A psychotherapist's critique of the psychotherapy industry.
Soon after I began training as a psychotherapist, I knew that I was going to have a major problem with Faith. I hoped that these doubts would fade, that my initial cynical mistrust of what seemed like self‑serving, made‑up gibberish would soon be challenged by the irrefutable (or at least plausible) evidence of Science and direct experience. Alas, it only got worse as I went along.
Upon close examination the bizarre, competing theories of psychotherapy turned out to be even cheesier than they looked from a distance. The empirical data was just as damning; no reputable researcher has ever managed to document much significant benefit from head‑shrinking. And my personal experience, as a properly trained and well‑respected therapist, only confirmed my initial impression that the vast majority of psychotherapy is a waste of time, equally likely to harm as to help.
Back when I'd first considered the Profession it seemed uniquely attractive. Sitting at my desk at my clerical job, which I'd held for nearly three years at that point (a “personal best” in my occupational history), I'd had plenty of time to contemplate the meaningless quality of most Work, and especially of my particular work. In fact, that was the period of my life when I first consciously embraced my Bad Attitude. Previously I'd simply avoided and ignored the phenomenon of Work as much as I could in a naive, unthinking way, without ever truly coming to grips with it.
There were a number of purely pragmatic and practical advantages to Becoming a Psychotherapist. Qualifying for The Profession required (at least) four years of graduate school, or from my perspective, that much more heavily subsidized prolonged adolescence and absence from the full‑time workforce. Thus, craftily, I committed to ending my career of perpetual postponement by taking just one, last half‑decade detour. For me, at least, School was fun as well as meaningful, in stark contrast to my current situation which was neither.
It was also prestigious, and would delight my bourgeois relatives (who found my career up to then somewhat disappointing) and piss the hell out of my boss, to say nothing of boosting my own self‑esteem as I ascended from lowly clerk to haughty, intellectual “professional.”
Finally, while I was still far from sharing the consumerist aspirations of the vast majority of my peers, I was beginning to feel the allure of a comfortable, middle‑class existence. If I absolutely had to work to support myself I might as well have a cushy job that, at its basic level, amounted to sitting around and talking to people and telling them how to run their lives better. Frankly, I felt I had some natural talents in this direction.
I still think I do, but I've given up on the notion of shrinking heads for a living. I've also surrendered to the painfully obvious fact that Psychotherapy is most certainly no “Science” (though it may qualify as an “Art”) and is a sad species of Profession, offering little of value in return for its amazingly steep fees. Overall I would judge it as valid, helpful and consistent a practice as the fortune‑telling done by the brujas who run little botanicas in marginal urban neighborhoods across the U.S.: the customers are satisfied and keep coming back, but it's difficult for the rest of us to detect any true benefits from these questionable ministrations.
Declining health due to AIDS gave me a good excuse to retire from the field after only a few years as a processional psychotherapist. In fact, counseling is an easy profession for a fatigue‑disabled person (after all, you get to sit the whole time and can limit your client load to match your energy level); but I had no stomach for it. If my time were limited, as it pretty much seems to be, did I really want to spend my precious hours listening to people whine and rationalize about why they had to live their lives exactly as they were, despite how miserable it was making them?
Viewed from that cold, harsh perspective, the answer was clearly “no,” and so I retired, not quite seven years after I'd started.
Reagan was just beginning his second term (1984) when I entered graduate school. I was one of a cohort of seven neophytes being initiated into the Counseling Psychology program, a sub‑group of the department's crop of 30 or so first‑year graduate students. About a dozen or so more were students in Clinical Psychology — the differences between “Counseling” and “Clinical” Psychology were endlessly debated but are, for all intents and purposes, non‑existent, having more to do with academic turf division than anything else. The remaining Psych grad students were in the “Experimental” (i.e., non‑clinical, research oriented) program.
But Experimental, Counseling or Clinical, we were all selected for our promise as academics and researchers, rather than for clinical skills potential and this showed. It was well‑known that expressing any interest in the professional practice of psychotherapy was the kiss of death as far as getting accepted into programs like ours at large, cheap state universities, which (mostly) supported you while providing training as a clinician. There are also urban professional schools, but these are upscale private institutions along the lines of law and business schools, charging top dollar in return for the prospect of easy entry into profitable guild, providing “meaningful” work.
Few of us were really interested in becoming academics or researchers and we mostly had our hearts set on Becoming Therapists, but we were all savvy enough to figure on concealing this for the next four years.
In line with this largely inaccurate assumption that we were all primarily motivated as researchers, the bulk of our classwork focused on statistics and a review of the relevant body of research on clinical psychology, rather than on clinical skills — not, but the way, that these can really be taught, but it was distressing to see them dismissed so easily. The statistics were boring. The research was horrifying in its revelation of psychotherapy's emptiness, at least as regards empirical evidence. The clinical skills stuff, when we finally got around to it, was fun but worrisome.
We began by doing role plays, acting out the part of shrinker and shrinkee and practicing the basic therapeutic techniques: simple reflective statements and reframings (“It sounds like you feel that your boyfriend is a psychotic, abusive creep and you're wondering what you should do about it.”) It was spooky how much shallow interactions sounded like “real” psychotherapy.
Then, in our second semester, we graduated to working on live clients, depressed freshmen who'd reported to the university counseling center and been turned over to us as guinea pigs. Therapy is one of those things that can only be learned by doing. Sessions were taped and presumably reviewed by supervisors, though in practice (as I learned as a fourth year student, when I provided such supervision to the fresh crop of neophytes) this uninteresting chore was often sloughed over; it was enough that you knew that someone COULD be listening to your efforts.
As we progressed, we received more advanced clients, seriously flipped‑out seniors instead of just homesick freshmen. You were expected to justify all interventions by one of the half‑dozen or so generally accepted competing theories of therapy (e.g. psychoanalytic, humanistic, or rational‑emotive [isn't that an oxymoron?] approaches), but it really didn't matter too much which you used. Anything that didn't drive the patients to suicide or litigation was acceptable.
In our later years, we did internships at local mental health centers and agencies. If you were a good finangler or kissed the right butts, you could get one that actually paid money. Otherwise you had to do unpaid therapy as part of paying your dues and logging your hours. There was no serious attempt to evaluate the effectiveness of your work, as the standards of practice were broad and lenient. Only the most blatantly and monumentally incompetent therapists ever had any trouble getting by—and even those ended up getting their degrees (and, subsequently, jobs) without too much trouble. The “standard of care” is so low that just about anyone not actively hallucinating can meet it.
THE LAW OF INVERSE EFFORT
An ironic thing about head‑shrinking, a phenomenon that illustrates its paradoxical nature, is that the more dangerous, useful and necessary your work, the less it pays and the less training it requires. Most suicide prevention hotlines are staffed by unpaid volunteers. Looking after dangerously psychotic people in a halfway house requires only a high school diploma and pays little above minimum wage. Doing essentially the same work in a high‑security private psych hospital (like the multitudinous Barclay's chain) usually requires a 2‑year degree, but pays like a medium‑scale union job. Many of these “Psych Techs” are on exactly the same anti‑hallucination meds as their “clients” (but, presumably, are responding more effectively to them).
Doing field work to prevent child abuse, ostensibly one of our nation's sacred duties and highest priorities, is poorly paid and often acutely dangerous. Child protection workers in rural areas have a high mortality rate because of trigger‑happy backwoods molesters with no patience for the Law's endless quibbles about age of consent and degrees of consanguity. Often counselors' only training is an advanced home ec or “mental hygiene” class in high school; accordingly, the job tends to pay small town librarian's wages, maybe $15,000 per year. But a dozen years down the road, counseling the wounded “Inner Child” that (presumably results) from such early abuse easily pays $100 an hour.
A shrink who focuses on traditional psychotherapy (i.e. hour‑long weekly meeting for perhaps many years [or even decades] with high‑functioning, well‑paid but slightly neurotic yuppies) can hope to earn close to a hundred thousand dollars with a decent practice. To do this safe and well‑paid work requires, oddly, several years' training and numerous degrees, licenses, and credentials.
This rule of inverse effort holds across the board in the The Profession with logarithmic consistency. An agency therapist, like the staff at a Counseling Center, gets the stability of a regular wage and benefits but earns half of what s/he'd make with a good practice. Top‑line therapists can hold lucrative training seminars, or even found new theoretical schools of psychotherapy. This is well‑paid, prestigious and rewarding work: it also removes you from direct contact with those whiny, demanding clients.
THE HELPING VAMPIRES
There are three things that keep Psychotherapy from becoming a worthwhile profession. They are: the pseudo‑scientific system of training; the potential shrinks who present themselves for this training; and the clients who indiscriminately patronize these “helpers” who seem mostly to help themselves.
The ability to read someone's vibes, to detect phoniness and the lurking, evil glint of psychotic madness, is to some extent an inborn skill. You got it or you don't; and as with learning to draw or sculpt or play music, natural abilities can be enhanced (or disfigured) but not created out of nothing. Contemporary psychology, determined as it is to assert its full status as a Science rather than a mere Art, refuses to acknowledge this. Thus it shuns its proper — and do‑able — task of weeding out the deadheads and fine‑tuning the naturals, instead opting to teach all and sundry a rigid and largely ineffective psychometric technology.
A true Art of psychotherapy would put much more emphasis by selection of both shrinks and shrinkees, use a more pragmatic and practical teaching approach, and critically evaluate results strictly on the basis of clinical effectiveness. Currently most therapists are credentialed on the basis of academic achievement (e.g. passing classes, writing these, etc.) and evaluated just once in their careers — at licensing time — by their score on a written test. Existing technology would permit performance‑based testing, but the gatekeepers of The Profession are painfully aware that the majority of its established, credentialed, high‑ranking practitioners could not pass such an exam.
Then there is the question of who wants to become a shrink, and why. I described my own frankly self‑interested motives above. They may seem mercenary or tangential, but people whose primary drive is to Help are usually lousy therapists, ranging from merely ineffectual to actively destructive. I call them the “Helping Vampires.” They long to rescue the world, to bond with the confused and downtrodden, to straighten out the disordered lives of their hapless clients by their own sage advice and moral vigor. Crazies often really cotton to them, which sometimes gives them a deceptive aura of competence; but they mostly exacerbate their helpee's symptoms until they blow up, at which point the Helping Vampire dumps them on a competent colleague or into whatever safety net offers itself.
Finally, there are the clients. Some are people in crisis, briefly disoriented and wanting help to get back on an even keel but basically sound. Motivated and competent, they are easy to work with, quickly identify and resolve the issues that brought them to therapy, and move on.
Most clients, however, are chronically afflicted long‑term neurotics who only want an hour to complain and carp without fear of contradiction. They will pay for this; most of them have to, as their friends certainly won't listen to this stuff for free. They seem to have no center, let alone any central issues, and are content to stay “In Therapy” indefinitely.
Thus these chronics and lifers naturally tend to dominate the market by lingering in it forever, while the acute‑crisis short‑termers pass swiftly through it. Mediocre therapists soon learn to cultivate clients who can be sold on endless re‑living of early experiences and Healing the Inner Child.
Sigmund Freud, the great Viennese inventor of “the talking cure,” would be horrified by contemporary professional psychology as practiced in the U.S. Even in the '30s, he damned the easy‑minded blandness of American psychiatry.
But contemporary psychoanalysts, the direct descendants of Freud, are just as kooky; what's more, they're generally politically conservative, impossibly rigid and frankly exploitative. True psychoanalysis requires at least five years of meeting three times a week. It could take more if you express too much “resistance.” To be admitted to the official psychoanalytic society, you must have successfully completed analysis with someone who was shrunk himself in direct link back to Freud himself, as if this conferred some spiritual or mystical immunity upon the shrinkee.
If this requirement is consciously based upon the “touch of Peter” (whereby each new pope is sworn in by a cardinal who was sworn in by a pope, etc., in a direct line back to St. Peter, the founder of the Vatican's authority), it is horrifyingly reactionary. And if it's not, you have to wonder how such insightful introspectors as the successors to Freud could have overlooked the similarity. In any case, such requirements reflect superstitious and magical thinking admixed with a blatant self‑interest.
GET A LIFE
The U.S. has more shrinks per capita (depending on how you define the term: I'm counting everyone who claims to provide “counseling”) than any other country. Psychotherapy is far less common in Europe, even less popular in Latin America, and almost unheard of in Africa and Asia.
Thus, everywhere outside of North America and Western Europe, the role of “counselor” is taken by family or spiritual advisors, paid or otherwise. North America needs more shrinks because it has so much less emotional infrastructure.
Lacking meaningful relationships with those around them, many people vainly seek attachment and identity in unusual and rather unpromising places. Thus churches, cults and counselors flourish. Just as much of our processed, packaged supermarket food is so drained of genuine nutritive value as it travels from its source to the market that it needs to have vitamins and minerals re‑added, so are our lives drained of meaning by our processing until many are driven to seek re‑injections of Meaning via Therapy.
According to the research done by scientists attempting to verify the benefits of psychotherapy, it is the least cost‑efficient of all possible alternatives. Drugs are cheaper (and work faster). Daily exercise regulates the mood better than the “talking cure” (and treats “excess” weight more efficiently than any professional weight‑loss program). Taking up a hobby, getting a new sex partner, changing jobs: all of these are far more likely to improve your quality of life in less time and at lower cost than it takes to have your head shrunk.
Psychotherapy makes the most sense for someone in crisis or transition. By definition, “crisis” can only last so long, and even “transition” is something that should occur within a few months. Anyone who has been “in therapy” for years should frankly ask themselves what they have gotten in return for the hundreds of hours of talking and the thousands of dollars spent.
Good therapy should produce change. Yet most clients are actually seeking to avoid change, to continue living the way they are but to somehow stop hurting. Their jobs drive them crazy, so they consider taking Prozac or talking with you for an hour every week. But the best thing they could do, probably, is change jobs. This is usually one of the last things they're willing to consider. Instead, they want a quick fix that allows them to change as little as possible.
This is even more obvious when “treating” the number‑one psychotherapeutic complaint: “Bad” relationships or dysfunctional families. Is your partner: addicted, abusive, asexual, indifferent, cruel, neglectful, insensitive, stupid, lazy, evil, dishonest, and/or no fun to be with? Well, then, leave the bum! Is that so difficult to figure out? Should conveying that really take more than a few sessions? But, but, but! they will stammer, and go on to explain why this isn't “possible”.
Their problem is a dysfunctional relationship. Yet instead of refusing to participate in it, they seek you out for another lopsided, dysfunctional relationship of a different sort. By piling one unbalanced relationship upon another, they hope to reach equilibrium. And that's exactly what they get, the perpetuation of a poor compromise that makes them miserable.
Why can't people just talk (for free) to their friends and partners? Because that is exactly what they seek to avoid. By restricting these revelations to a hired stranger one further alienates them, moves them away from their central issues. The rising popularity of long‑term psychotherapy is a symptom of declining emotional stability and increasing alienation. Like TV, it's a cure that makes the illness worse.
If families spent less time silently glued to their televisions, they might be able to support one another emotionally without sub‑contracting this chore to outsiders. If people lived in genuine groupings based on common interests, instead of being isolated in “nuclear” families by accident of birth, they could avoid much of the pain currently expressed, quietly, in the private chambers of psychotherapists.
And, finally and most importantly, if people led meaningful lives in the first place instead of being yoked to pointless and painful careers performing worthless labor, perhaps they wouldn't suffer so much. As it stands, this pain merely justifies one more mostly meaningless profession: psychotherapy.