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The Current Column:
What’s Therapeutic About Therapy?

by Jay Einhorn, Ph.D. First in a Series Lots of commentators have tried to answer this question, generally in terms of their theory of therapy. I’m more interested in the “what works, works” point of view; you might call me a pragmatic therapist. Lots of things do work...sometimes. Interpretation, reflection, support, challenge, suggestion, humor, the relationship of jointly investigating the client’s history and narrative about it, not to mention counseling in the sense of advising, are all conversational methods of therapy; of course, they all are based on the therapist taking the client seriously, listening carefully, and developing an effective working relationship with him. Relaxation training, hypnotherapy, role playing, somatic awareness, are all methods that can be therapeutic and that I use on occasion to supplement therapeutic conversation. Therapists trying to understand why therapy works generally start from a point of view, a diagnostic vision of what is wrong with people which therapy is supposed to put right. Each school has its own. Psychoanalytic and related schools locate the problem in the personality or self of the individual, where inner conflicts distort the client’s perception of reality and undermine her ability to find her own authentic way in life. Behaviorists see the problem as one of inappropriate behavior patterns that the client has learned through reward and punishment; we think and act as we’ve been taught to, even when we’re rebelling against something. Cognitive models see the client as applying inappropriate attributions to what she and others do; if I say hello and you don’t answer, how I feel about it will depend on whether I think you didn’t hear me, are preoccupied with a personal problem, or are snubbing me. Medical models interpret emotional problems as biochemical disorders to be treated with medication and/or, among the more enlightened, training in learning to react differently to stressful situations and get more in charge of our physical and emotional reactions, through biofeedback, for example. Thus, there is both a rational and an extra-rational aspect to therapy. It begins with a therapist and a client (or patient, I use the terms interchangeably) seeking help for distress in her life. It embarks from the belief that there is a rational explanation for the client’s distress and a rational method of treating it, yet the cause of her distress is outside the client’s awareness, presumably in her feelings, beliefs, mind and/or body, and the path to successful treatment is to bring that cause sufficiently into awareness for the patient to be able to make rational choices and apply self-management methods. I should add at this point that there is another, sometimes highly effective, approach to therapy in which patient insight is not particularly important. Strategic therapists follow the therapeutic genius of the late Milton Erickson in using hypnosis and suggestion, often indirectly, and strategic family therapy, to induce a movement in a client or family in a direction which they want or need to go in without necessarily bringing that into conscious awareness. There is probably an element of this in all therapy, since inner reorganization may necessarily precede the development of insight or awareness, but this is different from the primarily conscious, awareness oriented, conversationally based method which I am discussing and mainly use. I start from a historical and social perspective which sees families, and the individuals which they produce, as the products of their culture, and culture itself as both functional and dysfunctional, and evolving. In the late 1970’s, I was with the late author Peter Brent (author of Godmen of India and Charles Darwin: A Man of Enlarged Curiosity, among others) as he looked in wonder at the Chicago skyline and wondered what people would think of us 500 years from now. My prediction is that they will say something like: “Those people were technological geniuses but they were awful at human relations. Despite their technological accomplishments, they caused most of their own suffering.” When we seek psychotherapy, we are the products of our families and our cultures. The choices we’ve made, for better and for worse, that bring us to acknowledge our need for help, were chosen from among those which we were offered; including the choice to acknowledge our inability to solve our problems on our own and seek help. We live in a humanistically dysfunctional culture, but one in which the urge to progress, to find a way through obstacles and problems, is central to its evolution. Psychotherapy is one of our culture’s solutions to the problems of growing up within it. There is an ancient alchemical saying, “As above, so below.” I take that to mean that there are analogies between cultural and personal organization and functioning. In the same way that a culture is a collection of different groups and constituencies, with characteristic beliefs and behaviors, so each one of us is subject to varying states of mind, or, if you like, configurations of self, which churn and change, coalesce and transform into one another like the patterns in a kaleidoscope. The different groups and constituencies within a culture sometimes operate independently of one another, sometimes cooperate, sometimes compete, and often cooperate and compete in different ways at the same time. This is a metaphor of the individual’s inner life, particularly the individual with little or no training in how to understand and manage himself. When social conflicts arise, they have to be worked out one way or another, and the society defines itself by how these conflicts are resolved. When social conflicts are too great the society is paralyzed, and when the society finds temporary stability through delusional beliefs about itself and its role in the world, it will undermine itself and be defeated in competition with other societies. Similar processes occur within individuals. When our internal conflicts create enough trouble for us to recognize it, we “hit the wall” or “hit bottom,” phrases which mean that we acknowledge that we can’t live our way through the conflict without help. That is when a person (or couple or family) might be motivated to seek help through psychotherapy. What does this look like, practically? A partner in a marriage finally says that he or she can’t continue the way things are going. A person struggling for self-control in the face of increasing distress with diminishing results begins to experience symptoms that precede or accompany a heart attack, but medical evaluation shows no cardiac problems and panic attack is diagnosed. Another person, beset with similar distress, becomes depressed. One day someone realizes that she has become an alcoholic, or a drug addict, or is at risk to. A parent has to admit that he doesn’t know what to do about his child’s behavioral problems in school, or at home. A worker has to admit that he doesn’t know what to do with his career. A patient with high blood pressure which even medication doesn’t reduce to normal levels is referred for psychological treatment as an adjunctive therapy to help bring the pressure down. People suddenly run into “walls” in school, or in relationships, or else finally become ready to admit that they have, perhaps because someone whose opinion they value tells them so. Then, believing--by no means wholeheartedly--that it might be possible, with their own resources and the right kind of help, to achieve a better life, they come for psychotherapy.