by Morton Hunt
A few years later the psychologists Marvin Kahn and Sebastian Santostefano wrote, again in American Psychologist, that clinical psychology was “in a state of anxiety, great ambivalence, insecurity, and self-doubt. Clinical psychology states that it is a science, and then says that it is an art.”11 In 1972 and again in 1986, E. Fuller Torrey, himself a psychiatrist, devoted an entire book to the thesis that psychotherapists were akin to witch doctors and medicine men, and achieved changes in their patients by comparable nonscientific means.12
Attacking psychotherapy as nonscience has continued ever since, the attackers ignoring or belittling the many hundreds of controlled studies and meta-analyses of those studies validating aspects of the discipline that have been performed over the decades (we’ll hear about them later). Typical of such attacks is one of the latest, an op-ed piece in the New York Times in 2006 by Adam Phillips, a British child psychoanalyst:
Psychoanalysis is having yet another identity crisis. It… [is] trying to make therapy into more of a “hard science” by putting a new emphasis on measurable factors…It would clearly be naïve for psychotherapists to turn a blind eye to science, or to be “against” scientific methodology. But the attempt to present psychotherapy as a hard science is merely an attempt to make it a convincing competitor in the marketplace. It is a sign, in other words, of a misguided wish to make psychotherapy both respectable and servile to the very consumerism it is supposed to help people deal with.13
Thomas Szasz, a perennial gadfly to his fellow psychiatrists and other psychotherapists, made a different and radical attack on clinical psychology. Mental illness, he charged, is a “myth” fabricated by clinicians who, acting as lackeys of the establishment, diagnose forms of socially disapproved deviant or individualistic behavior as mental disorders.14
Still others have charged that psychotherapists falsely claim therapy to be useful against a wide variety of disorders although, these critics assert, it is helpful against only a limited number. In 1983 Bernie Zilbergeld, an Oakland psychologist and psychotherapist, said in his Shrinking of America that psychotherapy is effective for a few problems but that for most others it is of little or no value and is inferior to drugs or simply talking to a friend.15
Another favorite criticism in recent years has been that a number of conditions psychotherapists say they can treat are actually of physiological origin and are poorly remediable by psychotherapy but far better dealt with by medications.
Clinical (severe) depression, for one, has been shown to be of biological origin in many cases. Particularly in elderly people, it is often associated with an age-related imbalance in certain neurotransmitters. Research studies of recent years have shown, according to current information from SAMHSA (Substance Abuse and Mental Health Services Administration), that antidepressant drugs “chemically restore the balance and relieve the depression… [and] are effective across the full range of severity of major depressive episodes in major depressive disorder and bipolar disorder. [The named drugs are the tricyclic and hetero-cyclic antidepressants, MAOIs (monoamine oxidase inhibitors), and SSRIs (selective serotonin reuptake inhibitors.)]… The mode of action of antidepressants is complex and only partly understood. Put simply, most antidepressants are designed to heighten the level of a target neurotransmitter at the neuronal synapse.”16
Tourette syndrome—uncontrollable tics, grunts, barks, often the compulsive repetition of foul language—was long attributed by psychotherapists to profound psychological disturbances and interpreted as having hostile and anal meanings, but psychotherapy consistently failed to help. What has helped is the administration of dopamine blocking agents, which suggests that the disorder is due to a dopaminergic excess of organic origin.17
Compulsive gambling and other forms of sensation seeking have been seen by psychotherapists as disorders for which psychotherapy is appropriate, but by 1989 studies based on urinalysis and spinal taps showed that compulsive gamblers and sensation seekers have a chronic deficit of the neurotransmitter norepinephrine. That deficit, it was hypothesized, leads to a low level of alertness and a feeling of boredom, which victims try to alleviate by seeking danger—a condition in which the brain produces extra norepinephrine and which, though it makes most people extremely uncomfortable, makes these people feel good.18
Obsessive-compulsive disorder, in which certain obsessive ideas cause such persistent senseless actions as washing the hands dozens of times a day, has also been found by means of PET scans to be associated with abnormally high rates of glucose metabolism in the basal ganglia, a region of the brain between the limbic system and the cerebral cortex. By the late 1980s, clomipramine, an antidepressant, was found to sharply reduce the symptoms over a period of weeks, but it had unpleasant side effects, including sleepiness, difficulty starting urination, dry mouth, and a drop in blood pressure when rising from a seated position. Currently, therefore, the medication of choice is usually one of the SSRIs—fluvoxamine (Luvox), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), or citalopram (Celexa). If an SSRI does not work, clomipramine is the fall-back treatment.19 (Another SSRI now coming into favor is escitalopram oxalate [Lexipro]).
Given the long-standing derogation of psychotherapy and the many assertions that it is not science but, at best, a form of magical belief and, at worst, fraud, how can we account for its vast growth and wide acceptance? Some people offer sweeping social explanations: We live in a disconnected and alienated age; we seek sources of comfort and reassurance and turn to those who offer them for pay; in a secular age, psychotherapy takes the place of religious belief and is a secular sanctuary. And so on.
But if we meet some of the practitioners, eavesdrop on their clinical sessions, and look at the accumulated evidence of outcomes, we may arrive at a more empirical and less ideological explanation of the success of the psychotherapists and of psychotherapy.
Freud’s Offspring: The Dynamic Psychotherapists
One of the few generalizations that can be made about psychotherapy today is that few generalizations can be made about it. By now it is practiced in accord with half a dozen or more major methods, of which there are hundreds of variants. At one extreme is the patient lying on the couch—now very rare—and pouring out random thoughts while the psychoanalyst murmurs mmm from time to time; at the other, an alcoholic, after taking a dose of Antabuse (disulfiram) or Temposil (citrated calcium carbimide), is served a generous whiskey-and-soda in a treatment room and soon after drinking it gasps, breaks into a sweat, complains of rapid and irregular heartbeat, dizziness, nausea, difficulty breathing, and headache, and vomits violently into a handy basin.
Nonetheless, one legitimate generalization about modern psychotherapy is that a majority of all psychotherapists use forms of dynamic therapy (also called “psychoanalytically oriented psychotherapy ”) at least part of the time.* These are based on dynamic psychology, which conceives of psychological problems as resulting from intrapsychic conflicts, unconscious motivations, and the interplay of external demands with components of the personality structure.
This conception, though psychological, had its origin, as we saw, not in psychology itself but in the chance discovery of a neurologist— Freud—that he had more success treating hysterics with “the talking cure” than with physiotherapy or hypnosis. Psychology was slow to adopt his discovery and theories; during the early decades of the twentieth century, while psychoanalysis was gaining ground among physicians and psychologists in Europe, clinical psychologists in America were still chiefly performing psychological testing and measurement. Some universities did open psychological clinics before World War I, but these were limited to the testing and training of children with learning problems. Psychotherapy remained an exotic and alien treatment that was practiced largely in Europe.
American medicine was equally slow to adopt psychoanalytic methods. Early in the century, American psychiatrists mainly treated hospitalized psychotics and almost entirely by physical methods: constraint, tub soaks, exer
cise, and physical work. But World War I produced a bumper crop of veterans with traumatic neuroses, and in consequence a number of psychiatrists, aware that psychoanalytic therapy was said to have considerable success with severe neurotics, began to take an interest in it.20
A few went to Europe for training, and when several psychoanalytic institutes opened in American cities, a trickle of psychiatrists and others began analytic training. Some better mental hospitals, such as the Institute of Pennsylvania Hospital in Philadelphia, invited European psychoanalysts to come train their staffs. Eventually, organized psychiatry made psychoanalysis one of its specialties and, through its psychoanalytic societies, limited training to physicians, although only a minority of psychiatrists ever took training in it and practiced it. Psychologists and others who were not physicians but wanted training had to get it in Europe. Later a few institutes were founded in the United States for “lay analysts” (nonmedical analysts).
During the 1920s psychoanalysis became a favorite topic among the avant-garde, and psychodynamic concepts were taken up by the psychological establishment. As we saw, they were a major influence on Henry Murray, creator of the Thematic Apperception Test, and his research group at Harvard. By the 1930s, when a number of European psychoanalysts fleeing Nazism arrived here and the number of training institutes grew, psychoanalysis attained the status of a movement.
Like the earlier movement in Europe, however, it underwent frequent fissions. In the 1930s, some psychoanalysts in America altered and significantly added to Freudian doctrine, often distancing themselves from the main psychoanalytic body. Most notable were various “neo-Freudians” who worked out systems of their own and set up institutes to teach them. Although they did not reject Freudian dynamics, they gave social and cultural factors equal or even greater importance in character development and mental disorders. The gentle philosophic Erik Erikson, whose developmental theory we have already seen, was one of them; the fiercely independent protofeminist Karen Horney, another; and the poetic social-reformist refugee from Nazism, Erich Fromm, a third.
Another neo-Freudian of note was the psychiatrist Harry Stack Sullivan. He was an only child and the only Catholic child in his upstate New York farming community. Perhaps because of his loneliness, he became interested in the relationship between the growing child and the caretaking adult and how it affected character and behavior. The dynamic treatment he devised, “interpersonal therapy,” was based in part on Freud, but rather than relying on free association, it called for the therapist and patient to engage in face-to-face discussion, with the former behaving as a real person, not as a shadowy figure on whom the patient projects transference images.
Since, in the 1930s, the usual regimen of therapy by Freudians and neo-Freudians consisted of four or five sessions per week—Freud preferred six—for at least several years, the number of patients in treatment remained limited to the few who were both well-to-do and able to spare the time. But World War II produced far more psychologically damaged veterans than had World War I—in 1946, Veterans Administration hospitals alone had forty-four thousand of them as in-patients21—and an urgent need for a larger corps of psychotherapists and for briefer forms of treatment. The result was a sharp growth in the numbers of psychiatrists and clinical psychologists, who were increasingly beginning to use psychodynamic concepts and methods.
At the same time, psychoanalytic notions about the human psyche, popularized by such writers as André Breton, Thomas Mann, and Arthur Koestler, and by surrealist painters, became a fad among the intelligentsia; undergoing analysis was almost a rite of passage for the avant-garde. Psychoanalytic ideas were also reaching millions of ordinary folk; Dr. Benjamin Spock’s Book of Baby and Child Care, which advocated child-rearing practices based on Freudian views of human development, sold over twenty-four million copies between the late 1940s and 1970s and was the most important single vehicle by which Freudian psychology influenced American society.22 Unfortunately, psychoanalytic ideas were often distorted by enthusiasts who used them as license to blame their failures on their parents. As Erik Erikson ruefully said, “Even as we were trying to devise a therapy for the few, we were led to promote an ethical disease for the many.”
The impact of psychoanalysis was extraordinary, considering how few analysts and analysands there were. At the height of its popularity in the mid-1950s, there were only 619 medical analysts and about 500 lay analysts in the country and perhaps a thousand in training in some twenty institutes for physician analysts and a dozen for lay analysts.23 While no census exists of analysands, if most analysts worked eight hours a day and saw each patient four or five times a week, the total number in treatment at any time could have been only about nine or ten thousand, an insignificant fraction of all those with mental disorders. Nor could the relatively few psychoanalysts who specialized in treating children handle more than the select few with rich parents. A case report in The Psychoanalytic Study of the Child in 1949 concerned a five-year-old boy who was afraid to be in school without his mother and who was cured by a psychoanalysis that lasted three years. (The analyst never considered, and perhaps did not know of, any briefer way to treat the boy’s phobia.)24
The cost, time required, and disruption of daily life caused by regular appointments were bound to prevent the therapy from becoming widely used. But there were other obstacles. The cognoscenti soon learned, and made sport of the fact, that it often seemed a swindle, with the patient spending money, time, and effort while the psychoanalyst did and said almost nothing. Classically trained Freudians, who still constituted the great majority of psychoanalysts, had become more distant and unapproachable than Freud had ever been. (Freud once said, “I am not a Freudian.”25) Many spoke very little but simply listened to their patients, fending off questions about what they thought of the patient’s narrations or symptoms with evasions like “Why does that seem important to you?” and “Why do you think I would feel that way?”
The rationale was (and still is) that the analyst’s expressions of thought and feeling would make him or her a real person instead of a vague figure and thereby interfere with the patient’s transference—projection onto the therapist of an important figure from the patient’s childhood. Such transference was, as it remains for many analytic practitioners, an essential mechanism in the curative process. But even the most rigid analyst had to communicate now and then. Psychoanalytic training stressed that changes were produced by making the unconscious conscious through free association and through three processes requiring the analyst to speak (though not about his or her personal feelings): the interpretations of dreams, of transference, and of resistance.26
But though analysts did talk from time to time, many patients were aware chiefly of their silences and refusals to answer questions, and were infuriated—but unable to break away. One analyst wrote of treating an attractive young woman “who bawls me out unmercifully almost every hour, calling me immature, a quack, cold, a sex maniac, and so on, yet at the end of the hour she gives me a deep, longing look and says softly, ‘See you next time.’ ”27 In The International Journal of Psycho-Analysis another reported the following diatribe (here somewhat abridged) of a patient on one of her bad days:
I’m fed up. A whole year I’ve been at this—a mixed-up, miserable, wasted year. And for what? Nothing. Not a goddam thing. One of these days I’m going to find the guts to walk out on you and not come back. Why should I come back? You do nothing for me, nothing. Year after year, you just listen. How many years do you want? Who the hell do you think you are? How can you do it?—changing no one, curing no one, raking in the money and spending your weekends in Bermuda, too gutless to admit that you’re selling false merchandise. There’s more humanity in my garbageman than in you.28
Occasionally an analyst might even let a patient who was unable to voice his or her thoughts lie silent on the couch for the whole hour, or even a number of hours, without trying to help the patient break through—yet would charge for the time spent. Hu
morists and satirists made this seem a common occurrence, although it was actually very rare. Apart from a sense of obligation to help the patient, most analysts would have found such hours of silence unendurable.
What were they like, these formidable authorities who could exert such power over their patients while remaining aloof and seemingly uncaring? Some, outside their clinical hours, played a role that they gradually came to believe was their real self: wise, philosophic, penetrating of gaze, given to ruminative silences, formal, witty, fiercely competitive, and easily wounded—in short, as much like Freud as possible.29 But in truth they were no more all of a piece than are physicists, violinists, or plumbers. Psychoanalysts came (and still come) in all models, ranging from the glacial to the warm, from the austere to the amiable, from the strong to the weak. Nonetheless, some qualified observers were able to make a few generalizations about them. Arthur Burton, a lay analyst who edited a volume of short autobiographies by analysts, said that many of them feel special and lonely, are wise rabbinical teachers (even the non-Jews among them), possess certain so-called feminine qualities (“mothering,” intuition, sensitivity, emotionality), and tend to be both agnostic and liberal.30
A very different picture was painted by the author and educator Martin Gross in a vitriolic assault in The Psychological Society (1978). He portrayed psychoanalysts as aloof, money-grubbing, arrogant, addicted to oneupmanship, brainwashers of their patients, exaggerators of their results, and either self-deluded believers or self-aware charlatans. There might have been a modicum of truth in his charges, but by and large nonpartisan surveys and studies of psychoanalysts portrayed them far more positively.31 By the 1950s, moreover, many of them were shifting toward ego analysis, adopting some of the neo-Freudian emphasis on realistic interaction with their patients, and dealing actively not only with the patient’s unconscious and the past but also with his or her conscious processes and present problems.