Articles by David H Jacobs Ph.D

Most Psychotherapy Is Long Hard Work

Perhaps psychotherapy is misleadingly named. What does ‘therapy’ bring to mind? Everyone understands that psychotherapy means treatment. Everyone is familiar with medical treatment and dental treatment. The role of the patient in medical and dental treatment is to bring your body to the treatment site and endure what they do to you. Or take your medication as directed. Either way, you contribute little as an active participant. The success of treatment does not depend on you actively participating. By ‘you’ I mean you the person, not you the body that is being treated. A few years ago I had a hernia operation. Some kind of mesh was used. I have only the vaguest idea what was done. Nevertheless, the operation was a success.

Psychotherapy is fundamentally different. If you want to benefit, you must engage in very serious, difficult, uncomfortable, revealing talk. Obviously there is a (seemingly) wide selection of psychiatric medications available today, but being tranquilized or energized by drugs is not going to help you feel better about you or make your relationships more satisfying to you or give you a feeling of purpose in life, etc. You don’t know if or how psychotherapy might help you with such things, but here you are.

A lot of people quit psychotherapy soon after they begin. It’s demanding and it’s not at all clear that it will deliver what you want. A lot of people tell themselves once they begin that their problem is not that bad and they can make more of an effort to handle whatever it is on their own. In most cases I doubt they will be able to do that because in general people are already doing the best they can on their own to cope with or resolve their personal difficulties. A surge of determination to try harder based on discovering that therapy is demanding will probably not alter anything in an enduring fashion.

It seems it’s an unpleasant shock for some if not many people who begin therapy to discover via talking that their problems have deep roots and is not likely to resolve quickly. I’m talking about first time clients. People who have been in therapy before are more inclined to realize based on life experience that a surge of determination or minimization will not carry them very far. The current crisis may subside in the short run without any real resolution, but precisely because nothing has been resolved some variant of the present problem is likely to return. Wherever you go there you are.

It’s also dismaying to discover through talking that the problem you came in with is amorphous and has tentacles in many areas. Maybe you came in because your wife discovered you are watching porn, but after a while you find yourself talking about your inflexible need to be right and how that has affected your marriage. As you talk about your need to be right you realize it’s not discretionary, that is you just can’t drop it at will. It has deep roots and you’re pretty hazy about why you need to be right all the time. That’s not why you came in. Anyway the crisis is subsiding because you are not currently watching porn so you just stop going to therapy. It’s uncomfortable and seemingly without immediate benefit to talk about such personal matters. You leave therapy, but that doesn’t mean your marriage is all that satisfying to you or your wife. The kids are upset and frightened by the atmosphere in the home, too. When they start having problems you are relieved to hear that their problems have nothing to do with their home life and that medication is available (for bipolar disorder, or ADHD, or both and more).

It’s bad: the problem is amorphous and deep, and you have to search and bare your soul to make therapy more than a useless exercise. And the time frame is ambiguous. And there is no guarantee of success. And the expense. Can I go now?

In the main, people don’t die if they leave therapy prematurely. There seems to be no immediate penalty. The penalty is that no important change in the person has occurred. The penalty reveals itself over time in the form of persistence of personal problems and their consequences for quality of life. You can be a success in your profession and have an unsatisfying, conflictual marriage, for example. This won’t necessarily kill you, but you only get one life. And then of course there are the kids’¦

I don’t think the psychotherapy industry tries to convey the message that modifying personality or at least aspects of personality is really difficult and drawn-out. It’s a public relations nightmare, if you think about it. The public relations message is always that it’s effective and good for you. It’s a dirty deal that it’s so difficult and drawn-out because after all it’s not your fault. You didn’t select the circumstances under which you developed as a personality. None the less, if you don’t make the effort to find a simpatico therapist and stay the course you are stuck with you as you are, and that’s the you that has already had a lot of misery and trouble. This is frank talk. Most therapists are simply silent on the matter. I suppose they don’t want to sound discouraging, but the price is that a lot of people leave therapy quickly when they start to discover that the therapist has no quick and painless fix up his sleeve.

Why is changing so difficult? What we are really talking about is how hard it is to change adaptations to and consequences of maltreatment during the course of growing up. People who have a secure sense of self-worth based on positive treatment growing up don’t have to worry about trying to change something basic about themselves (for example). But people who have acquired a negative view/feeling about themselves based on maltreatment growing up are in the position of having to try to alter something basic about themselves in order to live without the burden of their legacy. It isn’t at all easy.

To get a sense why, try to think about how natural it is for you to maneuver in your home culture and how difficult it would be to learn to feel at home and act by second nature in a new culture and language. You absorb the mores, rules, conventions, beliefs, etc. of your home culture growing up. There is a certain amount of explicit instruction, but more importantly you learn by being present and participating on a daily basis. You can walk through a crowded mall without constantly colliding with people because you know and can react to the tacit norms, rules, cues, signals, etc. that people use to guide themselves in such a situation. You know them all because you grew up in circumstances where they apply and were practiced. You didn’t take a class in school that instructed you how to walk through a crowded mall without colliding with people. You absorb such knowledge and skill. Little by way of explicit instruction is involved or necessary or would be useful. You have to get the feel of it to get the hang of it.

Similarly, a great deal of how you feel, think, etc. about yourself and other people is derived from how you lived and how you were treated growing up. You absorbed the meaning, import, significance, etc. of how you were treated without reflection, judgment, criticism, and so on. Children are not in a position to think critically and skeptically about how they are being treated by the most important people in their lives. The just absorb how they are treated as definitive regarding self-worth and so on. They also react to anxiety and other bad feeling by adopting methods to reduce anxiety and other bad feelings’”again, without deliberation or choice as a rule. Such methods are tenacious precisely because they operate to reduce anxiety in the moment. In the long run such methods may do more harm than good, but by then they are so ingrained, so second nature that they are devilishly hard to alter because trying to do anything else raises anxiety’”thus the insanity of doing the same thing that produces bad results over and over.

You tell yourself not to be so anxious or whatever else but you are anyway. So much for self-instruction and taking your own advice. To a certain extent disclosing, venting, and social support is helpful. I think practically every one has experienced this at one time or another. Feeling that the therapist is a supportive, empathic ally can be strengthening. It often is strengthening knowing someone is in your corner. But enduring alteration, the kind of alteration you can rely on to operate when you need it to operate (in vivo and in situ, when you are on your own), takes a lot of time and work. Work you can’t do on your own because on your own you are just talking to yourself, whereas changing who and how you are requires taking in supplies from the outside. You can’t really either create or recreate yourself; you need assistance/input from the outside. You may dislike this, but that’s how it is anyway.

So there it is: therapy will probably be difficult and take a long time. I’m reminded of Churchill’s speech to the population of the UK as war with Germany began. He said he had nothing to offer but blood, sweat, and tears. Not an attractive proposition, but his audience understood the alternative.

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