![[Therapy's nervous breakdown]](therapy970203.gif)
C a n t h e t a l k i n g c u r e m a k e i t i n t o t h e 2 1 s t c e n t u r y ?
"On the Couch: Great American Stories About Therapy." Edited by Erica Kates, Atlantic Monthly Press, 387 pages. "Constructing the Self, Constructing America: A Cultural History of Psychotherapy."
"The Intimate Hour: Love and Sex in Psychotherapy." BY LAURA MILLER
in a mere 100 years, psychotherapy has gone from a tiny, marginal, quasi-scientific European profession to a $12 billion-plus industry with over a million practitioners that touches almost every aspect of American life. Whenever a bomb explodes or a plane crashes, we're assured that phalanxes of counselors have been dispatched to clean up the emotional wreckage. (I imagine them helicoptered in like SWAT teams, toting notepads and boxes of tissue instead of guns.) Therapists dispense advice on radio call-in programs, TV talk shows, in bestselling books, in courtrooms, through myriad seminars and self-improvement classes and, of course, during office visits. For many of us, disillusioned by organized religion and bewildered by philosophy, therapy is the last remaining way of making sense of the world and our own lives. And, like the law, therapy is an arena where we thrash out ideas and beliefs. It doesn't just mirror the passions of our day; it often drives them. In the 1950s, Freudianism won popular acceptance, its harsh vision of the path to "adjustment" suiting the conformism of the times. In the '60s and '70s, radical theories (orgasm is the key to life, schizophrenia is social subversion) and kooky practices like Rolfing and rebirthing intertwined with scary, manipulative group therapies and cultish mass gatherings. In the '80s, sufferers began to identify with their problems — addiction, a history of abuse — and formed outspoken "communities," imitating the trend toward identity politics. As for the '90s' infatuation with anti-depressant drugs, well, it's the perfect answer to the downsized, low-maintenance world of managed care. Over the past century, psychotherapy has mutated from the management of "mad" people to a way of making sane people more happy — or at least less miserable. This evolution opened up the therapist's office to our fantasies as well as our nightmares: What once appeared to be a dungeon might, after all, be Ali Baba's treasure chamber. Here we might figure it all out at last, and change our lives in the process. The fiction writers who contribute to "On the Couch: Great American Stories About Therapy" (edited by Erica Kates) take an ironic view of this invasion of their territory. Dissecting and summing up people's inner lives, their dreams and dilemmas, used to be the province of artists alone — with no promise of a "cure" required. Still, therapy is great material, and this anthology reflects that. Sad, comic, hair-raising, moving, alarming and fun, "On the Couch" is much more vibrant than the average tepid contemporary short story collection, a sure sign that the topic taps deeply into our collective psyche. A few of these stories are resolutely cynical, like one that describes a doctor who's almost too clever for his hit-man client — almost, but, unfortunately for him, not quite. In another, a woman's therapy sessions (and entire life) involve a Byzantine structure of pointless lies, so difficult to maintain that it nearly drives her crazy (or crazier). Nevertheless, most of these stories show a stubborn faith in the talking cure. Like the heroes of fairy tales, characters visit their therapists (in what John Updike calls "the cave of knowing") and come away with frustratingly banal instructions — "take a trip," "keep a journal" — which, to their surprise, actually work. (One of the hardest things for smart people to learn is just how effective the most commonplace bromides can be.) Some of the therapists portrayed here are downright loopy, treating their clients in ways that border on the unethical, but, in the end, what the doctor orders magically turns out to be exactly what's needed. If the stories in "On the Couch" are any indication, we still believe in the therapist as medicine man or oracle, possessed of the power to transform our fate. Therapists themselves, however, are less certain. Two recent books argue that the profession faces a crisis — although they disagree on just what it is. Philip Cushman, author of a "cultural history of psychotherapy" titled "Constructing the Self, Constructing America," insists that the entire ideology of therapy needs an overhaul. In its most common forms, he argues, therapy fosters the isolated individualism that causes many of the problems it pretends to treat. If therapy were really doing its job, Cushman maintains, it would realize that people's identities are "constructed" — that is, the products of historical and social forces, not the internal struggle of drives or organic developmental stages. Of course, if therapy did that, he says, it would be compelled to "challenge the status quo" and become a force for social change. In short, Cushman has discovered French post-structuralist theory, in its politicized American academic form. "Constructing the Self, Constructing America" is an earnest, somewhat muddled and self-contradictory book that nevertheless makes a few intriguing points. Cushman deftly illustrates how different societies customize their definitions of mental illness according to their own agendas. In the established culture of 19th century Europe, people suffered from hysteria, seen as the incomplete control of dangerous, antisocial impulses. In young America, a country striving to settle a continent, they contracted the opposite: debilitating neurasthenia. "The absence of initiative, the inability to work," Cushman observes, "was considered sickness." In spite of Freudianism's inherent pessimism, mid-century Americans embraced it, Cushman suggests, because they'd run out of geographic frontiers, and the unconscious struck them as virgin territory ripe for exploration. Furthermore, the possibility that each of us has a powerful but manipulatable unconscious mind proved mighty appealing to the burgeoning advertising industry. Cushman blames consumerism and the capitalism that drives it for creating our modern "empty self," forever seeking to fill up with new products and images, and thereby fueling an economy based on selling stuff that nobody really needs. Today's addiction-obsessed therapies and "trauma theory" — which sees people as shaped by past wounds, especially sexual abuse — are, Cushman argues, based on notions of "bad consumption." According to this thinking, we must be "fed" the right early experiences or we become "dysfunctional" and prone to helplessly pursuing substitute forms of destructive consumption. At their worst, both of these therapies just reinforce the passivity that makes for model consumers. Cushman challenges therapists to take in the big picture — how social forces shape our problems and how therapy can reinforce their impact. But, surely, any good, hands-on therapist will take her client's race, gender and class background into account while trying to ferret out the roots of an emotional problem. That's just common sense, yet Cushman claims that it's extremely rare. Since he's in a position to know, we might be inclined to trust him on that — if his grasp of history and politics weren't so shaky in other areas. For example, he seems to believe that capitalist America practically invented social "domination and control" as well as demeaning stereotypes of women, the poor and racial "outsiders." But even a cursory glance at history shows the same poisonous threads running through nearly every society, with ours actually more open than many. Sometimes Cushman's myopia leads to absurdity. He's perfectly capable of bemoaning, on one page, the loss of the "religion, tradition and community" that once brought moral certainty, then naively speculating that rabid anti-abortion protesters are displacing their rage at dehumanizing modern culture on the next. He doesn't seem to recognize that these people see themselves as acting out of a moral certainty grounded in religion, tradition and community — and they're right. Not only does Cushman wallow in idealizing nostalgia (Remember the good old days of feudalism?), but he doesn't recognize how dangerous and, yes, oppressive the "folkways" he mourns can be. Still, Cushman comes across — particularly in the rare passages where he describes his work with clients — as a decent, well-intentioned doctor truly interested in making the world a better place. Like a lot of leftist intellectuals, he glorifies political activism without really understanding what makes it tick. He sincerely believes that trying to blend and reconcile all the contradictory values in a multicultural society will enable us to "make more moral ground" for decisive action. Hello? This effort — "honoring" each value system and "envisioning the political process as a dialogue between various aspects of one large tradition, or between two or more traditions" — however worthy, has baffled the American left for years and stymied its ability to figure out what it wants, let alone its ability to act. I'd also argue with Cushman that our tendencies to crave status, to fetishize celebrities, to passively obey authority, to demonize the people we mistreat and most of all to demand easy, one-dimensional answers are as old as Adam; capitalism has just found a new way to make them pay. What does it take to create the kind of human being who can behave compassionately and morally without being ordered to by "religion and traditional community"? That's the dilemma of our time. It does seem that strong, mature, self-reliant citizens who value relationships are called for, and, despite what Cushman says, that's what most good therapists work toward. We don't need better theories so much as we need more good therapists. Susan Baur's "The Intimate Hour: Love and Sex in Psychotherapy" speaks to that need more convincingly than Cushman's lofty intellectualizing. She warns that the opportunity to provide good therapy is shrinking. Although its packaging and title make vague promises of titillation, "The Intimate Hour" is really a passionate protest against the increasing regulation of therapy in the world of managed care. Baur believes that love — affection, warmth, concern, admiration and sometimes physical attraction — is the cornerstone of therapy, which is at heart an intimate, if very lopsided, relationship. She doesn't advocate ever acting on the "occupational hazard" of sexual feelings that sometimes crop up between doctor and patient. But, she cautions, to insist that those feelings can never occur is to ask therapists to shut down emotionally once they open their office doors. Baur contradicts the recent, prevailing "official" position that therapists who experience such attractions are always "exploitative" and "sick." "Even a position of inquiry," she says, describing heated discussions at professional conferences, "was off-limits," and therapists now exercise extravagant caution to avoid provoking a potentially litigious client. One of her colleagues has adopted the slogan, "Hug a patient, hire a lawyer." Leading the crusade to squelch or punish all wayward desires in the therapeutic relationship are groups of (mostly) women who have suffered sexual abuse at the hands of their therapists. They dominate any discussion of the issue with a brand of sweeping, extreme and simplistic rhetoric that's become all too familiar lately. Outrageous abuses do occur, Baur readily admits, but they aren't the whole story. A more insidious threat is being overlooked in all the furor. Can good therapy survive when counselors are instructed to keep their distance and "taught to practice defensively — to be afraid of the people they are trying to help"? Baur observes that "psychotherapy is becoming a standardized service provided by a system rather than a private interaction between individuals." Drastic regulations aimed at preventing sexual misconduct provide bureaucratic self-protection for the "insurance companies, social service agencies, and licensing boards" and managed care administrators who control who gets services and how much. More and more, these officials monitor how therapists handle a variety of dilemmas, including possible child abuse and duration of treatment, dictating uniform policies in all cases. Asking therapists to act like mental technicians tidies up what has always been a messy, if sometimes miraculous, relationship. This may head off lawsuits, but at what price? If we lose the mess, we could also lose the miracles. The less autonomy therapists have, Baur also argues, the more alienated and cynical they grow about their work. This, she fears, might actually lead to more exploitative incidents, and certainly to less intimacy. But since women practitioners are the rapidly growing majority in the profession, and are far less likely to be accused of violating sexual ethics than men, the whole "crisis" looks like a bit of a red herring. What's really at stake is how therapy can retain its humanity. In that case, doctor-patient love (unconsummated) might even come down on the right side. Baur interviewed a female psychiatrist at a hospital who fell in love with a manic-depressive patient. She found herself suddenly critical of the mental health system as she tried to "write a discharge summary in the usual professional terms ... The customary explanations seemed like formulas to make the staff feel justified ... When I liked a patient as much as this one and knew him as a person ... then I began to realize how little of each life we were taking into account."
Don't all of us hope that our therapist, if we have one, or any other doctor, feels this kind of concern for us? For that matter, doesn't this psychiatrist's love lead her to the broader sociopolitical perspective that Cushman advocates? As Baur makes abundantly clear, close relationships are often volatile and risky, and every once in a while, doctors and patients will slip, disastrously. But if we can't take that chance, we might as well learn to live without therapy. Is therapy in danger of losing its human touch in the age of managed health care? Get on the couch in Table Talk. |
