Since the New York Times published an article by psychotherapist Jonathan Alpert, "In Therapy Forever? Enough Already" (April 21, 2012), there has been lively debate within the psychotherapeutic community about the benefits of short-term, goal-oriented, advice-driven therapy vs. the longer, open-ended, free-associative linguistic wandering brand espoused and practiced by psychoanalysts. The lengthiness of treatment is a question that Freud, the originator of the notion "interminable" analysis, himself asked. He experimented for a time with what we might call today, "speed therapy" (comparable to "speed dating" -- first impressions count for all). Ultimately, he wasn't particularly impressed with the results. But Freud's goal (in this seemingly "goalless" endeavor) was radically different from the goal of today's popular short-term -- often with adjunctive psychotropic drugs -- therapies. Perhaps the best way of describing the difference is that the goal of short-term therapy is to feel "better," which can translate into feeling "less." On the other hand, the goal of psychoanalysis is to feel both "deeper" and more "outward" which, at least in the beginning of the process, might translate into feeling "more" and "worse."
Psychoanalysis is different from all other forms of psychotherapy in that most treatments of the psyche support the ego (that part of the self that we identify as "me"). Psychoanalysis both expands the ego and gives it deeper roots. Support builds upward; expansion goes outward, which then allows for steadier building upward. You get more support if you build a 10-story building that has a ground floor support area of 10,000 square feet than a 20-story building that has only 5,000 square feet supporting it. You've got the same square footage in both buildings, but a strong wind might topple the taller building. So, too, with the ego. It is supported by the drives, impulses, feelings and desires -- by all the stuff that we often try to squash down, the stuff that we generally think of as "crazy" or irrational. Unless we give sufficient strength to all the materials constituting the foundational support, the ego built on top will be weak and fragile.
For Freud, the discovery of the unconscious (wherein resides the stuff that is under the building) changed his game plan. He noticed that when the unconscious comes into play, things are not necessarily as they seem. The unconscious can twist things; it can reshape and redefine reality -- make us see things that are not there, or not see things that are there. It can be our best friend, leading us to magnificent insights and creative discoveries, or it can be our worst enemy, torturing us with repetitions of the past that we would rather disown as parts of ourselves. Long before the scientific discoveries in quantum physics of nonlinear processes, unstable states of atoms, hybrid molecular structures, Freud developed a method of inquiry for a science of the invisible -- for the uncanny, the surprise, the accidents of language, the inexplicable thoughts, feelings and behaviors, for dreams, and more.
In "Analysis Terminable and Interminable," Freud quotes Goethe's Faust: "So muss denn doch die Hexe dran!" ("We must call the Witch to our help after all!"). Throughout the ages, skilled men and women have known the art of enchantment. Perhaps it can be said that the skilled analyst knows, like the magi or shamans of other cultures, how to understand magical and baffling effects. This is, of course, because we know how to work with the unconscious. In the world of the psyche, all magic and mystery derives from the unknown arena of the unconscious -- that which we can't see, hear, taste, smell or touch.
In analysis, we learn how to capture the energy of the unconscious, and to transform it into a force for healing. In stories of magic, the hero, who is usually in the beginning of the tale unwise and powerless, must learn to absorb the powers of the sorcerer. Too, the patient can be, at the beginning of the analysis, quite unwise and powerless. During the analysis, patient and analyst explore, through a unique form of dialogue, how the patient has created his psychic universe, and he is then enabled to grasp onto the power of being his own master. As Benjamin Wong has said of the radical conversation that is psychoanalysis, though at times it may look pointless to an outsider, it is a first step toward the introduction of new lines of communication between affect and reason.
Psychoanalysis is a method of time-travel, a journey back to our individual pasts. Freud likened the work to archeology. It is an archeological dig into the soil of the psyche. It is hard labor, tedious, time-consuming and delicate. But at the end, we are able to reconstruct the lost civilizations of our minds. Our own lost memories, like ancient civilizations, are buried under the heavy sands of repression, or they are like the civilizations of fragmented personalities lying on top of the original construction. Yet, the old self, the original self, lies underneath, waiting to be excavated. The past, which is still defining for each of us our unique present, is put together piece by piece, leading then to a better future.
What is at question, then, in the debate about short-term vs. long-term therapy is not how long the treatment takes. It is, rather, the existence, and the desirability (or not) of working with the unconscious. And yes, Alpert is correct: Not all patients want the longer, deeper archeological excavation, some want the short-version fix -- which can, at times, give faster symptom relief results.
I remember fondly one young man, Sam, who came to me with a specific question. He wanted to know whether he loved his girlfriend enough to marry her. He explained that she told him that she missed him when they weren't together; she said that she looked forward to being with him and was eager to share with him her experiences since the last time they were together. He, on the other hand, never missed her when they weren't together, never had any real excitement about the prospect of seeing her, and never thought about what he would want to talk to her about when they got together. He questioned whether he really loved her.
During the course of the 10 sessions that we had (surely a number that Alpert would heartily endorse), Sam seemingly parenthetically (he didn't see it as particularly relevant to the task at hand) revealed that his mother suffered from quite a serious case of obsessive-compulsive disorder. He explained that in the beginning of her disease, she would take a half-hour to leave the house, needing to check on locks, on the stove, on anything that came to her mind that she might be leaving unfinished. The half-hour quickly morphed into an hour. By the time my patient had reached 14, his mother's pathology had become a four-hour ritual. At that point, the father decided it would simply be more efficient to move into the car, thus shortening the ordeal of the time consumption of leaving the house. And thus, from 14-18 years of age, ending only when Sam went away to college, he lived much of his life in a car. When I asked him where he slept, he said, with only a whiff of irony: "I had the DE-LUXE backseat as my bed."
Such a case would be a field-day for any analyst. But my patient wasn't interested in any of the questions that came to my mind. Sam spent his 10 sessions speaking philosophically and neutrally about the meaning of love, and exploring what he felt he could bring to this relationship in a loving way. Sam used his "speed therapy" effectively to his specific emotional
needs at that time, and left in a satisfied state.
A longer therapeutic experience might have led Sam to ask questions like what did he want from a relationship, why is he so disconnected from his feelings, might there be a relationship between his mother's pathology and his emotional disconnection, what is the origin of his uncertainty of his ability to love, would he like to be more connected to his feelings.
The choice of what to want to know and what to not want to know lies with the patient. To a great extent, a larger extent than most of us realize, the choice of what to know, and what to not know, lies with the unconscious and our interest in coming to be friendly and familiar with it. As my mentor Hyman Spotnitz used to say: "An analyst can't be more ambitious for the patient than the patient is for himself."
If you would like to see all letters written to the New York Times in response to Jonathan Alpert's article, as well as other interesting tidbits from analysts, go to http://www.freudianachachacha.wordpress.com.
For more by Jane G. Goldberg, Ph.D., click here.
For more on mental health, click here.