It’s the end of psychotherapy as we knew it (and I feel fine?)

For the last 30 years I’ve been in many types of therapy, and this has made me a witness to how dramatically the process of therapy has changed over these years. While many of the changes have been for the better, others not so much.

Years ago, therapy took much too long and there was no clear evidence of how (or if) it worked. Patients were encouraged to blindly trust that talking about whatever came to mind multiple days per week for years would eventually help them. And therapists were trained to resist jumping in to the conversation with information, direction, or even human responses. The lack of human response was itself distressing to many patients, and having to invest in a lengthy, unproven process wasn’t in the best interest of anyone. So clearly something had be done to relieve suffering faster, and to scientifically determine what can make therapy helpful or not.

Today, for those able to locate well-trained specialists, there are efficient therapies being developed and scientifically tested for nearly every type of psychological problem. Many of these specialized treatments represent tremendous strides, and the importance of this is not to be underestimated. But my own view is that these changes have been accompanied by a deterioration in services for the average patient seeking help from the average practitioner, and I’m concerned for the future of the profession.

Here are the general trends I’ve noticed:

1.The need to carefully listen to patients has been replaced with a readiness to jump in with handouts and unsolicited advice. I’m not advocating a return to the silent psychoanalyst, or the client-centered therapist who only repeats back what the patient just said. But if the therapist is talking at the patient much more than he/she is listening, something is out of whack.

While my experiences in individual psychotherapy have generally followed this trend, nowhere was it more pronounced than in the changes I witnessed in inpatient treatment. Twenty-five years ago, my stay on an inpatient psych unit centrally involved talking to people (doctors, therapists, interns, nurses, and other staff). Our group therapy sessions also involved a lot of talking and exchanges of ideas among the patients. By contrast, when I stayed on two inpatient units more recently, it was absolutely no one’s job to talk with me or listen to me. When in a moment of despair I asked someone on the staff if I could talk to her, she spent the whole “conversation” asking me what the point of it was, rolling her eyes and tapping her pencil on her pad. Even the required group sessions involved having the patients take turns reading out loud from pamphlets on topics that often had no particular relevance to anyone in the group. Being listened to was just missing from the entire experience.

2. Many therapists seem to have stopped considering it necessary to be careful about what they say or do in therapy, as if their actions no longer have the potential to be harmful or a waste of patients’ time and money. Whereas perhaps old-fashioned therapists were paralyzed by overthinking everything, and considering some aspects of the therapeutic process (such as transference) much more fragile than they really are, many of today’s therapists are just saying and doing things without appropriate thought to the potential meaning or consequences of their behaviors.  Gently recommending well-chosen books seems OK, and that’s not really what I’m talking about. But one therapist told me with a sense of authority that I really ought to quit the job that I had spent five years writing a grant just to get. Another therapist brought out a dead butterfly for me to touch — and when I asked her why she said she had no real reason, it was just a spontaneous idea and no big deal (at least not to her). Crap like this makes me almost miss the days when therapists exercised the self-restraint to say little but “uh-huh”.

3. Therapists no longer feel committed to continuously working on their own issues. Seeking their own therapy and extra supervision used to be considered a necessary part of a therapist’s training and later professional growth. In today’s culture, by contrast, being a therapist no longer requires getting any therapy of one’s own, and two or more years of training is often considered sufficient expertise, period. Obviously there have always been bad therapists, and there always will be bad therapists — but what I think is new is that the professional expectations for therapists no longer emphasize modest and careful attention to the personal flaws that can influence their work.

So why not just use apps instead?  Ultimately, by not listening to patients’ individual needs in the moment, many of today’s therapists are making themselves entirely replaceable by smartphone apps. Clearly, smartphone apps could be a valuable adjunct to a caring therapist. But with so many therapists interacting with patients in ways that range from robotic to sloppy to just plain insensitive, I don’t see much motivation for the average patient to bother with a human therapist at all. I guess the larger question is whether the rejection of therapists in favor of smartphone apps would be a detriment or benefit for patient care over the next decade or two, and we’ll have to wait to find out. Smartphone apps, at least, are not expected to have self-awareness or the ability to listen and respond with compassion.

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