begin with. Not so wisely, insurers still tend to support, more or less unquestioningly, inpatient psychiatric treatment. This policy encourages the unconscious of patients and some psychotherapists with hospital connections and hospital loyalties to encourage the apparent need for inpatient treatment. What used to be treatable on an outpatient basis now seems to require month-long ‘programs’ for depression, addictions and an assortment of problems in living.
Power, as well as money, will continue to influence psychotherapy should the inter- and intra-professional rivalries continue or, sadly, increase. Instead of science and patient welfare being determining, treatment selection, training and decisions will increasingly be made on the basis of who ‘wins’—psychiatry or psychology, dynamicists or organicists, those who work with thoughts and feelings or those who work directly on changing behavior.
In summary, individual psychotherapy costs more than most people can afford and insurers are inclined to spend as little as possible on claims. The result is that cutting expenses takes precedence over other considerations. If none of this changes, the future will be characterized by treatment of symptoms more than the whole person, changing behavior directly rather than systematically through examination of thoughts and feelings, relying on biology more than psychology, on groups rather than individuals, on short rather than long treatment and in hospitals rather than outside of them. None of these measures are necessarily bad. The shame is that they are being espoused for financial and political rather than scientific, humanitarian and overall professional reasons.
For some of this individual psychotherapists have themselves to blame. That blame stems from various neglects and from the inherent dangers of private practice. Many individual psychotherapists have unquestioningly conceived of their work as open-ended and long term. They have derided short-term and fixed-endings only as poor substitutes for kingly long-term treatment. They have done so on theoretical grounds with the understanding of the intractability of the unconscious, the need to understand and thus moderate defenses and to ‘work through’. Respectably done researches, demonstrations and theoretical rationales for short-term approaches had some, but not much, influence (Appelbaum 1967, 1975; Malan 1963; Mann 1973).
Similarly, group psychotherapy has had to struggle to be seen as anything more than an inexpensive way of getting psychotherapy of a limited sort to larger numbers of people than could get it on an individual basis.
If Freud had been a schoolteacher or social worker, psychotherapy fees would be commensurate with the modest rewards of those professions. They would have been made available largely through agencies and been supported by government. Instead, psychotherapy was swept up into the reward system as well as training and practice conditions of medicine and, as with medicine, was largely delivered by way of private practice. While private practice offers some conditions helpful to the work, for the most part its structure is inimical to the best work (Appelbaum 1992).
The evils of private practice include conflicts of interest that can easily influence decisions—decisions such as whether to take the patient, what kind of treatment is best, how often one meets, for what length of time, for how long each session and for how long the treatment should continue. It can influence what one takes up with the patient and what the goals should properly be. The answers to such questions are sufficiently ambiguous as to make easy rationalizations for answers that suit the therapist’s wishes more than the needs of the patient. As heir to the images of mother-healer and witch doctor, the psychotherapist reigns supreme behind the closed door of the consulting room. Other than the personal and professional conscience of the therapist, there are no checks and balances with which to backstop what, with the best ethical and technical will, are difficult and arguable matters. As socio-economic trends continue to militate against private practice, it will be increasingly difficult to accept it as a matter of course. What survives may well be improved as a result of the criticism that prompts self-confrontation.
Despairingly to a dynamic psychotherapist, the portent of one kind of future is already here and growing stronger. That future would have psychotherapists identify themselves wholesale with health psychology: In addition to brief psychotherapy they would be ‘life-style’ counselors, advisers on prevention and healthy emotional living (Cummings 1978). They would do this as a way of dealing with the realities of loss of some present and more future lack of financial and social support for private practice, long-term psychotherapy and dynamically-informed ways of understanding. In deference to these same realities psychotherapists would interest themselves in heretofore under-served populations, such as the brain-damaged and the elderly.
Issues from inside psychotherapy
Psychotherapists have no more responsibility or opportunity to influence the external changes likely to determine the future of psychotherapy than any other citizen. We all act upon and are acted upon by societal and cultural world events in benevolent or vicious circles. By contrast, psychotherapists have the unique and major responsibility for activities within psychotherapy which are likely to determine the future. These activities can be categorized as those which stem from differences between committed dynamic psychotherapists and those between traditional dynamic psychotherapists and non-traditional, more or less non-dynamic theories and pragmatic activities.
As to the differences between dynamic psychotherapists I shall summarize briefly issues of deep contemporary concern to psychoanalysis. How these are decided will influence the range of dynamic therapies. The perennial question about the scientific status of psychoanalysis increasingly impinges on practical conceptions of the nature of clinical work and technique. The ‘scientific’ camp hews to Freud’s conception of structure and dynamic forces built upon biological and physicalistic models. These were developed by Freud, probably motivated, at least in part, to satisfy his own and the scientific consciences of others of his era. Their heuristic or scientific utility is probably still joined by the felt need of some to ape the respected language, conceptualizations and models of physical science, the better to feel respectable. As society frees itself of the worship of such manifestations of ‘ hard science’, as seems to be the trend, that reason for maintaining Freud’s models will have less appeal. Powerful voices are already being raised in favor of a non-physicalistic conception of psychoanalysis. In this soft science, humanistic-view psychoanalysis is conceived of as a hermeneutic exercise, a search for meaning involving memories, life stories and motives, a view of people as acting more than being acted-upon (as Schafer has pointed out). Another version of the basic tension between ‘things’ and people is to see psychotherapy as a means of modifying ‘object relations’ or the ‘self, usually with some ambivalence about structural considerations. Finally, Freud’s historic struggle to recognize the influence of actual trauma and fantasied events has once again become a lively issue, with important consequences for conceptualization and consequent technique. As we have discovered that the extent of actual sexual, physical and emotional abuse is greater than once thought, there is a growing tendency to revert to abreaction and catharsis, to recovery of memories and associated affects, on the assumption that is necessary for therapeutic change to occur. While such modes of treatment have been explored and exploited by many non-psychoanalytic therapies to the extent that there is a tilt back to the actual from the fantasied within psychoanalysis, such technical means will become popular within the dynamic therapies as well. The various schisms, tensions and competing conceptualizations within psychoanalysis are well delineated in such recent books as those of Greenberg and Mitchell (1983), Eagle (1985) and Pine (1985).
Issues within psychotherapy but outside dynamic psychotherapy
As measured by the number of patients relative to practitioners, number of applicants to traditional psychoanalytic institutes, training practices and psychoanalysts in academic and clinic positions of power, the heyday of psychoanalysis of the 19 50s has given way to organicists and drug therapy on the one hand and the counterculture new therapies on the other. With regard to the increased use of drug therapy, the more drugs are used, the less psychotherapy is used, even allowing for those psychotherapists who combine the two. Even if the ideas are relatively unexamined, if people become disenchanted through personal failures with non-traditional therapies, they will turn to traditional therapies. But if the ideas are examined, they may provide salubrious correctives to some historical legacies from, and often misunderstandings of, Freud. Then psychoanalysis and its offshoots will be strengthened; effectiveness will replace trendiness. Toward that last possibility here are some of the issues raised by the new therapies.
The new therapies are loose and pragmatic about the structure of the meetings. The traditional structure of time-limited office visits may be eschewed in favor of meetings at hotels and campgrounds for marathon lengths of time. Even if held in offices, sessions may go on for indeterminate lengths in order to give the ‘client’ the opportunity to go deeper, get into it and not have to stop at some arbitrary point. Traditional psychotherapists have seen fit to shorten the 50 minute hour to 45 minutes for their own convenience. There seems to be no substantive reason why one might not consider lengthening the session to see whether it could redound to the patient’s benefit.
The theories that guide the new therapies are a mixture usually based on gestalt psychotherapy and drawing upon Oriental traditions as well as Western pragmatism in the form of reliance on will-power and positive thinking.
In keeping with holism as an article of faith in the new therapies, body and mind are seen as one. In principle there is nothing new here. But, less encumbered by the medical tradition, consciously or unconsciously, new therapists are more free than traditional ones to apply meaning as causes and accompaniments of physical ills. Since, according to the new therapists, the whole body and not just the brain carries memories and meanings, they may employ direct physical intervention to loosen the resistances and encourage expression of such memories and meanings (Rolfing, the Alexander Technique, bioenergetics, etc). What psychoanalytic therapist has not wondered at times, especially with certain obsessive-compulsive patients, how better to summon feelings with which to enliven and make useful the patient’s many ideas? Direct bodily intervention might just be such a way, as Wilhelm Reich adumbrated in his ideas of character being armored in the body.
Consciousness, will-power, positive thinking
In opposition to the traditional psychoanalytic attention to unconscious forces exerting inexorable influences on behavior, the new therapists emphasize what the person can accomplish through employment of consciousness, will-power and positive thinking. Perhaps the excitement and drama of the discovery of the unconscious has led to a minimization of the powers of consciousness (Appelbaum 1981) to a view of the person as more helpless and passive than is warranted. After all, sooner or later the patient has to will and do something different on the basis of new self-knowledge if change is to come about (Wheelis 1956). And maybe, so long as one avoids narrowing awareness through excessive denial, it would not be a bad idea to think positively, colored more by hope than cynical or other varieties of despair.
It can be offensive to traditional psychotherapists to be lectured about humanism, the opposite of which is inhumane. But there is much in traditional psychotherapy that poses a danger that practitioners will be over-abstract, intellectualized or machine-like for example rigidity of clinical structure, a meta psychological theory that may intrude upon the introspective, experiential clinical process or the felt need of the profession to be considered scientific in the formal sense. The future will be better served by the recognition that psychotherapists are as much artists and teachers as they are technologically-informed professionals, that their raw material is solely introspection (Kohut 1959) and that their task is the recognition of experience from which meanings can be derived.
An allied criticism is that traditional psychotherapists underplay feelings and that they fail to promote emotional expressiveness on the part of patients and, sometimes, on the part of themselves. Those therapists who dramatically emphasize the abreaction of feeling (Janov 1970) demonstrate the depths and intensity of feeling of which people are capable. Traditional psychotherapists, by contenting themselves with a scale of feelings that is miniature compared to what is available, may be short-circuiting the therapeutic process. There probably has been an undue emphasis on what is said as compared to how it is said or otherwise communicated (Appelbaum 1966). Much therapeutic impact is lost by not selecting, training and exploiting the capacity for evocativeness which can make the difference between a communication that fails to stir and is quickly forgotten and one which is emotionally moving and may, therefore, never be forgotten.
Present versus past
The new therapists say that traditional psychotherapists are preoccupied with the past. They assert, instead, the primacy of the ‘here-and-now’. Freud’s dramatic discoveries of how the past influences the present, and the fascinating plots by which that is done, has, perhaps, unduly promoted the exploration of the past by some. Yet exploration of the transference and the recognition of the ‘real relationship’ (Greenson 1967) attest to the present immediacy of the work. The new therapists are not above exploring the past themselves, even as they promulgate the here-and-now, sometimes merely as a rallying cry or slogan. The fact is that information can come from past, present and the relationship or transference; anyone of them can be used as a defense against the others and can also furnish useful material. Both individual therapists and various theoretical approaches can have constant errors in unduly emphasizing one source or another, and so the raising of the question about the source of psychotherapeutic material can serve as a useful corrective.
Models of interaction
The new therapists characterize traditional psychotherapists as being in thrall to a medical model in which people are considered to be sick and therapists to be healers. Such a model, according to the new therapists, encourages authoritarianism on the part of the therapist and submission on the part of the patient. The recognition that psychotherapy best follows social and interpersonal considerations rather than the authoritarian medical ones is already well underway, in part even within medicine itself. As such, that movement fits with the egalitarian trends of the times and makes possible the most sensitive recognition of the interpersonal, psychological nature of psychotherapy.
One consequence of the new therapists’ egalitarian and explicitly humanistic bent is their espousal of a radical neutrality. They criticize traditional psychotherapists for merely pretending to be neutral while pursuing a priori value-laden assumptions about how life should be lived, in their having a fixed conception of mental health in analogy with a fixed conception of physical health. The new therapists assert that traditional psychotherapists are more interested in adjustment to prevailing codes than in the creation of one’s own code. One insidious way in which that is done is through what they choose to take up with patients. A rigid conception of mental health in analogy with physical health does pose a persistent danger to the relativistic and individual creation of one’s own standards. To the extent that psychotherapists are rewarded with money and prestige, it may be especially difficult to be free of loyalty and belief in the rightness of the culture that rewards them. Or, they may unconsciously encourage patients to act out upon that culture the therapists’ antipathies to it. Either way, the patient is handicapped in making independent decisions and freely exploring alternatives, in learning as much about oneself as possible.