In the movies you often see dramatic breakthroughs in therapy. In the classic movie, Ordinary People, which won an Oscar for Best Picture in 1981, a teenaged protagonist recalls a memory of his brother drowning and how he both wanted him to drown and was guilty about it. In this climactic scene he yells at the therapist, cries, and has a catharsis when he realizes he is suicidal because he has been blaming himself for his brother’s death. Afterwards he is seemingly all better.
In reality therapy hardly ever happens like that. Instead, it usually starts well with new insights springing forth each session, but after the newness rubs off it begins to be a grind. It involves session after session in which nothing seems to happen. It becomes a chore to go to the sessions, and the patient starts to wonder when it is going to be over.
The progress that is being made in therapy is so subtle that it is often impossible for the patient to realize anything is happening. One patient put it succinctly, “It seems like I come here every week and I talk about the same thing and you give the same answers. We keep going over the same thing week after week and nothing seems to be changing.”
I answered, “Nothing seems to be changing. The key word here is ‘seems.’ ” I pointed out to him that he wasn’t having any more panic attacks. He acknowledged that to be true. I pointed out that he had asserted himself with a store clerk recently in a way he never had before. He acknowledged that to also be true. I pointed out that he had approached a strange woman on the street, whereas he wouldn’t have been able to do that before. Again, he acknowledged that to be true.
“But how do I know that’s because of therapy and not just some kind of normal maturity that would have occurred anyway?”
“Good question. Did this kind of maturity happen to you before therapy?”
He thought a minute. “No, not really.”
What we have learned over the years is that psychotherapy does help, but it helps in a very subtle way. At a certain time it becomes a grind, just as relationships at some point become a grind. This is when the main work of therapy begins. This is when one is confronted with his deepest resistances to intimacy.
We all grow up learning how to be intimate from our parents. They are the first model of intimacy, and we assume, consciously or unconsciously, that this model is the model to follow. We develop attitudes toward and defenses against intimacy. Since most childhoods are less than perfect and most original family intimacy is fraught with pitfalls, we hold back. We do not tell the truth about our deepest feelings, not even to ourselves.
I kept encouraging a certain patient to share his honest feelings about me and about therapy. Yet he came in session after session and filled them with talk about other things. One day, upon much prodding, he finally admitted that he sometimes had the feeling I need his approval. He compared that to his father, who he also thought needed his approval. He had secret contempt for his father, and he had been carrying a secret contempt for me. After saying this and after I listened to it without comment, his attitude toward me began to change and he began to have more insight into his failed relationships. He had the same block in his outside relationships as he had with me.
Progress in therapy depends on three things: the therapist’s competence, the patient’s motivation to overcome his or her resistances, and the strength of the bond that develops between them. Most therapies fail because of one or two or all three of these factors.
Even when all these factors are positive, progress is slow. Research over the years has shown that therapy can only help so much. The adult patient generally comes to therapy after having spent years operating a certain way and viewing life a certain way. Everybody resists change; it seems to be part of the human endowment. No matter how bad a person’s addiction is, they stubbornly hold on to it. No matter how many failed relationships somebody has, they chaff at any suggestion that the way they are going about it is counterproductive. The overwhelming desire is to blame one’s problems on others.
With what sometimes seems to be a herculean effort, you can help a patient stop drinking. But the urge to drink is forever inside him, often causing a relapse. He never changes to the point where he has no urge to drink. After many years of therapy, you can help a patient to feel less depressed. But they will never reach the point where they feel no depression at all. The tendency to fall into a depression will always linger.
Persuading a patient to look at how he operates in the world, rather than how others are treating him, is one of the main tasks of the therapist. The second task is getting the patient to stay in therapy when his deepest urge is to find reasons to leave. When he continues to feel depressed, he wants to blame the therapist for not helping him get over this depression. But the depression will only diminish gradually, imperceptibly over years of grinding. The patient must wait it out and be willing to give up cherished attitudes such as that his anger at the world is reasonable and necessary for his well-being.
Yes, psychotherapy can help, but it doesn’t perform miracles. Like anything else, you get out of it what you put into it.