Is therapy dead?

A new book argues that the decline in long-term psychotherapy -- along with our reliance on medication and quick fixes -- is a public health tragedy.


Fred Branfman
January 5, 2004 11:07PM (UTC)

With the sharp rise in the use of antidepressant medications, and the lack of health insurance coverage for long-term talk therapy, the days when patients spent years on the couch getting analyzed seem almost quaint. Dr. Robert Firestone, the author of nine books and a practicing therapist for more than 40 years, believes that the decline in psychotherapy makes it virtually impossible for emotionally troubled individuals to get adequate treatment for their problems. He also believes that this decline deprives well-functioning individuals of information that could help them lead more rewarding lives and robs society of valuable knowledge that could reduce violence and the likelihood of war.

Medication and quick fixes are insufficient, Firestone says, because they help people avoid emotions and merely provide symptomatic relief. We can only reach our fullest potential for happiness, he argues, by learning to face and tolerate painful feelings, and doing so requires in-depth, time-consuming psychological work.

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Salon spoke with Firestone recently at his office in Santa Barbara about his new book, "Creating a Life of Meaning and Compassion: The Wisdom of Psychotherapy," the prohibitive costs of long-term mental health care, the lifelong value of uncovering emotional trauma, and the reasons even healthy people can benefit from therapy.

You wrote an article in the Journal of Psychotherapy describing what you call "the death of psychotherapy."

There is a serious decline in the interest in and practice of so-called talk therapy, a process that attempts to understand the in-depth source of people's emotional reactions, unconscious motivations and internal conflicts. There is also an increased reliance on antidepressants and short-term cures that are not only impersonal but inadequate. Although medication and other shortcuts have certain value in conjunction with therapy and are sometimes essential, they generally represent only symptomatic cures and fail to address the deeper emotions and conflicts that produced them. These internal conflicts are likely to persist and continue to harm people's relationships, children, work habits and overall quality of life.

But isn't old-fashioned 20th century psychotherapy anachronistic?

No. Depth therapy helps people work through deep-seated character problems that negatively impact their closest relationships. It offers a unique perspective for self-understanding and also addresses a host of social problems including suicide, violence and substance abuse. Nowhere else but in therapy is a person observed, listened to, and emotionally supported in a unique inquiry into his or her personal and family life. The psychotherapy process is one of the most powerful sources for understanding every aspect of human relationships. In an age when everything is becoming more mechanized, uncaring and materialistic, psychotherapy is an outpost for maintaining our humanness.

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Perhaps most importantly, by overcoming personal trauma people can manage to avoid passing on their emotional difficulties to succeeding generations.

Do you feel that most everyone, not only those with crippling emotional problems, can benefit from therapy?

Definitely. All of us experienced varying degrees of emotional pain in our earliest relationships within our family. We all developed psychological defenses against painful emotions, such as turning inward, becoming distrustful of others, avoiding close personal relationships, projecting negative feelings onto others, developing psychosomatic symptoms, and becoming dependent upon soothing but deadening routines or addictions. We then unconsciously carry these defenses into our adult lives, where they diminish our tolerance for intimacy with mates and friends, harm our children, and reduce our capacity to feel for ourselves and others.

You've even suggested that successful people may benefit more from therapy than those with serious emotional problems.

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A person can be "intact," that is, earning a good living or raising a family, and still be seriously limited compared to what his or her life could be. When I was a practicing therapist, most of my clients had reasonably successful careers. But they were experiencing a lot of unnecessary suffering, such as mild to severe depression, anxiety attacks, relationship problems, maladaptive child-rearing practices, psychosomatic symptoms, paranoid feelings, and excessive use of drugs and alcohol. But in addition to recovering from their symptoms they wished to lead more exciting, meaningful and creative personal lives.

Psychotherapy offers more than an opportunity to relieve symptoms. Individuals who are less damaged tend to be more open and therefore have a better chance to improve their lives and their closest relationships.

One reason many successful people avoid therapy is that they fear being labeled "sick" or somehow deficient. Others fear that they are putting themselves in a subordinate position to their therapist.

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In spite of changing times, these stigmas remain. In therapy, it is actually the client who is doing the majority of the work, not the therapist. The therapist is simply a guide. That's why it's not degrading. You're not seeking assistance like a helpless child. You're actively searching for understanding and self-knowledge, utilizing others and everything in your experience to improve yourself and fulfill your potential as a human being.

How does psychotherapy help individuals expand their lives? Can't intelligent adults, perhaps with the aid of the right books or a good friend, figure things out for themselves?

It's difficult to get past your own rationalizations and defenses by yourself. In therapy, you enter into a relationship with your therapist that is different than any relationship you have known in the past. Because clients do not know their therapists, the latter become somewhat of a blank screen. The therapist may be the first person in their lives who really listens to them. The therapist's concern and objectivity enables the client to form an emotional, trusting and non-manipulative relationship in which the client can reveal his or her deepest needs and desires. Clients learn how they project feelings onto the therapist and how to resolve these inappropriate transference feelings. This allows them to improve their interactions with their spouses, children and co-workers.

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Your new book is called "Creating a Life of Meaning and Compassion." How does psychotherapy encourage a more meaningful life?

Rather than seeing themselves as their parents and/or society has defined them, clients learn to question their lives and come to feel for and value their own experience and insights. You're not going to find the meaning of life hidden under a rock written by somebody else. You'll only find it by giving meaning to life from inside yourself. And it requires an emotional struggle. It's not easy to become free of harmful family and societal influences.

I avoided therapy for most of my life because, like a lot of people, I didn't want to revisit childhood pain. Why should a person who leads a comfortable life, who is not symptomatic, risk opening a Pandora's box that could make them miserable?

I would not say they "should," necessarily. It's not been my policy to tell people what they should or shouldn't do -- it's not my way of thinking. But the fact that a person is comfortable does not preclude the possibility that they may be leading a limited or restricted life. There are serious disadvantages to certain behaviors that provide comfort. Compulsive work habits, excessive TV watching, addictive behaviors such as overeating, abusing alcohol and drugs, etc., are all ways of deadening ourselves. In my opinion, what most people call "comfort" is usually achieved at the expense of limiting their life experience.

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What's wrong with avoiding painful feelings?

If you seek to cut off from unhappy feelings, it's inevitable that you're also going to cut yourself off from joyful, loving, tender and compassionate ones. It drains energy to block out or repress emotions or experience, and you're likely to feel less alive. Your relationships are likely to be more maladaptive and unrewarding. You're more likely to hurt your children in the way you were hurt. And blocking out feelings can also lead to physical problems.

It's not fun doing hard work in therapy, particularly in the beginning. That's why there's resistance. But it's exciting too. You can't imagine how many doors it opens. You learn that emotional pain is bearable and you don't have to be so afraid anymore. You don't have to spend your life running away from or avoiding important issues.

The kind of therapy you advocate is often referred to as "talk therapy," and it's often derided in popular culture as "interminable." Its poster boy is Woody Allen.

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"Interminable" psychotherapy is a misnomer. Virtually all people who engage in psychotherapy do terminate. But a therapy that helps you undertake important changes in your mode of living generally requires several months or years. It cannot occur in four or five sessions or through reading a self-help book. And why should it? You don't expect to get a college degree after four classes or reading five books. Why shouldn't it take time and effort to accomplish the difficult task of understanding yourself?

But long-term therapy is so costly. If your funds are limited, isn't it more important to spend your money on your kids, your family, or your home than on therapy?

It's appalling that long-term therapy is so expensive and that it has only limited availability. But there are three important considerations to be noted: First, clients need to give it a higher priority. My clients were not rich. Many were working people -- bank tellers, teachers, nurses. But they placed the highest possible priority on therapy. They realized, for example, that in the long run proper therapy would help them and their children far more than other material expenditures that would not significantly improve their lives.

Secondly, therapists need to have a sliding fee scale for their clients, as I did when I was practicing -- including offering pro bono help to people who could benefit from therapy but are too poor to afford it.

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Thirdly, society needs to find a way to subsidize long-term therapy, for example, at community mental health clinics. Not only is this the most humane course of action, but long-term therapy may actually be cost-effective. It reduces the cost to society of a wide variety of maladaptive behaviors.

What about people who fear going to a therapist because of privacy concerns? Some health insurance companies have begun to demand session notes from therapists.

Such violations of the therapist-client relationship are despicable. Action should be taken to oppose these policies. The therapist-client relationship, just as the lawyer-client relationship, must be sacrosanct in order to be effective.

You've made a case for the value of psychotherapy, but you say we are moving in the opposite direction. In what sense are we witnessing the "death of psychotherapy"? After all, millions of people still see psychiatrists, psychologists and other mental health specialists.

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Well, that's true. But my concern is that therapies today are often superficial or reductionistic and do not get at core emotional problems. The most obvious sign of decline is the fact that health insurance companies only pay for a limited number of sessions. This alone precludes the kind of personal understanding, growth and development that should be the real goal of psychotherapy.

And this refusal to support long-term therapy has also encouraged an excessive use of medication. I am not against the use of medication to deal with anxiety disorders, severe depression, schizophrenia and other psychoses. And I believe that antidepressants have value, especially in those cases when they sufficiently alleviate debilitating depressive symptoms, enabling the client to engage in the therapy process. But the goal of depth psychotherapy is to help people learn to deal with emotional pain, not run from it. And I think that too many therapists and doctors prescribe medication that only helps their clients avoid disturbing emotions. This is a patching-up process that deals only with symptom relief. It's the difference between prescribing pills to relieve chronic headaches versus changing whatever is causing them. The patients are still limited and debilitated in major areas of their life. These kinds of treatments may actually prevent patients from reaching their full emotional development and keep them from experiencing the energy and aliveness that comes from dismantling psychological defenses.

It also seems that there is an increasing tendency to turn to quick fixes, 10-point programs, "how to" rather than "why." If Dr. Freud was the most famous 20th century therapist, today it's Dr. Phil.

Well, I don't know much about Dr. Phil. But I know that people today are impatient and looking for a quick fix for psychological ills. And, as I have indicated, it just doesn't work that way. There is no substitute for deep emotional work in order to transform your life.

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You also believe that therapy has global -- not just individual -- benefits.

Therapy has the potential for improving society at large by offering an understanding of the core issues behind aggression, violence and prejudice. The sources of societal violence are traceable to frustration and rejection in dysfunctional families that then lead to emotionally disturbed individuals. Psychotherapists have learned that anger, like all other feelings, is an acceptable emotion. We help people to accept their feelings uncritically and to learn that only their actions must be subjected to reality and moral considerations. By helping people accept their angry feelings, we enable them to get more control over their expression rather than act them out blindly or turn them against themselves.

I believe that if what I and many other therapists have learned were really understood and integrated into our culture, there would be more of a one-world view. We would empathize more with each other as fellow human beings and be less likely to divide the world into "us" and "them." We need widespread education that focuses on what people have in common, such as anguish over death, rather than emphasizing differences between peoples of diverse ethnic and religious backgrounds. And we need to understand that physical and emotional violence perpetuates itself.

But how much of a contribution has psychotherapy really made to bettering the human condition? There's a book [by James Hillman and Michael Ventura] called "We've Had a Hundred Years of Psychotherapy and the World's Getting Worse."

It's difficult to say. Violence is proliferating, and we are degrading our own biosphere at the expense of the children we love. If this continues, we are at serious risk of destroying ourselves. You have huge numbers of disenfranchised people who don't have anything and are hurting. If we don't become more aware and compassionate toward others and give value to human beings in a new way, if we don't become more emotionally mature, terrorism and violence may well spiral out of control.

But can the insights of psychotherapy really help us confront problems such as terrorism? Isn't that a little idealistic?

Of course it's idealistic. But in theory the knowledge that therapy offers could make an important contribution if future generations sought to eliminate violence and war as viable alternatives.

So if depth psychotherapy is so great, why don't more people embrace it?

Ultimately I believe it's because the truths revealed by psychotherapy are threatening. People expose a multitude of unpleasant secrets of family life in psychotherapy sessions. Clients describe countless tales of emotional, sexual and physical abuse in "nice" families. Too many parents defend themselves against the truth that they are abusing their children. And too many couples tolerate the deadness or conflict in their relationships because it's less threatening than risking the pain required to change them. Stifling the deeper insights of psychotherapy is throwing us back into a darker, more unfeeling and dangerous age.

It sounds like you're not too hopeful about the future.

When I became a therapist in 1957 the times were exciting. There was a belief that we could accomplish miracles, that we could really change our lives. And many of us did. But the culture was more liberal and open to change at the time. It has become far more rigid today. But I can imagine a strong reaction to today's conventionality and conservatism at some point in the future. People seem to have a basic desire for feeling in their lives, and I can foresee a reaction against today's increasing trends toward mechanization and manipulation of emotions. Discouraging as present trends are, I remain hopeful that people may once again become hungry for more feeling and meaning in their lives.


Fred Branfman

Fred Branfman can be reached at Fredbranfman@aol.com. His Web site is www.trulyalive.org.

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