Dr. Stanley Goldstein - Author and Psychologist

The greatest danger of poor psychotherapy is not its waste of time and money but rather that the process becomes distrusted by the patient. Conducting psychotherapy may be one of the most complex of jobs since it involves interaction between the conscious and unconscious minds of two people, this causing inevitable errors. The antidote for this is self-awareness by the therapist, their good training, and honesty. But no therapy is perfect, an eminent British psychoanalyst, Michael Balint, wrote long ago in a paper posthumously published by his wife, that having been treated by the most eminent British analysts he gained a little understanding of his life from each.
If a therapist is excessively narcissistic and the patient feels inadequate they may become tied to their therapist, unable to leave and gain more competent treatment. This is the greatest danger of inadequate treatment: that the patient henceforth avoids it, no longer trusting the process because of their earlier destructive experience. 

I recently watched Netflix documentaries on the investigation of cold case murders in Los Angeles and New York City. in one, two teenagers from affluent families were convicted of murdering a middle-age man in Manhattan's Central Park, they later receiving the shockingly brief prison sentence of six years and serving half before being paroled. Thereafter, the girl was returned to prison to serve out her remaining sentence after she assaulted a fellow-parolee in their half-way residence while the boy remained out of trouble. No motive was ever established for the boy's vicious knife attack and the girl's complicity except rage.

While both their families had been caring, the girl had been adopted, which is a risk factor if the child is past infancy when adopted, and the boy had been a loner and shy. She had been in numerous drug treatment programs and both attended excellent schools. This raising the issue of whether, even given the best of treatment, their lives would have been different.

Change through therapy depends on the depth of psychological problems, the talent of therapy provided and its length. Luck too is a factor: had the youths not been drinking in Central Park that evening the murder might never have occurred. Which is why therapy is best provided in early childhood, before the stresses of adolescence and adulthood are encountered and lives are wasted.

Movies have not often portrayed psychotherapy accurately, usually including fanciful mysteries, murder, or romance between doctor and patient which, though rare, is illegal outside film. I recently watched the classic (1962) "David and Lisa," and was struck by its accurate depiction of the psychotherapy of the severer adolescent disorders. The doctor was empathic, understanding, and accepting while the patients were driven by unconscious impulses deriving from long-term parenting mistakes done unknowingly.
What was clear in the film was that the unconscious is powerful and personality change is not easy or quickly done.

While the film's acting and script were superb, my unexpected deep emotional involvement with it likely derived from my work in a similar treatment setting many years ago and described in my first book, "Troubled Children/Troubled Parents: The Way Out," which contains its own dramatic stories including that of a clinician who secretly married his much younger patient. "David and Lisa" is likely available online or in your library. Watch it!

A recent Wall Street Journal aarticle ("One Surprising Psychosis Treatment That Works: Learning to Live With the Voices"/December 21, 2024) aroused these thoughts. Schizophrenia is vastly misdiagnosed particularly with substance abusers, and no medication can "cure" it since its symptoms reflect faulty early-childhood development of the basic critical ego capacities governing control of thinking, behavior, and more, apart from the debilitating side effects of psychotropic medication when used for more than briefly. The benefits of psychotropic medication tend to be exaggerated by drug companies and doctors with their side-effects downplayed.

Long ago a gifted psychiatrist/psychoanalyst in my training told of treating a hospitalized VA patient who frightened others by talking aloud to himself. The doctor advised him that if he continued this behavior he would be given electric shock treatment, which neither of them wanted. So when he felt compelled to behave like this he should go to the bathroom and talk into the toilet. Years later the patient's sister thanked the doctor for the remarkable improvement in her brother's behavior. Sadly, America's National Institute of Mental Health prioritizes drug treatment of emotional disorders though a study fifty-years ago showed the highest rate of recidivism (re-hospitalization) of severely disturbed psychiatric hospitalized patients was of those who were prescribed psychotropic medication in the hospital and following discharge, the lowest recidivism rate was with patients prescribed no medication in the hospital or after discharge, and the in-between recidivism rate was with patients who were prescribed medication in the hospital but not after discharge. Nuff said.

Central to psychotherapy is the concept that behaviors can have symbolic, often unconscious motives. For example, a potentially dangerous road rage action can indicate both annoyance at another's driving but also anger from another situation: a workplace happening, an interaction in a relationship, or a lingering emotion from childhood.
Thus, missing several psychotherapy sessions without reasonable cause (illness, hazardous driving weather, death in the family), especially if the therapist isn't notified but left waiting, can reflect diminished interest in treatment, be an indirect expression of anger, or indicate excessive narcissism, the feeling that the world revolves about them.
 The therapist then has two choices: to accept that, in their patient's current level of emotional development, they cannot behave differently; or, if excessive, to end treatment. It is not unreasonable to expect simple courtesy from all.

Even with the best medical treatment the survivor of a serious medical condition is rarely as healthy as before their affliction overcame them. Similarly, while psychotherapy can effect profound improvement of behavior and capacities, a patient will never be as well developed emotionally as if they had experienced a "good-enough" parenting during their formative years.
Their healing can never be total since early life experience is the bedrock of the adult personality and the unconscious is powerful. Yet there are healing events outside therapy too: nurturance from a loving spouse; and helping others and identifying with them, as can happen with parents and health workers, creating interactions which foster the emotional growth of both
Having regrets, feeling guilt for past mistakes is part of the human experience and cannot be avoided when living a thoughtful life.

A July 16, 2023 article in The Wall Street Journal ("The Doctor Won't See You Now - Therapists who judge, recoil, or quietly rage at their patients can't provide effective therapy") quoted psychologists who advocate political positions to their patients, blaming the patient's unhappiness on these rather than unwise personal decisions. But here the patient is smarter than the doctor.

People know why they come to therapy. No patient raised a political issue during my long work as a psychologist in hospital, clinic, and private practice settings. They spoke of anxiety or depression or marital/parenting/job problems but never that, not even people holding political office.
What it comes down to the clinician's  lack of understanding what psychotherapy is and not acknowledging the historically accepted belief in the power of the unconscious. As a psychiatrist colleague, a long-time government consultant, once remarked to me, "The unconscious is very powerful and one must respect its power."

Lacking sophistication of developmental psychopathology (a term devised by my doctoral advisor) and child psychological development has created other issues including the current gender misconceptions. Long ago, during a months long graduate school course at Columbia University ("Human Reproduction and Sexual Development") taught by an OB/GYN, the word "gender" was never uttered.
A reader's comment to The Wall Street Journal article spoke of clinicians having their own emotional problems and suggested that sufferers avoid mental health treatment. While a 1970s paper in the Bulletin of the Menninger Clinic acknowledged this ("The Sad Soul of the Psychiatrist"), having experienced and resolved life issues can create a more effective, intuitive clinician. They having unresolved emotional problems are, of course, another matter. Nuff said.

The degree of personality change that can be effected through psychotherapy depends on: the talent and knowledge of the therapist; the degree of early-life emotional damage that the patient endured; and, to a degree, their intelligence. But luck is a factor too, as with all activities. Ideal mates may meet through chance or not, and one may carelessly cross a street. Consider our world had Winston Churchill been fatally injured upon being hit by a car while crossing a New York City street in 1931. But granted the best of fate, the question remains: how much change can psychotherapy effect? A great deal but not coomplete.

The critical ego capacities develop early in life. These enable the child and later the adult to control their thinking and behavior, distinguish reality from fantasy, modulate their mood, and create a sense of who they are or, as psychologists term it, a "sense of self." But for these to develop the child must experience a "good-enough" parenting. Which depends on luck since even the best intentioned parents are a product of their own life experience, babies are not born with instructions, and good health services and nutrition are not available to all.

The therapist's task is to provide the equivalent of the "good-enough" parenting which the patient lacked early in life. Then, like a plant yielding toward the sun, the mind becomes nourished to heal the past psychological damage. Yet even as some plants that receive sufficient nutrients fail to flourish, all therapy is not successful. It takes a long time for an infant's mind to become adult, the early mental structure is its bedrock and, being conservative like all nature, resists change, aided by its powerful unconscious which demands respect.

The four basic psychotherapeutic postures, ways in which the doctor relates to their patient, are: the analytic posture, during which the patient's life is explored and understood; the relationship posture, during which the patient's mistrust is diminished and their basic trust is strengthened; the supportive posture, during which the patient's existing healthy modes of relating are strengthened; and the replacement posture, during which the patient's inadequate ego capacities are re-developed to greater maturity. Of these the analytic posture, the interpretation of troubling thoughts and feelings, has the oldest historic roots, it being Freud's mode of treatment after abandoning hypnosis. The analytic posture comprises several beliefs: that there is an unconscious conflict between different parts of the patient's mind of which they are unaware, its history deriving from childhood; and that interpretation can eliminate their distress. A process that is complicated by the therapist's need to interpret in installments as therapy proceeds, modulated by the therapist's own conscious and unconscious goals for the patient's development. The work of psychotherapy is not simple since it involves creating a patient's new life narrative, and one for which objective factual data from the past is lacking..

The historic psychoanalytic model of silently listening to patients interrupting only with an occasional cogent interpretation is rarely useful, lacking as it does much of a living experience. Nor is offering gratuituous hoary wisdoms like "all people have problems" helpful. Instead, the clinician should, by providing psychological information and enlightening anecdotes, educate their patient on the complexity of life, and the need to experience a "good-enough" parenting during childhood to avoid adult emotional difficulties, and their tendency to persist,.

A crucial fact is the power of fantasy, enjoyable even if sometimes fearful and threatening, to disrupt life, and the limited power ot the ego's defenses against the unconscious.

While brief psychotherapy is possible for a recent and isolated life problem, the treatment of deeper discontents must be lengthy (though not interminable), sometimes persisting intermittently for decades, since psychological limitations are long in development and the mind resists change, being inherently conservative.

Many patients deny the harm caused them by their parent(s), being unable to conceive they were not loved as a child since this belief serves as the bedrock of the human personality and is essential to survival. Yet there is also the mind's thrust toward psychological health and life fulfillment, evidenced by nightmares which communicate unconscious awareness of the need for change and its fear.