Towards Thinking Openly: Barriers to Individuality in Psychotherapists

November 11, 2008

Obsessive Ruminations #4

(Bolstered by Soren Kirkegaard’s lament that “ours is a paltry age because it lacks passion,” Dr. Alan Karbelnig writes this regular column to provoke thoughtful reaction from his SGVPA colleagues. He has been a member of SGVPA since 1988, and served as its president in the early 1990s; he has chaired the SGVPA Ethics Committee for 14 years. Alan is a Training and Supervising psychoanalyst at the New Center for Psychoanalysis and the Newport Psychoanalytic Institute. He practices psychoanalytic psychotherapy and forensic psychology in South Pasadena.)

As they enter the consulting room for their first meeting with a person, psychotherapists should feel terrified. They enter the room with, well, nothing. They carry no technical devices. Unlike physicians, who have any number of tools from blood pressure cuffs to electrocardiographic machines, psychotherapists have only themselves. Unlike attorneys, who take notes, refer to legal authorities, and compose official documents, psychotherapists offer only ideas and emotional responses. They present in an exposed state; they carry only their inherited or learned psycho-biology and their knowledge of whomever of the various theorists they have found the most influential.

This nakedness notwithstanding, persons seeking the services of psychotherapists arrive with expectations, even demands. They complain of stale marriages, paralyzed employment situations, or painful emotional states. They request solutions and relief. They insist their psychotherapists take action. This combination of demand, on the one hand, and lack of technology, on the other, creates unease if not abject anxiety in psychotherapists – particularly in the early stages of their work.

How do they then cope with such vulnerability? Some psychotherapists take refuge in dogmatic theoretical approaches. For example, if they have the conviction that all psychopathology results from pent-up aggression and envy, they will view problems exclusively through this lens. If they believe that failures of empathy are the cornerstones of psychological difficulties, they will conclude that emotional troubles result solely from interpersonal deprivation. And so on.

At the other end of a continuum, some psychotherapists eschew theory, and practice some variety of “rent-a-friend.” As one colleague put it, somewhat crassly, psychotherapy is “a love affair without the affair.” Perhaps these psychotherapists are helpful, but they run serious risk of violating the patient, crossing boundaries, or otherwise failing to adhere to the fiduciary aspect of the psychotherapeutic contract. “Patients” are paying a fee for a service, and if only love and friendship are provided, their “sessions” smack of a variant of prostitution.

Striving to find the “middle zone” between these two extremes, psychotherapists face incredible complexity and uncertainty. Even within the confines of the psychoanalytic model, for example, wide variance in theory exists. Different theorists hold that psychopathology results from deficits in maternal care, from intra-psychic conflicts, from unresolved Oedipal complexes, from pent-up aggression and envy, from repressed sexual urges, from existential concerns like fear of death, or from primitive mental states characterized by excessive splitting and projective identification.

Ideally, all these variants should not be causes of anxiety but embraced as part of the beauty and fullness of human experience that psychotherapy uniquely mediate. Psychotherapists do face incredible ambiguity. They should feel awed and humble. They err if they are too rigid in theory; they err if they are too loose. They must struggle to find their way between these two extremes – all the while keeping an open a mind.

But keeping an open mind is anything but easy, particularly when feeling uncomfortable. G. K. Chesterson once wrote that “an open mind is like an open mouth, it looks for something hard to bite into.” Psychotherapists must avoid biting into anything hard. In his recent book called The Black Swan, Nassim Taleb describes theory as “like medicine (or government): often useless, sometimes necessary, always self-serving, and on occasion lethal.” He suggested that theory “be used with care, moderation, and close adult supervision.”

Hopefully, psychotherapists cherish the mystery of the persons who sit before them. Hopefully, they strive to understand what they speak, feel, or display, and then respond in a unique fashion. And as they navigate through the clouds on their lonely journey towards helping others, they can ultimately rely only on this: Their own sense of integrity.


2 Responses to “Towards Thinking Openly: Barriers to Individuality in Psychotherapists”

  1. kaleachapmanpsyd Says:

    Love affair without the affair — psychotherapists must avoid biting into anything hard(!) — the thoughts on theory (often useles, occasionally lethal…) — AK2, this rocks!

    I was just stopping by to see if you’d been up to anything on your blog and it seems you are back full force!

    I was wondering if I might quote parts of it, and of course, link to it?


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