The Gift of Therapy

• Remove the Obstacles to Growth
• Avoid Diagnosis (except for insurance companies)
• Therapist and Patient as "Fellow Travelers"

The Gift of Therapy has 85 short chapters, each offering a suggestion or tip for therapy. The first three chapters are reproduced here.

Remove the Obstacles to Growth

When I was finding my way as a young psychotherapy student, the most useful book I read was Karen Horney's Neurosis and Human Growth. And the single most useful concept in that book was the notion that the human being has an inbuilt propensity toward self-realization. If obstacles are removed, Horney believed, the individual will develop into a mature, fully realized adult, just as an acorn will develop into an oak tree.

"Just as an acorn develops into an oak." What a wonderfully liberating and clarifying image! It forever changed my approach to psychotherapy by offering me a new vision of my work: My task was to remove obstacles blocking my patient's path. I did not have to do the entire job; I did not have to inspirit the patient with the desire to grow, with curiosity, will, zest for life, caring, loyalty, or any of the myriad of characteristics that make us fully human. No, what I had to do was to identify and remove obstacles. The rest would follow automatically, fueled by the self-actualizing forces within the patient.

I remember a young widow with, as she put it, a "failed heart"—an inability ever to love again. It felt daunting to address the inability to love. I didn't know how to do that. But dedicating myself to identifying and uprooting her many blocks to loving? I could do that.

I soon learned that love felt treasonous to her. To love another was to betray her dead husband; it felt to her like pounding the final nails in her husband's coffin. To love another as deeply as she did her husband (and she would settle for nothing less) meant that her love for her husband had been in some way insufficient or flawed. To love another would be self-destructive because loss, and the searing pain of loss, was inevitable. To love again felt irresponsible: she was evil and jinxed, and her kiss was the kiss of death.

We worked hard for many months to identify all these obstacles to her loving another man. For months we wrestled with each irrational obstacle in turn. But once that was done, the patient's internal processes took over: she met a man, she fell in love, she married again. I didn't have to teach her to search, to give, to cherish, to love. I wouldn't have known how to do that.

Avoid Diagnosis (except for insurance companies)

Today's psychotherapy students are exposed to too much emphasis on diagnosis. Managed care administrators demand that therapists arrive quickly at a precise diagnosis and then proceed upon a course of brief, focused therapy that matches that particular diagnosis. Sounds good. Sounds logical and efficient. But it has precious little to do with reality. It represents instead an illusory attempt to legislate scientific precision into being when it is neither possible nor desirable.

Though diagnosis is unquestionably critical in treatment considerations for many severe conditions with a biological substrate (for example schizophrenia, bipolar disorders, major affective disorders, temporal lobe epilepsy, drug toxicity, organic or brain disease from toxins, degenerative causes or infectious agents) diagnosis is often counterproductive in the everyday psychotherapy of less severely impaired patients.

Why? For one thing, psychotherapy consists of a gradually unfolding process wherein the therapist attempts to know the patient as fully as possible. A diagnosis limits vision, it diminishes ability to relate to the other as a person. Once we make a diagnosis, we tend to selectively inattend to aspects of the patient which do not fit into that particular diagnosis, and we correspondingly over-attend to subtle features which appear to confirm an initial diagnosis. What's more, a diagnosis may act as a self-fulfilling prophecy. Relating to a patient as a "borderline" or a "hysteric" may serve to stimulate and perpetuate those very traits. Indeed, there is a long history of iatrogenic influence on the shape of clinical entities, including the current controversy about multiple personality disorder and repressed memories of sexual abuse. And keep in mind, too, the low reliability of the DSM personality disorders category (the very patients often engaging in longer-term psychotherapy.)

And what therapist has not been struck by how much easier it is to make a DSM-IV diagnosis following the first interview than much later, let us say, after the tenth session, when we know a great deal more about the individual? Is this not a strange kind of science? A colleague of mine brings this point home to his psychiatric residents by asking: "If you were in personal psychotherapy or are considering it, what DSM-IV diagnosis do you think your therapist could justifiably use to describe someone as complicated as you?" (C. P. Rosenbaum, personal communication, Nov. 2000)

In the therapeutic enterprise we must tread a fine line between some, but not too much, objectivity; if we take the DSM diagnostic system too seriously, if we really believe we are truly carving at the joints of nature, then we may threaten the human, the spontaneous, the creative and uncertain nature of the therapeutic venture. Remember that the clinicians involved in formulating previous, now discarded, diagnostic systems were competent, proud, and just as confident as the current members of DSM committees. Undoubtedly the time will come when the DSM-IV Chinese restaurant menu format will appear ludicrous to mental health professionals.

Therapist and Patient as "Fellow Travelers"

Andrè Malraux, the French novelist, described a country priest who had taken confession for many decades and summed up what he had learned about human nature in this manner: "First of all, people are much more unhappy than one thinks...and there is no such thing as a grown-up person." Everyone—and that includes therapists as well as patients—is destined to experience not only the exhilaration of life, but also its inevitable darkness: disillusionment, aging, illness, isolation, loss, meaninglessness, painful choices, and death.

No one put things more starkly and more bleakly than the German philosopher Arthur Schopenhauer:

In early youth, as we contemplate our coming life, we are like children in a theater before the curtain is raised, sitting there in high spirits and eagerly waiting for the play to begin. It is a blessing that we do not know what is really going to happen. Could we foresee it, there are times when children might seem like condemned prisoners, condemned, not to death, but to life, and as yet all unconscious of what their sentence means.

Or again:

We are like lambs in the field, disporting themselves under the eyes of the butcher, who picks out one first and then another for his prey. So it is that in our good days we are all unconscious of the evil that Fate may have presently in store for us — sickness, poverty, mutilation, loss of sight or reason.

Though Schopenhauer's view is colored heavily by his own personal unhappiness, still it is difficult to deny the inbuilt despair in the life of every self-conscious individual. My wife and I have sometimes amused ourselves by planning imaginary dinner parties for groups of people sharing similar propensities—for example, a party for monopolists, or flaming narcissists, or artful passive-aggressives we have known or, conversely, a "happy" party to which we invite only the truly happy people we have encountered. Though we've encountered no problems filling all sorts of other whimsical tables, we've never been able to populate a full table for our "happy people" party. Each time we identify a few characterologically cheerful people and place them on a waiting list while we continue our search to complete the table, we find that one or another of our happy guests is eventually stricken by some major life adversity—often a severe illness or that of a child or spouse.

This tragic but realistic view of life has long influenced my relationship to those who seek my help. Though there are many phrases for the therapeutic relationship (patient/therapist, client/counselor, analysand/analyst, client/facilitator, and the latest—and, by far, the most repulsive—user/provider), none of these phrases accurately convey my sense of the therapeutic relationship. Instead I prefer to think of my patients and myself as fellow travelers, a term that abolishes distinctions between "them" (the afflicted) and "us" (the healers). During my training I was often exposed to the idea of the fully analyzed therapist, but as I have progressed through life, formed intimate relationships with a good many of my therapist colleagues, met the senior figures in the field, been called upon to render help to my former therapists and teachers, and myself become a teacher and an elder, I have come to realize the mythic nature of this idea. We are all in this together and there is no therapist and no person immune to the inherent tragedies of existence.

One of my favorite tales of healing, found in Hermann Hesse's Magister Ludi, involves Joseph and Dion, two renowned healers, who lived in biblical times. Though both were highly effective, they worked in different ways. The younger healer, Joseph, healed through quiet, inspired listening. Pilgrims trusted Joseph. Suffering and anxiety poured into his ears vanished like water on the desert sand and penitents left his presence emptied and calmed. On the other hand, Dion, the older healer, actively confronted those who sought his help. He divined their unconfessed sins. He was a great judge, chastiser, scolder, and rectifier, and he healed through active intervention. Treating the penitents as children, he gave advice, punished by assigning penance, ordered pilgrimages and marriages, and compelled enemies to make up.

The two healers never met, and they worked as rivals for many years until Joseph grew spiritually ill, fell into dark despair, and was assailed with ideas of self-destruction. Unable to heal himself with his own therapeutic methods, he set out on a journey to the south to seek help from Dion.

On his pilgrimage, Joseph rested one evening at an oasis, where he fell into a conversation with an older traveler. When Joseph described the purpose and destination of his pilgrimage, the traveler offered himself as a guide to assist in the search for Dion. Later, in the midst of their long journey together the old traveler revealed his identity to Joseph. Mirabile dictu: he himself was Dion—the very man Joseph sought.

Without hesitation Dion invited his younger, despairing rival into his home, where they lived and worked together for many years. Dion first asked Joseph to be a servant. Later he elevated him to a student and, finally, to full colleagueship. Years later, Dion fell ill and on his deathbed called his young colleague to him in order to hear a confession. He spoke of Joseph's earlier terrible illness and his journey to old Dion to plead for help. He spoke of how Joseph had felt it was a miracle that his fellow traveler and guide turned out to be Dion himself.

Now that he was dying, the hour had come, Dion told Joseph, to break his silence about that miracle. Dion confessed that at the time it had seemed a miracle to him as well, for he, too, had fallen into despair. He, too, felt empty and spiritually dead and, unable to help himself, had set off on a journey to seek help. On the very night that they had met at the oasis he was on a pilgrimage to a famous healer named Joseph.

Hesse's tale has always moved me in a preternatural way. It strikes me as a deeply illuminating statement about giving and receiving help, about honesty and duplicity, and about the relationship between healer and patient. The two men received powerful help but in very different ways. The younger healer was nurtured, nursed, taught, mentored, and parented. The older healer, on the other hand, was helped through serving another, through obtaining a disciple from whom he received filial love, respect, and salve for his isolation.

But now, reconsidering the story, I question whether these two wounded healers could not have been of even more service to one another. Perhaps they missed the opportunity for something deeper, more authentic, more powerfully mutative. Perhaps the real therapy occurred at the deathbed scene, when they moved into honesty with the revelation that they were fellow travelers, both simply human, all too human. The twenty years of secrecy, helpful as they were, may have obstructed and prevented a more profound kind of help. What might have happened if Dion's deathbed confession had occurred twenty years earlier, if healer and seeker had joined together in facing the questions that have no answers?

All of this echoes Rilke's letters to a young poet in which he advises, "Have patience with everything unresolved and try to love the questions themselves." I would add: "Try to love the questioners as well."

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