Crucial Choices, Crucial Changes

The Urgency for the Creation of the Specialized Profession of Psychotherapy

A craft for the humble, A task for the wise.—Pierre Janet

Nothing will ever be attempted, if all possible objections must be first overcome.—Samuel Johnson

To Take Arms against a Sea of Troubles
This title, a quote from Shakespeare, appears for good reason. Powerful professional-interest groups are fighting against the public interest. So far they succeeded blocking indispensable changes. The writer Isaac Asimov has stated: “No decent human being would allow an animal to suffer without putting it out of its misery. It is only to human beings that human beings are so cruel as to allow them to live on in pain, in helplessness, in living death, without moving a muscle to help them.”

This statement applies here perfectly. Our volume deals with the suffering of the nonpsychotic emotionally ill and the frequent lack of truly adequate help.

Presently, most psychotherapists had to spend many years in medical, or psychological, or social work studies before starting training in psychotherapy. However, these disciplines have little bearing on psychotherapy. Many expert psychotherapists consider this time devoted to academic studies as a complete waste and wish that they could have spent their efforts on intensive training in psychotherapy.

All the evidence in Crucial Choices— Crucial Changes points to the need for a new profession, the competent clinical psychotherapist. Is that a new idea? Not at all. Some 50 years ago the psychiatrist Lawrence Kubie, a man concerned with patient welfare and devoted to improving psychotherapy as well as making it available to far more people, again and again made this point. We have also spoken of the laudable efforts of Robert S. Wallerstein in that direction. Any professional interested in the idea should read The Doctorate in Mental Health: An Experiment in Mental Health Professional Education, (Wallerstein, 1991, Lanham, MD, University Press of America). Additional information about Kubie’s outstanding efforts and a number of the quotes that the reader will encounter further on in Crucial Choices— Crucial Changes are to be found in Robert R. Holt’s chapter in that book.

Another volume of much interest, edited by Holt, is New Horizon for Psychotherapy: Autonomy as a Profession (1971, Madison, CT, International University Press). In that book, Holt also briefly mentions the American Mental Health Foundation’s efforts in this matter.

Since early 1948, the Foundation has made the establishment of the new profession one of its priorities. Our focus is considerably less on academic work than that of Kubie and Wallerstein. It is instead on intensive clinical experience and supervision. In 1957 and 1958 I met with Kubie three times regarding those matters. Since then, the situation has worsened considerably. The present emphasis on short-term treatment and superficial methods, as well as the many other factors mentioned in Crucial Choices—Crucial Changes, have rendered effective treatment for serious emotional illness almost impossible to obtain.

People are aware of the existence of the homeless, since they are visible. Despite that, indifference to their misery has often become more widespread. How much worse is the fate of the seriously emotionally ill, who suffer their agony unseen and mostly alone! As dreadful as it seems, those who can commit suicide may well be the lucky ones. And we should not hesitate to point the finger at those who are largely responsible.

The only remedy for the present situation is to create a new profession entirely devoted to psychotherapy and mental health. In an age of specialization among physicians and psychologists, it is absurd that a discipline requiring specific knowledge and extensive training has not already come into existence.

The major reason is the opposition of the professions that now provide the teaching of the studies that precede psychotherapeutic training and those that offer the training itself. Robert Holt asks, “Can we continue to urge the continuance of our disciplinary self-interest and the unnecessary brake it puts on progress?” Because of the dearth of professionals of vision, moral integrity, and dedication to improved patient care, such as Kubie, Wallerstein, and Holt, the reactionary professional forces have prevailed.

Change can come about only when those who sincerely want to acquire valid psychotherapeutic knowledge and those who suffer from the present professional inadequacies persistently clamor for quality training and quality care. So far, there is mostly silence.

How should the education and training of the profession of psychotherapist be structured? In this volume, we have described what is positive and what is negative in psychotherapy. We have pointed out which knowledge and which skills are essential.

Obviously, the conditions and facilities necessary to establish a special education and training for this profession will vary enormously from place to place, resulting in considerable differences in the initial curriculum. It will be difficult to find the kind of professional one would really like to fill the faculty positions and supervise the students’ psychotherapeutic work. However, it is important that the first steps be taken, while insisting on certain fundamentals. Difficult though it will be, the selection of students must be on the basis we outlined.

Courses must be carefully established and kept to a minimum. The whole enterprise would be destroyed if self-interest were allowed to turn it into another academic behemoth. All the courses should be selected with one goal: to become the building stones that will allow the student to acquire clinical expertise.

That focus alone will create an educational endeavor infinitely more useful than the pseudointellectual and pseudoscientific waste offered to students today. Robert Holt succinctly asks, “Can we seriously propose to waste the time of so many urgently needed therapists in years of irrelevant and marginally useful training along traditional lines?” Holt envisions the new professionals as knowing “all that they need to know in order to be excellent psychotherapists, without being loaded down by unnecessary intellectual baggage.”

Holt carefully and cogently discusses the academic work required of the psychiatric, psychological, and social work students, something we cannot do here. Nevertheless, let me quote a few of his comments on the formation of clinical psychologists, because they contradict the spurious claims frequently made that psychology studies bestow competence in psychotherapy.

Like psychiatry, clinical psychology only gradually became differentiated from its mother profession. When I got my Ph.D. in 1944 it was simply in psychology; there were no specialized graduate programs for particular kinds of psychologists. Graduate training expressly and exclusively for clinical psychologists began after the second World War, helped along by the rapid expansion of the Veterans Administration’s efforts to meet the mental health needs of returning veterans.

Despite this practical impetus, the design and control of the new graduate programs remained firmly in the hands of conservative, elder, academic psychologists with little knowledge of clinical practice, but with a firm conviction that anyone calling him/herself a psychologist of any kind had to have a sound scientific education and research apprenticeship culminating in a Ph.D. dissertation. (That was known as “maintaining standards.”) Consequently, generations of clinical psychologists went through programs in which their first year or so of graduate work was identical with that of peers who were headed for academic careers of teaching and experimentation in general, social, child, or physiological psychology. A large part of what they studied and mastered for their qualifying examinations, even in generations when psychotherapy had become the dominant theme of their future practice, had as little relevance to clinical work as most of the psychiatrist’s postgraduate studies. It generally took from four to six years to get the Ph.D. if all went swimmingly, plus a year of internship, direct practice under supervision, but often with a strong emphasis on diagnostic testing. Even after about 1960, when clinical doctoral programs were giving both theoretical and practical instruction in psychotherapy, which was also stressed in the internship, many clinical psychologists sought further postdoctoral training in psychotherapy (most of it being mainly practice under supervision). Since large numbers of them experienced years of delay in completing their dissertation research, the psychologist’s postgraduate training years were generally no fewer than those of the psychiatrist.

As far as Holt’s comments on social work studies, I will only excerpt the following: “Because psychotherapy was a late addition to the skills of case workers, a high percentage of the two graduate years is spent on learning content and skills of little eventual applicability in a therapeutic career.”

Holt also points out: “Whether in an institution or in private practice, what actually transpires between the provider and the recipient of the service differs remarkably little according to the diploma on the therapist’s office wall.” This is true. And the quality of that professional activity would be considerably higher were it not for our inane system of selection and education.

The supervision of the student’s work with patients and his or her personal psychotherapy experience form the core of training. The supervisor will need to be able to teach the student how to build a three-dimensional representation of each patient’s unconscious, based only on the clinical data he or she has painstakingly gathered. Unfortunately, few supervisors currently have the necessary expertise. We will show in the last section of this chapter how to create such a representation. The student must do so without using any of the terms of accepted dogma. No use of “anal,” “pre-oedipal,” “oedipal,” and “phallic mother” when describing the clinical data. Theoretical and dogmatic considerations can be brought in later, when the student can discriminate what he or she does and does not need for a true understanding of the psychodynamics of the patient and to form the necessary temporary hypothesis.

The more gifted he or she is, having the necessary sensitivity to understand feelings and their linkage to dreams, the more he or she will be able to build those hypotheses without the crutches of generalizing dogma. The student will modify the hypotheses constructed as he or she proceeds in the treatment of the patient. Dreams will become more revealing, reaching deeper and more meaningful levels, and will help to guide the student to the proper course of action.

Once more: the more gifted a therapist is, the less the therapist will use the crutch of dogma. Frankly, those who are capable only of a simple approach, applied indiscriminately with every patient, have no place in this profession. If they insist on engaging in academic work, their capabilities might qualify them for work in statistics or administration. But why should they, when they can secure far more remunerative and prestigious employment in the faculties of our universities, as supervisors and analysts of the trainees in the institutes, and as the supposed “healers” of patients?

Of course, no matter how accomplished a therapist is, the treatment of the seriously emotionally ill is difficult. The clinicians who deal with difficult cases are unsung heroes who deserve our admiration. But their labor, dedication, and continuous striving to acquire additional knowledge that can help their patients are not enough to stop the deterioration of psychotherapy.

During all the decades that were marked by the hegemony of intellectual and dogmatic institutions, there have been men and women who, without fanfare, have striven to do the right thing. It is their valuable knowledge that we are trying to unearth and revive. We need teachers and supervisors who have such clinical expertise. They will form the core of the program.

We are trying to have this volume published in many languages and distributed in many countries. The obstacles to creating the new profession will vary greatly from country to country. In some places third-party payers will make insurance payments only to psychiatrists and psychologists. However, that is not a hindrance in many situations, since the average wage earner will be able to pay the relatively moderate cost of the intensive, extended group psychotherapy method described in this volume, out of his or her own pocket. If the teaching and training programs are properly set up and dedicated professionals of quality are involved, recognition of the new profession will expand.

Those willing to set up such a program would do well to study the pioneering work and experience of Robert Wallerstein and modify it according to their own judgment. Speaking about men and women of courage and goodwill, such as Wallerstein, Samuel Butler wrote these memorable words: “The first undertakers in all great attempts commonly miscarry and leave the advantages of their losses to those who come after them.”