Good Therapy: Answering Abigail Shrier
The psychotherapy profession has become dominated by a series of bad ideas. But some of us can still help people.
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This address was presented at the Therapy First Retreat in Pennsylvania on June 18, 2024.
At the beginning of our second session, I asked “Doug” if he’d had any thoughts or reactions during the week since our first meeting.
“I don’t really have much to say,” he answered. “I’m probably wasting your time.”
Sometimes psychotherapy clients will open a door into their psyche with very few words. Doug felt isolated and unimportant, it seemed obvious. He probably thought no one would take a genuine interest in him or his experience. As background: he’d reached out to me after reading one of my articles on autogynephilia and saw aspects of himself in my description. He was in his mid-20s and had never had a sexual partner or any kind of romantic relationship. He’d never come close.
At the beginning of our third session, I asked him to tell me about his week. He said: “There’s not much to say. It was pretty uneventful.” On a hunch, I said: “Even if not much happened on the outside, it might have been an eventful week inside of you.” Doug talked almost non-stop during the rest of the session. It doesn’t really matter about what. Let’s just say it had indeed been an eventful week.
It was during our next session, number four, that I realized how endearing I found Doug. I took note of my own feeling about him. And at the beginning of our fifth session, he seemed unusually energetic, greeting me with a small smile. “I have a lot to talk about,” he said. “I’ve made a list.”
I’ve been a therapist for over four decades and I still love my work. I still feel moved whenever I can forge a connection with someone like Doug. Over the years as I’ve grown less wedded to theory and more confident in my own perspective. I’ve come to believe that this kind of genuine connection (even more than accurate insights and interpretations) promotes the lion’s share of the growth and healing that can occur in a psychotherapy relationship.
Helping someone like Doug to feel less alone in the world also helps me to feel less alone. I thrive on intimacy, and a strong interpersonal connection between client and therapist can be very intimate, even if I’m not revealing details about myself during session. I’m intensely present in the moment with another person, bringing the sum of all my life experiences to every session, my ways of thinking and feeling, my understanding of human nature. Sometimes I feel that I’m more myself as a therapist with my clients than I am with anyone except my closest friends and family.
I spent many years myself in analysis, and though it ended more than 30 years ago, I still consider it to have been one of the most important relationships of my lifetime. I felt him to be fully present, every time, listening carefully to what I said as he tried to understand me. I’m grateful for the chance I had to spend so much time in contact with his considerable intellect and personal warmth. In no small way, I’m the person I am today because of who he was with me for so many years.
Though it took place five decades ago, I still recall important details about our first session. I was telling him about the almost paranoid discomfort I felt around most people, imagining that they secretly held me in contempt. He said, “I wonder if that’s going on right now—that you imagine I’m thinking bad thoughts about you.” I acknowledged that it was true. And so began the unfolding of the transference.
Most people think of transference as a distortion, as a misapprehension of the therapist as if she or he were a stand-in for some significant person from the client’s past—mom or dad, usually. Even many therapists think of it that way. This version is usually referred to as transference in the “narrow sense,” and the same description can be applied to the therapist’s countertransference.
In the “broad sense,” however, transference and counter-transference refer to the projections and introjections going on between client and therapist, a kind of beneath-the-surface communication available to be understood and used by the therapist for insight. In Session Two, when Doug said he thought he was probably wasting my time, he had recreated in our fledgling relationship his experience of himself as alone and irrelevant to everyone in his world. That’s transference in the broad sense; it wasn’t a distortion, but rather a kind of communication, and it helped me to understand him.
Nowadays, I also believe that I have a psychological and emotional relationship with my clients that’s real and often healing in itself, beyond the insights I offer or the interpretations I make. I feel lucky when a client comes to me for therapy and understands it’s a relationship that’s on offer, even if they don’t know it at first, even though it weirdly involves a payment for services rendered. They agree to let me care for and about them, trusting that I’ll do my best to understand things about them that they can’t see. I believe that’s the bedrock of good and effective therapy, at least for therapists like me who practice from a psychodynamic perspective.
Which brings me to Abigail Shrier and her recent book Bad Therapy.
It’s odd to criticize an author whose views I mostly endorse, at least when it comes to the disastrous effects of pseudo-therapeutic approaches infecting schools and parenting styles. I even agree with much of her criticism directed at the practice of psychotherapy itself. But Shrier paints with too broad a brush, one dipped in contemptuous ink, and her brief disclaimer noting that psychotherapy may be indicated and helpful in some cases doesn’t mitigate the harsh message. The naive reader comes away believing that all therapy is bad therapy.
But as I said, I do agree with much of Shrier’s criticism. I believe the psychotherapy profession has come to be dominated by a series of bad ideas I’d like to mention briefly before going on to discuss what’s truly good about the work we do.
Let’s start with the medicalization of mental health and bogus theories arguing that mental illness results from an imbalance in brain chemistry, a commonly held belief for which there is precisely zero evidence. And then there’s the increasing focus on mental health issues as discrete disease categories akin to those listed in the ICD-10. With all these diagnostic codes in the DSM, it’s natural to assume that these are discrete and well-understood disorders. That belief too is wrong.
Complex Post-Traumatic Stress Disorder (CPTSD) is a popular diagnosis on social media and with my younger clients. The framing of virtually everything as trauma is widespread these days, and I agree with Abigail Shrier that it has had some bad effects: as she points out, designating every painful experience as a trauma encourages us to over-emphasize our painful emotions and to view ourselves as victims of harmful events in life. When promoted by poorly trained therapists, it can encourage a sense of helplessness rather than promoting resilience. But these days, designating treatment as “trauma-informed therapy” gives it an aura of legitimacy, much like calling manualized forms of treatment “evidence based.”
There’s another bad idea dominating psychotherapy I’d like to mention. In general, professional training institutions currently shape future therapists into social justice warriors; for this new generation of therapists, helping clients in psychotherapy means teaching them to identify their place in the oppression hierarchy and encouraging them to stand up for their rights. Such a view is inimical to growth because it eliminates any sense of personal agency or responsibility by putting the locus of control outside the self. It encourages splitting, projection, and other defense mechanisms that make an accurate perception of truth impossible. This practice has nothing to do with psychotherapy as I understand it and completely ignores the basic truths about human nature we’ve garnered over the centuries.
And finally, of course, there’s “gender-affirming care.” I can state quite confidently that gender-affirming care is not psychotherapy. Based on an unevidenced belief in the concept of an innate “gender identity,” this approach is entirely incurious and doctrinaire. With one bald assertion, it halts exploration of the client’s understanding of herself and ignores everything we’ve learned about identity development from Erikson, Kohlberg, Vygotsky, Piaget and other theorists.
In short, our profession has become dominated by a set of very bad ideas that have corrupted it. This retreat is part of Therapy First’s ongoing effort to preserve and share our understanding of what good therapy actually means.
So what is it?
Many of you will have heard first-hand or watched the recording of Steve Levine’s address at Genspect’s conference in Denver last year. If you haven’t, I urge you to watch it. “Here’s my ideal conception of what a psychotherapist should be,” Steve says. You need to hear him saying these words slowly, with a brief pause between each one of them. “Warm, interested, respectful, evidently kind, reliably present (not on vacation every month), patient, and–shocking to my residents in psychiatry–conversational.”
I believe Steve lays emphasis on this word conversational because he understands that the psychotherapeutic relationship takes place between two human beings and transcends their roles as client and therapist. I imagine his residents in psychiatry are shocked when he gives this advice because they no doubt believe they should retain a professional demeanor with their patients, as they’ve been trained to do in other rotations during their medical education. Perhaps they view the client as the one suffering from an illness and their own role as curing it. But Steve instead advises his residents to be real.
I have a memory from my earliest training that still brings a twinge of guilt whenever I remember it. I’d worked with a 17-year-old girl for about nine months before she went off to college. We’d ended with the assumption that she was permanently leaving town; but some months later, after she dropped out of college and returned to her parents’ home, she wanted to resume our work together. On the day I went out to greet her for the first time, somewhat doctrinaire intern that I was, I kept my face “professionally” neutral as I opened the door. She was deeply upset by my unfeeling demeanor and wept about it in session. I call that bad therapy. I will add that we did recover, that I learned something, and we went on working together for years.
So, first and foremost, good therapy is a warm and genuine relationship between two people. Lisa Marchiano and I lead a monthly supervision group through Therapy First, and I observe this connection with every case presented by the therapists in our group. I always privately note, and will sometimes say it aloud, that the clients come alive in these presentations in large part because of the unspoken affection their therapists feel for them. I said earlier that I find Doug endearing. It’s the word I most often use to describe how I feel about my long-term patients. That is, I am fond of them.
Warm is the first word Steve uses in his list of ideal attributes for a therapist; interested is the second. It seems obvious that a therapist needs to take an interest in his client to be effective, but let’s not gloss over it. And let’s not underestimate how powerful it can be for a client (that is, for another human being) to find that someone else is genuinely, deeply curious about who he is. With Doug, I think my taking a warm interest in him made all the difference. It’s how we got started and how we “bonded.”
Throughout my decades of practice, people have usually assumed that I became a therapist because I wanted to help people. Not true as it turns out, though I’m very glad to be of help. I decided to become a therapist because I saw it as the only line of work that could hold my interest for a lifetime. I think a good therapist needs to be deeply curious. You must want to understand what makes people tick, even those regarded by most other people as pariahs. I think it helps if you’re a lifelong learner, too—the sort of person who always wants to be discovering something new. One of the more discouraging aspects of gender-affirming care is that it forbids curiosity. A child knows his or her gender identity, we are told. End of inquiry. Nothing more to be learned.
When I first started working with gender-distressed teens, driven by the desire to save other families from what had happened to my own, I felt an urgent need to “rescue” them. I learned soon enough that I couldn’t rescue anybody and eventually fell back on my usual stance. Bion famously said we should approach each session without memory and desire—that means without an agenda, especially when working with this cohort. Warm connection, genuine curiosity and open-mindedness make for good therapy.
Here’s something interesting I’ve recently learned by asking my clients a lot of questions. Boys on the spectrum who grew up struggling to identify their own feelings often find that estrogen cracks open their emotional lives. They have a greater range of emotions and an easier time getting in touch with them. You won’t read about this in studies describing all the harms associated with cross-sex hormones. Also: boys who felt afraid of and disgusted by their own sexual impulses often find immense relief from taking androgen blockers. They feel less self-hatred and find it easier to function in many respects without the intense pressure of their sex drive.
I’m not saying I support the administration of blockers or hormones. I’m saying that I now have a different understanding of what “detransition” might mean to my clients from how I used to see it. Once I would have called trans-identification a kind of delusion and characterized detransition as facing up to the truth. I suppose I still do, but I also understand that detransition involves a loss of something valuable to some young men, and for others, it means leaving behind a place of relative calm and self-acceptance, however growth-inhibiting that calm might have been.
Understanding what these medications mean to my clients, despite my private concerns about them, helps me to articulate a storyline, you might say. I use that word because I think a large part of what we do in good therapy is co-create with our clients a narrative about their past that accounts for who they are today. Articulating such a narrative makes them feel seen and helps them make sense of themselves. In 2012 when I was actively writing my blog After Psychotherapy, I put up a post called Bearing Witness and Being Seen. It’s always a relief to read something you wrote long ago without feeling embarrassed by it. I still believe what I said back then:
Human beings are social animals: part of our sense of self comes from our relation to other humans—being seen, acknowledged and validated by other members of our pack or tribe. To an important degree, this is what it means for life to have meaning. I have a number of clients who live extremely isolated lives; they’re deeply pained because they feel they don’t matter to anyone, that they’re invisible and that it wouldn’t matter if they were to disappear. It isn’t just that they feel lonely and long for emotional contact with others; without anyone to bear witness to their lives, they have trouble maintaining a sense of their own personal worth and the meaning of their existence.
At the outset of a recent session, Doug told me that he’d at last confided his struggles with autogynephilia to a colleague he thought might be becoming a friend. This young man said he was glad Doug had let him know because he’d noticed that something seemed to have been “off” with him lately. He’d felt certain Doug was struggling though he didn’t know why. Doug was shocked that anyone had observed him so closely, and the fact that this friend had noticed his suffering moved him deeply. In the beginning of our work together, Doug struck me as withdrawn and emotionally shut down; he seems to be coming to life now, in part as a result of being seen and understood within our relationship. We still have a long way yet to go and I imagine we’ll be working together for many months if not years.
Shrier makes some cynical remarks about therapists who supposedly consider a regular client with a weekly slot to be a reliable source of income and who will therefore encourage dependency. Even some well-known therapists with names you would recognize have spoken disapprovingly of any course of treatment lasting longer than 15-20 sessions. I typically see clients for years and I feel no embarrassment about it. I suppose if you’re offering manualized therapy, the work comes to a natural conclusion after a few months because you’ve exhausted your toolkit. Not so if you’re building a relationship that develops over time, with insights emerging slowly as that relationship evolves.
From everything I’ve said so far, it might sound like I think good therapy provides the “corrective emotional experience” first described by Franz Alexander. I don’t, because even good therapy can’t completely undo the effects of a deficient or damaging childhood. During my 30s, I used to view myself as part of the enlightened elect because I’d had a lengthy and successful analysis; as I learned the hard way during my 40s, even good therapy only takes you so far. I’m still the same person I ever was, but with enough earned insight to observe myself in action and say, “There you are, doing again what you always tend to do.” Usually (but not always) I have a choice to behave differently, to wait for the storm of emotion to pass, to accept shame rather than react defensively. But I’m not the same as someone reared by a woman who actually loved being a mother. Good therapy is only second best to having had a happy childhood.
So when does a successful course of therapy come to an end?
I usually say to my clients what my analyst often said to me years ago. “This therapy ends when you decide it’s no longer worth the considerable time and expense for what you’re getting out of it.” I also say, as did he, “This therapy ends when you feel you can carry on the work alone without me.” And by “the work” I mean what my teacher and supervisor Don Marcus once said years ago: the goal of psychotherapy is to help our clients to feel deeply and think clearly. That is, to recognize and tolerate the full extent of their feelings without being overwhelmed by them, and to go on thinking in the presence of emotions that are often intensely painful.
In my view, that’s what therapy at its best can do for you.
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I've had good therapy and bad therapy. Good therapy ends on such a positive note. Bad therapy had me wondering if there was something so wrong with me, I couldn't be helped. Our gender confused daughter had 6 months of horrible gender affirming therapy that worsened her mental health. With good therapy for 4 years now, which has vastly improved her emotional well being, and which we know will one day serve her so well that she won't need it anymore, I'm confident that she will be in a better place. And I'm grateful for the "good" therapist!
Ok, so suppose there a still a few "good therapists" out there. How would a potential patient tell whether the therapist he was considering was one of the good ones? How would he be able to find one of these good therapists from among the sea of bad ones?