One of the annoying verbal tics present among a certain subpopulation of Americans is an insistence that "everyone needs therapy". This has always struck me as bizarre and probably pushed me too far away from viewing therapy as useful for some people in some circumstances. This book is a useful corrective to that overreaction. I first became familiar with the author from reading his novel The Schopenhauer Cure. I liked that book well enough so I looked up what else he'd written and came across this book, a memoir of ten case studies from his therapeutic practice. Below are some of my highlights.
One experiences interpersonal isolation, or loneliness, if one lacks the social skills or personality style that permit intimate social interactions.
On meaning (similar to Viktor Frankl's conclusions in Man's Search for Meaning)
The search for meaning, much like the search for pleasure, must be conducted obliquely. Meaning ensues from meaningful activity: the more we deliberately pursue it, the less likely we are to find it; the rational questions one can pose about meaning will always outlast the answers. In therapy, as in life, meaningfulness is a by-product of engagement and commitment, and that is where therapists must direct their efforts—not that engagement provides the rational answer to questions of meaning, but it causes these questions not to matter.
On therapists who have sex with their patients
First, there was Matthew. He infuriated me. I’ve seen too many patients badly damaged by therapists using them sexually. It’s always damaging to a patient.
[…] While plenty of patients may need sexual affirmation—those who are markedly unattractive, extremely obese, surgically disfigured—I have yet to hear of a therapist affirming one of them sexually. It’s always the attractive woman who gets chosen for affirmation. It is, of course, the offending therapists who are in need of sexual affirmation and lack the resources or resourcefulness to obtain it in their own personal lives.
On therapists' autobiographies
Nietzsche claimed that a philosopher’s system of thought always arises from his autobiography, and I believe that to be true for all therapists—in fact, for anyone who thinks about thought.
Emotions trump reason (or facts are worthless without feelings)
From the beginning, of course, I had know that the pure forcefulness of my argument would not penetrate deep enough to effect any change. It almost never does. It’s never worked for me when I’ve been in therapy. Only when one feels an insight in one’s bones does one own it. Only then can one act on it and change. Pop psychologists forever talk about “responsibility assumption,” but it’s all words: it is extraordinarily hard, even terrifying, to own the insight that you and only you construct your own life design. Thus, the problem in therapy is always how to move from an ineffectual appreciation of a truth about oneself to some emotional experience of it. It is only when therapy enlists deep emotions that it becomes a powerful force for change.
The uses and limitations of ideologies
If they are helpful to patients at all, ideological schools with their complex metaphysical edifices succeed because they assuage the therapist’s, not the patient’s, anxiety (and thus permit the therapist to face the anxiety of the therapeutic process). The more the therapist is able to tolerate the anxiety of not knowing, the less need there is for the therapist to embrace orthodoxy. The creative members of an orthodoxy, any orthodoxy, ultimately outgrow their disciplines.
Group therapy creates a miniature social world
I continued, “And that one of the most important principles of groups is that the group is a miniature world—whatever environment we create in the group reflects the way we have chosen to live? Remember that I said that each of us establishes in the group the same kind of social world we have in our real life?”
On not undermining functional beliefs unless you have a better alternative
In the past I hadn’t tampered with his [death] denial. In general, it’s best not to undermine a defense unless it is creating more problems than solutions, and unless one has something better to offer in its stead. Reincarnation is a case in point: though I personally consider it a form of death denial, the belief served Carlos (as it does much of the world’s population) very well; in fact, rather than undermine it, I had always supported it and in this session buttressed it by urging that he be consistent in heeding all the implications of reincarnation.
What fear of death reveals
From both my personal and my professional experience, I had come to believe that the fear of death is always greatest in those who feel that they have not lived their life fully. A good working formula is: the more unlived life, or unrealized potential, the greater one’s death anxiety.
What he views as "good therapy"
To my mind, “good” therapy (which I equate with deep, or penetrating, therapy, not with efficient or even, I am pained to say, helpful therapy) conducted with a “good” patient is at bottom a truth-seeking venture. My quarry when I was a novitiate was the truth of the past, to trace all of a life’s coordinates and, thereby, to locate and to explain a person’s current life, pathology, motivation, and actions.
I used to be so sure. What arrogance! And now what kind of truth was I stalking? I think my quarry is an illusion. I war against magic. I believe that, though illusion often cheers and comforts, it ultimately and invariably weakens and constricts the spirit.
But there is timing and judgement. Never take away anything if you have nothing better to offer. Beware of stripping a patient who can’t bear the chill of reality. And don’t exhaust yourself by jousting with religious magic: you’re not match for it. The thirst for religion is too strong, its roots too deep, its cultural reinforcement too powerful.
She hated what was happening, and she hated Dr. Z., but my every suggestion was met by “but” or “yes, but.” She was a “yes, but-er” (also referred to in the trade a “help-rejecting complainer”) of considerable prowess.
Enforced busyness is often the friend of the bereaved and Elmer [N.B. the patient's dog] provided blessed distraction in the early stages of mourning. (In our culture the busyness may be supplied by the funeral arrangements and the paperwork of medical insurance and estate settlement.)
The misuse of archeological therapy
When I first began to work as a therapist, I naively believed that the past was fixed and knowable; that if I were perspicacious enough, I could discover that first false turn, that fateful trail that has led to a life gone wrong; and that I could act on this discovery to set things right again. In those days I would have deepened Marge’s hypnotic state, regressed her in age, asked her to explore early traumas—for example, her father’s sexual abuse—and urged her to experience and discharge all the attendant feelings, the fear, the arousal, the rage, the betrayal.
But over the years I’ve learned that the therapist’s venture is not to engage the patient in a joint archeological dig. If any patients have ever been helped in this fashion, it wasn’t because the search and the finding of that false trail (a life never goes wrong because of a false trail; it goes wrong because the main trail is false). No, a therapist helps a patient not by sifting through the past but by being lovingly present with that person; by being trustworthy, interested; and by believing that their joint activity will ultimately be redemptive and healing. The drama of age regression and incest recapitulation (or, for that matter, any therapeutic cathartic or intellectual project) is healing only because it provides therapist and patient with some interesting shared activity while the real therapeutic force—the relationship—is ripening on the tree.
Damaged people can't fix themselves by getting in a relationship
People who feel empty never heal by merging with another incomplete person. On the contrary, two broken-winged birds coupled into one make for clumsy flight. No amount of patience will help it fly; and, ultimately, each must be pried from the other, and wounds separately splinted.
Events can be emotionally significant even if they don't seem that way
I finally learned that six months ago Marvin had made the decision to retire and sell his accountancy firm. The information emerged slowly, not because he was unwilling to tell me about retirement, but because he attached little importance to the event.
I felt otherwise. The markers of one’s life stages are always significant, and few markers more so than retirement. How is it possible for retirement not to evoke deep feelings about the passage and passing of life, about the meaning and significance of one’s entire life project? For those who look inward, retirement is a time of life review, of summing up, a time of proliferating awareness of finitude and approaching death.
I believed that Marvin was entirely wrong when he said that sex was at the root of his problems; far from it, sex was just an ineffective means of trying to drain off surges of anxiety springing from more fundamental sources. Sometimes, as Freud first showed us, sexually inspired anxiety is expressed through other devious means. Perhaps just as often the opposite is true: other anxiety masquerades as sexual anxiety.
When investigating sexual problems it is always important to ask, Are there more than two people present during lovemaking? The presence of others—phantoms of parents, rivals, other lovers—vastly complicates the sexual act.
Against this dread, he lacked even the most common defenses: childless, he could not be comforted by the illusion of immortal germ cells; he had no sustaining religious belief—neither of a consciousness-preserving afterlife nor of an omnipresent, protective personal deity; nor did he have the satisfaction of knowing that he realized himself in life. (As a general rule, the less one’s sense of life fulfillment, the greater one’s death anxiety. ) Worst of all, Marvin could foresee no end to his anxiety.
So Marvin and I had reached a crucial point, a juncture to which full awareness inevitably leads. It is the time when one stands before the abyss and decides how to face the pitiless existential facts of life: death, isolation, groundlessness, and meaninglessness. Of course, there are no solutions. One has a choice only of certain stances: to be “resolute,” or “engaged,” or courageously defiant, or stoically accepting, or to relinquish rationality and, in awe and mystery, place one’s trust in the providence of the Divine.
Therapy often conflicts with marriage
I remember thinking how fortunate it was that Marvin’s change had spurred Phyllis to change. Often therapy doesn’t work that way. In fact, not uncommonly therapy places strain on a marriage: if a patient changes and the spouse stays locked in the same position, the the dynamic equilibrium of the marriage often disintegrates. The patient has either to forego growth or to grow and jeopardize the union.
I've always been interested in the habits of high-performers. This seems like a good way to improve and learn what works and doesn't work.
I always schedule patients for a one-year follow-up session—both for their benefit and for my own edification. I also make it a practice to play for the patient a tape recording of part of our initial session.