Daphne Merkin's penetrating, moving, and poignant article in the New York Times Magazine, which describes the hopes and disappointments of nearly 40 years in various forms of analytic treatment, is likely familiar to many. Her article has the blogosphere frenetic, with many bloggers hurling critiques at psychoanalysis. Though many of these critiques are justified, it is a bit like shoving the small kid off of the monkey bars on the playground; it's just too easy to be satisfying.
That said, maybe traditional psychoanalysis still needs a wake-up call about the limitations of the theory and the ways that patients have been let down, or even failed.
The reality is that psychoanalysis has, as Merkin says, experienced a long decline in both popularity and perception of usefulness. Many of today's patients want and need concrete answers to complex questions. In this context, non-analytic approaches and medications are seductive offerings. But in my reading, the interesting subtext of Merkin's article is that quick fixes don't offer much either. So what are well-intentioned patients, who genuinely want to alleviate their suffering, to do?
I've been bumping up against the limitations of a theory that I am in love with for many years now. I am not an analyst, but I am a psychoanalytic psychologist. And to not keep you in suspense, my view is that psychoanalytic therapy, provided it is with the right personality fit between patient and therapist, and the right mix of dealing with the here and now, with subdued (and not overstimulating) allusions to hauntings of the past, can be one of the most important investments in mental health that anyone can make.
But it is not easy. First, it is hard to find a good therapist. Why this is so, given that there are so many of us, is a bit curious, but research regarding the therapeutic relationship points us in the right direction--the relationship a patient and therapist have is key. It is crucial that patients feel understood. After all, we can't share what we are most embarrassed about if we don't feel that our therapist "gets it."
But we therapists don't always get everything. To me, this is the crux of Merkin's article. Therapists of any stripe are people too, and as she points out, quite fallible. Of course, I could talk about how the wish patients have for us to be perfect is related to transference, and that part of successful treatment involves coming to terms with the limitations of the therapist; this a good thing to work out because it usually generalizes to the wish many of us have for those we love to never disappoint us. On the other hand, we are in a customer service business. Patients are paying us for a health service, and it is reasonable that patients should feel free to ask us questions about our practice style, theoretical orientation, training and education. If patients have some curiosity about our lives (though surprisingly many don't), it seems reasonable that we should answer some questions, while being mindful that too much information is not useful and that patients are there to talk about their lives and not ours. My point is that being a non-withholding person with our patients just makes sense.
For a long time psychoanalysis sat on a high pedestal. It's elevated position, as well as traditions in the field, exacerbated its mystique and some analysts hid behind rigid approaches and dogmatic theories and forgot about the human side of the analytic encounter. Further, there has been an expectation among some analysts that patients should enter treatment and "trust the process." But I think that most of us realize that this is simply not reasonable. If I had a medical doctor who refused to explain to me how a particular treatment worked, I would find a new doctor. We need to talk about our understanding of how treatment works, the empirical evidence supporting it, as well as the limitations and risks.
It is mistaken to believe that psychoanalytic therapy should not result in behavioral change. Behaviors can and should change as a result of what many people refer to as, "insight oriented" treatment. Insights are only useful to patients insofar as they help them adjust their lifestyles. As I often tell students, " You can have whatever brilliant ideas you want regarding your patients, but if you do not speak to them in a way that matters to them, you are left alone in your office, with no patients, and only your brilliant thoughts."
As people, as therapists, we need to acknowledge our own limitations. We can't help all patients; and our personalities match better with some people more than others. This is a blow to the egos of some. But as therapists we are charged with managing self-esteem related injuries of our limitations. (After all, who doesn't want to be seen as helpful?) But patients should feel entitled to find a therapist who is the right fit, and if a treatment is not working, it's okay to leave.