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A Psychologist's Thoughts on Clinical Practice, Behavior, and Life

Missing Appointments During Psychotherapy

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.

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The Limits of Adult Personality Change Through Psychotherapy

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.

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 Psychotherapists Who Advocate Politically To Their Patients

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.

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 How Much Personality Change Can Psychotherapy Effect?

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.

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The Nature of Psychotherapy

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..

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How A Psychotherapist Should Speak To Their Adult Patients

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.

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Psychological Ignorance and Bliss in Modern Society

The number of unsophisticated beliefs about behavior in today's society is astounding due to widespread public ignorance about psychological functioning and development. But these come from the lips of clinicians too. Consider treatment acronyms like DBT, "Dialectical Behavior Therapy" which I thought to mean "Diabolical Behavior Therapy" when I first heard it. This and others are mere abbreviated corruptions of the basic long-held treatment postures of psychoanalytically oriented psychotherapy (Relationship, Replacement, Supportive, Analytic).
An enthralling Netflix documentary series about a Hollywood teenage burglary ring that robbed celebrities is "The Real Bling Ring." I usually watch only the first episode of these series before reading what happened on Wikipedia but watched this in entirety. As crazed (but clever) was their robbery planning is the celebrity culture they hungered to join.
And as far as being "traumatized" by a scene from a book or film or a comment. When one doesn't know the technical definition of "traumatized" it can mean "feeling upset" or "not liking it" or having "hurt feelings." Development requires learning to cope with such human failings as jealousy and envy and sadism, on jobs and elsewhere.
Long ago a woman told me that her therapist said, "I love you." "Wow! That's a pretty unusual thing for a therapist to say," I responded. "Well, he didn't say exactly that. He said, 'You're lovable.'" When words can mean whatever the speaker wishes them to mean and belief becomes fact, we are in a world in which everything is OK and acceptable, or perhaps a psychotic one. Nuff said.

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How To Insure That An Adult's Psychotherapy Will Fail

In addition to the therapist lacking talent and training, certain professional practices will insure that a patient's treatment fails. (1) Using a vague unintelligible diagnosis will make the patient be considered untreatable. One like "Borderline Personality Characteristics reflective of Post-Autistic Development" would be excellent. To insure confusion and professional acceptance, a biologic or genetic phrase can be added like "A possible malformation of the patient's adrenal medulla causing irregular production of the epinephrine and norepinephrine hormones may influence the patient's moods." (2) Advising that psychological deterioration is inevitable unless many years of twice-weekly individual treatment is obtained since this is rarely possible. (3) Having the most disturbed patient be treated by the clinic's least experienced worker. A beginner trainee would be a wise choice. (4) Making life decisions for the patient. This will further lower their self-esteem by indicating how inadequate their doctor believes them to be. (5) Never responding directly to a patient's question. Thus if asked why their symptom exists the doctor should reply, with an air of condescension and omniscience, "Severe problems like yours take a long time to understand." This, even if the symptom has been long understood since psychotherapy is least likely to fail when a patient receives explanation.

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Transference and Counter-transference During Psychotherapy

Healing during psychotherapy occurs through the therapist-patient interaction which, ideally, is the "good-enough" parenting that the patient lacked during their early development. While emotional expression heals during psychotherapy, unconsciously derived reactions are common: forgetting an appointment, day-dreaming during the therapy session, or boredom. These, termed "transference" on the part of the patient and "counter-transference" on the part of the therapist, are inevitable. Though sometimes reducing the effectiveness of treatment when experienced by the therapist, they are part of the human condition, occur whenever people interact, and can point the therapist toward providing better treatment.

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The Curative Factors in Psychotherapy

Several factors are now considered to comprise the healing elements of individual psychotherapy, both classic psychoanalytic treatment, which is uncommon today and suited for few, and the frequent psychodynamically oriented treatment. Gaining insight into one's behavior has far less effect than has been promulgated by movies since a patient who gains great insight may achieve little life change. A second factor is the patient's attachment to their therapist, the theapeutic relationship, within which a more benign and thoughtful orientation toward themselves is adopted. During this corrective emotional experience the patient comes to view themselves and others differently, and long-held, unconscious terrors are extinguished.

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