Psychotherapy's Pilgrimage


Psychotherapy's Pilgrimage

Shaping the Consciousness of Our Time

January/February 2017


Like many people who entered the field in the late 1970s and early ’80s, when the therapy profession was in an expansive phase, I grew up professionally reading the Psychotherapy Networker. We Boomers were surfers riding a big cultural wave, which took psychotherapy off the couch and made it into a force shaping the zeitgeist. Along the way, the Networker’s goal was to capture the collective adventure of understanding human experience from fresh angles and offer up-close and personal reporting on what it was like for practitioners to try out the range of the novel and often emotionally intense methods being generated by a field filled with creative ferment. In the Networker, I could count on regularly hearing the voice of my fellow adventurers who were facing the same challenges I was, who shared my intellectual curiosity and sense of being on a quest for the authentic and the true.

What follows is my take on the last 40 years of psychotherapy, inevitably reflected through both the prism of my personal biases and the attitudes common within my generation of therapists. But beyond describing my own experience, it’s an attempt to offer the perspective that time and reflection make possible about what I now see as the intimate relationship between what goes on within the seeming sanctuary of therapists’ offices and the hurly-burly of the wider culture.

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As an idealistic Catholic boy growing up in Philly in the 1950s, I saw just two pilgrim paths to the consequential life I wanted to live: become a priest and save souls, or become a therapist and save minds. After a stint in a seminary, where the celibacy requirement and I had a disagreement, I entered the therapy field in the early ’70s, when the slow, archaeological-dig approach of psychoanalysis was being challenged by a new tribe of humanistic therapists and encounter-group leaders, who went for quick breakthroughs.

In those days, you could get graduate course credit for doing an encounter group that culminated in a marathon overnight session to break down our defenses and reveal our true selves. I found my “true self” late one night by telling someone asking for hugs all around that I didn’t want to hug him. After he responded with his “true hurt self,” it was game on. By morning, we all felt more enlightened—and superior to people who had never encountered one another in this way.

The Gestalt therapy experiential training groups I later joined were more skillfully conducted. Through enactments and open-chair work, we learned to get unblocked and open up our core emotions and desires. I had one of those powerful moments when I used the open chair to challenge, first cautiously and then loudly, a father figure from my seminary days, after which I felt a visceral release from guilt and resentment. We watched videos of Fritz Perl doing sadistic-looking confrontations of emotionally stuck clients whom he called fakes and frauds. After first responding with intellectualizations, these clients would eventually get angry and scream back at Perls—who’d then turn gentle and say, “Now you’re here with us.” Watching this was ghastly but fascinating for those of us familiar with unconditional positive regard.

Sometimes I got up the courage to try this stuff in my own work, and it created some dramatic moments. I recall inviting a pedantic husband telling me how to run a couples therapy session to continue his advice-giving by standing up and delivering a lecture on good therapy. When he complied, I coached him on using his gestures more forcefully to make his points. After a moment or two, he ran out of gas and sheepishly sat down. My technique was right out of the Gestalt therapy playbook, and I felt proud of myself. Unfortunately, it turned out to be our last session.

For many of us, this way of working was about more than individual and group therapy: it was about social change. We were challenging the strictures of psychological oppression that infected society: rigidity, either/or thinking, conformity rather than authenticity. Businesses were experimenting with weekend encounter groups to improve team functioning. I even remember thinking that if we could just get every member of Congress into a personal growth group, political enlightenment and social justice would be right around the corner


The Coming of the Liberated Self

Eventually I (and lot of other therapists) came to see these intense therapeutic encounters as a kind of sugar high, with a crash afterward—or at least a return to baseline functioning. I also came to see the humanistic psychology movement as having lost its intellectual moorings with the waning influence of people like Carl Rogers and Rollo May. And I saw it as not relational enough—too much about the individual client and not the extended emotional web of the client’s connections to others. In recent years, I’ve realized that my dormant Catholic roots had left me with a more collectivist, less individualistic worldview, which occasionally asserted itself early in my career. Catholicism was also not into quick breakthroughs, but rather the long pilgrimage, with many slips, falls, confessions, and reconciliations along the way. Rinse and repeat.

In forging an alternative to psychoanalysis, the humanistic therapy movement was offering a new idea of the self in modern society. Therapy movements are more than a set of theories and techniques—they’re about what it means to be a human being at a particular time and in a particular culture. Psychoanalysis had offered up the idea of the Complex/Conflicted Self, the psyche full of ambivalence and contradiction. Successful therapy aimed to help people understand and accept their basic needs and desires, many of them socially unacceptable, and integrate them in a complex sense of being, never entirely free of internal conflict, but combining love and hate, attachment and fear of engulfment, responsibility and self-indulgence, insight and self-delusion.

Despite what our therapy textbooks imply, ideas like this don’t just spring purely out the heads of founders of therapy models, or just from distinct scientific breakthroughs. Social historians and writers like Adam Curtis, author of The Century of the Self, have shown how this conflicted Freudian Self fit with the darkness of World War I and the Great Depression, followed by the horror of Nazi genocide. The era between 1920, after Freud landed on American shores, and the 1950s, when psychoanalysis flowered among cultural elites, was mostly a time of survival and living with limits. Indeed, James Strachey, Freud’s translator and editor, wrote that one of Freud’s enduring themes was “the irredeemable antagonism between the demands of instinct and the restrictions of civilization.” Sometimes the instincts won out.

Baby Boomers in the Age of Aquarius wanted nothing to do with this mindset. An unprecedented economic boom and a rising educated middle class set the stage for the social revolutions of the 1960s. The world was being recreated—and the new therapies promised immediate change, which didn’t require years of archival work on the human psyche. Social historian Jessica Grogan, in her book on humanistic psychology and the making of the modern self, describes how psychologists like Abraham Maslow both instigated and responded to a hunger in American culture for a more positive understanding of human growth and potential. What emerged was a new image of the self—I’ll call it the Authentic/Liberated Self. It appealed to pent-up desires to be self-determining, self-actualizing, individuated from overbearing families, and not boxed in by expectations of social conformity.

And boy, did we like self-determination! When I was in graduate school, many of us hung posters in our rooms of the Gestalt “prayer,” penned by Fritz Perls:

    I do my thing and you do your thing.
    I am not in this world to live up to your expectations.
    And you are not in this world to live up to mine.
    You are you, and I am I.
    And if by chance we find each other, it’s beautiful.
    If not, it can’t be helped.

I attended weddings where this prayer was recited by the bride and the groom. It was sometimes followed by new vows, ending with “as long as we both shall love.” Like Dorothy, I knew I wasn’t in Kansas (or in my case, seminary) any more.

While underlying conceptions of the self loom far in the background for most clinicians, they’re at the heart of what shapes the way therapists practice. For me, during the 1970s and early ’80s, when a client would bring a conflict between needs of the self and responsibilities to others, I reflexively, at times blindly, would side firmly with the self. This would show up with clients making decisions during the big divorce revolution. I used to recommend that clients considering divorce think about four things: how would leaving help you, what would leaving cost you, how would staying help you, and what would staying cost you? In retrospect, this was a classic cost–benefit analysis, which left out any other stakeholders in the decision. When clients introduced concerns about their children, I (and many other therapists) reassuringly urged them to focus on what they needed to do for themselves: the children would be fine if the parents were fine.

I recall a client, Maureen, who had four teenage children and an alcoholic husband who was emotionally checked-out but a good breadwinner. She was unhappy in her marriage, and her husband wouldn’t work on his drinking problem. Despite my urging her to focus on the implications of her unmet needs in the marriage, she decided to stay until the last child left home, because she wanted to launch the children from a stable, economically sound family—and because she thought her husband wouldn’t be a competent single parent when the children were with him. I accepted her decision, but inside I felt she was selling herself short, betraying her authentic self. I now understand that she was doing a complex juggling of her personal needs and parental responsibilities.

Some of my new perspective comes from more decades of life experience, including 45 years of marriage and seeing in my clinical practice as many casualties as success stories from decisions to leave marriages. But at the time, my membership in the Liberated Self club didn’t allow me to validate Maureen’s sense of moral responsibility as a legitimate consideration in her divorce decision.


The Family Systems Movement

Around the time that therapists were pulling back from the excesses of the human potential movement of the ’70s, some of us began a love affair with family therapy and systems theory. This was the new road on my pilgrim path. It turned out to be an even more definitive break with staid old psychoanalysis. First of all, family therapy was grounded in cutting-edge cybernetics, which eventually brought the digital revolution, and in general systems theory, challenging the field of biology. It was about interdependence in the here and now. The clinical dramas that pioneers like Salvador Minuchin, Carl Whitaker, and Virginia Satir created were breathtaking. Even though nobody on the faculty in my graduate program was particularly into family therapy, in the intellectually fertile atmosphere of the field in the mid-’70s, I could learn from going to workshops, watching videos of these masters, and reading the torrent of literature that was being generated by the family therapy movement.

For me and many others, being a family therapist was a kind of awakening into a powerful and encompassing worldview, complete with the hero worship of charismatic gurus who competed with one another for primacy. And it was thrilling to share that excitement with others during conferences, like this magazine’s annual Symposium, that regularly brought us devoted followers together. Oh, how we loved getting together!

The Networker initially established its position among us with a series of personality profiles that captured both the thinking and personal appeal of family therapy leaders, who each had their own fan club. I was a staunch member of the Salvador Minuchin fan club (still am, in fact). I’d learned how to do family therapy from watching his videos and reading his book Families and Family Therapy—and here was my hero profiled in a cover story by the magazine’s editor that captured the incandescence of his clinical style doing a live demonstration:

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“Standing in front of an audience of 200 therapists, Minuchin, a compact, dapper man with a Latin accent as thick as his black mustache, exuded an air of brusque command at odds with the traditionally pacifist culture of psychotherapy. Heaven protect anyone who stumbled through a lame question or tried to say a kind word about psychoanalysis. He seemed to me the most confident person I’d ever met, as if he had been to the mountaintop, seen the Truth and discovered he was It. Of course, he was exactly the kind of hero I was looking for. And when he began to explain a clinical strategy by quoting from a 16th-century book called The Way of the Samurai, any last reservations I may have had completely disappeared.

“The centerpiece of the workshop was a live family therapy session broadcast to the audience via closed circuit TV. Once the interview started, Minuchin’s intimidating aura dissolved and he became a kind of therapeutic sleuth—patient, respectful, infinitely curious, frequently playful, surprisingly gentle, but above all, utterly focused on figuring out the puzzle of what was maintaining the problem the family was trying to resolve. Sometimes Minuchin leaned back in his chair and took long drags on his cigarette as he questioned the family—a poor black single mother and her three young children—about their presenting problem: the eight-year-old boy’s disobedience and school difficulties. Hyperalert to the family’s every gesture, every pause, every shift of mood, he seemed to drink in information through all his pores as he pursued his inquiry.

“Toward the end of the session, Minuchin asked the defiant eight-year-old to stand up, explaining, “I’m still trying to figure out what makes you so powerful.” The boy smiled slyly as he rose to his feet, clearly delighted to take part in whatever game this curious man was devising. After speaking with the boy for a while and complimenting him on how strong and healthy he looked, Minuchin asked the mother to stand up. As she did, towering over her small child, Minuchin asked, “Where has he got the idea that he’s so powerful? He’s just a little kid who has somehow convinced you that he’s much older than he really is.

“It was, I learned later, one of Minuchin’s favorite gambits, but as I watched it unfold, I was stunned by both the power and the sweetness of the moment. Both mother and son were smiling, basking in the attention they were receiving, coming more fully to life as if renewed by the prospect of order being restored in the family. And later, as the mother, with Minuchin’s gentle persistent coaching, was finally able to lay down some simple rules in the session with a newfound authority in her voice, there was no doubt that she and her family had recorded a small victory in that room.”

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Minuchin’s example even freed up my inner theater director. In my first job working with teens and their families, I’d get on the floor to draw nearer to someone in the family, playfully turn kids’ seats to face the wall if they wouldn’t stop interrupting people, alternatively being affectionate and tough, admiring and sometimes even a bit harsh. I recall a widowed mother and her 15-year-old daughter, Jessie. Six months after the death of her husband, the mother was starting a new social life by going to community dances, and Jessie wasn’t happy about it. In fact, Jessie would yell and curse at her, and refused to stay home alone if she knew her mother was going to a dance. So the placating mother took her to the dance one night, during which the girl made a public scene while pulling her mother away from a male dance partner. The mother was upset and befuddled, the daughter overly defiant.

During the first family therapy session, Jessie wouldn’t let me speak directly to her mother; she interrupted continually and told her mother it was ridiculous to be talking with a shrink. Clearly, she was having a serious grief response to the death of her father, and an anxious attachment reaction when her mother tried to connect with any other man. Sensing that she was thoroughly in charge of her mother at this point, and that this power scared her, I channeled my inner Minuchin and asked the mother how she felt about her daughter interrupting and talking to her so disrespectfully. The mother acknowledged that she hated it, whereupon Jessie escalated her verbal attacks—“You’re stupid! You don’t know what you’re talking about!”

I decided that the one boundary I could be in charge of was around my relationship with the mother. So I told her I wanted to have a conversation with her even if Jessie interrupted, and I asked if she’d be willing to maintain verbal and eye contact with me no matter what Jessie did or said. (I’d learned in a bit of theater training that it’s possible to keep a quiet conversation going despite a lot of distracting noise if you maintain eye contact.) She agreed, and we began an exchange about her concerns around getting out socially and Jessie’s reaction, which became almost comical because Jessie kept up a steady flow of critical commentary.

Finally, Jessie stood up dramatically between me and her mother to block our view of each other. When I looked to either side, she stretched out her arms that way. I somehow relaxed with the drama of the moment, calmly saying, “I can’t see through teenage girls, but fortunately my voice can travel around them.” So the mother and I kept talking, and Jessie finally gave up, looking defeated but not upset. I ended the session by saying that Jessie was doing her best to protect her mother from making a mistake by moving on too fast from the death of her husband, and that it was the mother’s job to take Jessie’s concern into account and then make her own decision about resuming a social life.

When I saw them a month later, everything had shifted. Jessie was friendly in the session and being a normal teen at home. Mom had gone to a couple of dances, and they’d had some good conversations (their first) about how hard it was to lose a father and husband. What Jessie now had was a confident mother. Of course, there could’ve been other appropriate therapeutic ways to help Jessie and her mother, but this structural family therapy approach worked by lancing a boil so that they could move on and heal together. It all made me even more convinced of the deep wisdom of structural family therapy.


Psychotherapy Falls from Grace

All too soon, this blissful era of enchantment ended. The optimistic, even messianic, spirit of the 1970s gave way in the ’80s to an awareness of the dark side of family life (abuse, secrets, sexism) and how societal oppression could be enacted in the therapy room. Incest in particular was a game changer, both as a symbol of male domination and a horrible pathology that therapists had ignored since the time of Freud. (In my early training, I was told that if I ever saw a single case of incest in my career, that would be remarkable.) The “pass” that therapy had somehow received from social ferment about gender (and race and sexual orientation) expired in the mid-’80s. Erstwhile, gurus were now accused of being patriarchs, and the Networker documented the upheaval. Searching articles by therapists like Virginia Goldner questioned whether, rather than transforming therapeutic practice, feminism had merely been co-opted and defanged:

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“I’ve sometimes wondered this year whether feminism has become our newest fashion, replacing epistemology as a high-status subject for competitive family therapists to claim as their own. I’m pleased, as any outsider wanting to ‘get in’ would be, since epistemology, with only a few exceptions, has been a turf owned by men. But now that everyone is declaring themselves a feminist, I can’t help being concerned that the critical edge which is feminism’s essential attribute has been blunted by quick success.

“This wouldn’t be an unusual outcome. Taming a dangerous idea by claiming it as one’s own is a time-honored political strategy, and I do believe that feminism is dangerous to family therapy. One of the most effective tactics I’ve seen for disarming this subversive point of view is a simple one—transforming feminist commentary from a threatening critique into a banal who-could-disagree, piece of liberal cant.”

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At first I followed the critiques of the therapy field with wounded interest. I hated the attacks on my therapy masters (I hadn’t noticed that they were mainly white men like me), and I worried that therapy was becoming “politicized.” But I came to realize that my field, and my own practice, weren’t immune to the pathologies and power imbalances of society. I’d accepted traditional gender roles, ignored racial injustice as a therapy issue, and embraced a systems view of domestic violence that ignored the fact that injuries and fear were usually one-sided.

The only path of integrity was to agree that my beloved profession sometimes caused harm, both to marginalized clients and also to the fabric of society—and that we had to change. Chastened by the vehemence of some of the critiques, I hoped our well-intentioned profession would make some collective headway toward a more socially conscious psychotherapy.

But then, quite publicly and dramatically, the therapy field lost its moorings, when we went from denial to obsession, from constructive critique to fearmongering. With media celebrities like Oprah and Sally Jessy Raphael now focusing on the sexual abuse of children, some therapists started finding it everywhere. I recall colleagues saying, with no research justification, that 90 percent of women with bulimia had been sexually abused as children. (Those who didn’t recall abuse were encouraged to locate it in their memories.) Daycare centers were seen as rife with molestation when questionable interview tactics drew stories out of young children. And influenced by the “satanic panic” occurring in the culture of the early ’80s, therapists started reporting a plague of ritual abuse and even the sacrificial murders of babies in forests and cult houses. Pushback came from courts (which required actual evidence that daycare teachers were molesting children), and the FBI (which couldn’t find the cults or the missing babies).

As much as I regretted dismissing sexual abuse earlier in my career, I was now alarmed at the witch-hunt mentality I saw around me. (A local therapist started to carry a hand gun because he feared the satanic cult leaders would come for him.) Thus, I welcomed the corrective of Lawrence Wright’s blockbuster 1993 New Yorker article “Remembering Satan,” and subsequent book with the same title, which painstakingly dissected how therapists absorbed and then gave support for 1980s and ’90s cultural beliefs about cult sexual abuse and even alien abductions, often through questionable therapeutic practices that led to “recovered memories,” which therapists nearly always believed.

The lack of standards in the field, Wright and others argued, had led to “fads and malpractice.” This was a powerful blow to therapists’ credibility: it’s one thing for therapists to say that your mother messed you up, but it’s entirely different to say that she gave you up to a satanic cult. The Networker, for its part, weighed in with its own critique in an issue entitled “Fallen from Grace,” showing Icarus, the victim of his own hubris, plummeting to earth. As senior editor Katy Butler put it, “Some therapists believed every memory of satanic ritual abuse as gospel, passed around their own invented statistics, misused hypnosis, overdiagnosed, and drew heavily on self-help literature, autobiography, and pop psychology.” In retrospect, she concluded, the profession had wound up feeding a broader cultural fixation on victimhood.

I feel guilty today that I didn’t speak out about it at the time. When colleagues said that 90 percent of women with bulimia were incest victims, I didn’t ask for the evidence, afraid that I was behind the times and perhaps insensitive as a male therapist to what women had experienced. But silently, I wasn’t buying the moral panic of the time. So when the field recovered its sanity, I vowed that I’d never again be silent if I saw therapists go to either extreme, ignoring or exaggerating serious problems in our society.

Around that time, I received some bracing lessons in the limits of therapeutic miracles. I was working in a family medicine setting and got a call from a gastroenterology resident asking me to see 25-year-old Jeanne and her parents. Jeanne was at grave risk because of her out-of-control Crohn’s disease, and the resident hoped that addressing her family issues and drug problem would lower her stress level. When I met with them in the first session of medical family therapy, Jeanne admitted using cocaine and expressed little desire to quit. The parents admitted to having given her a generous amount of financial support, knowing that she probably used some of it for drugs. Halfway through the session, I asked the parents if they wanted to keep subsidizing their daughter’s drug use, even though it was killing her. They both sat up and said, “No!”—whereupon Jeanne bolted out of her chair, screamed that this was unfair, and threw her can of Coke up to the ceiling, spraying the room and everyone in it. She then bolted out, slamming the door behind her.

I calmly urged the parents to not pursue her or apologize in any way, and we continued to talk about how they could stay in her life but communicate that their drug support was over. About five minutes later, Jeanne came back with apologies. She cleaned up the mess she’d made and rejoined the conversation, acting like the adult she was. I called the referring resident the next morning to say that the session was an important start but probably not stress-reducing in the short run. In turn, the resident informed me that Jeanne had just called to say that the therapy wasn’t working because it had increased her stress.

We had a few more sessions and ended on an uncertain note, as it wasn’t clear whether Jeanne had stopped using drugs or found another source of funding. My key learning from this case came six months later, when I got a call from the mother. She wanted to thank me for my work because the past six months, with Jeanne off drugs, had been the best times they’d experienced with her since her childhood—and she also wanted to let me know that Jeanne had died after a flare-up of her Crohn’s disease.

I can’t recall ever having such conflicted feelings about a therapy case. I’d assumed that successful therapy improves lives and, in the case of nonterminal medical illness, extends them. But that day I grew up a little as a therapist and handed in my “miracle worker” badge, accepting with a more mature awareness that even when my clients and I work together well and they move on to do their best, some sad outcomes are out of anyone’s control. Writing this now, it seems embarrassingly obvious. But it took Jeanne and her family to ram home the lesson that therapy, even activist family therapy, often has mixed outcomes. Addictions resurface, depression fails to loosen its grip, or the patient feels better but dies anyway. Therapy is more about the journey than the destination.


The Consumer Self

In addition to the sobering clinical revelations I was having during the 1980s, I had one especially head-spinning intellectual epiphany. In May 1985, I picked up a copy of Habits of the Heart: Individualism and Commitment in American Life, by sociologist Robert Bellah and colleagues. As I read it in bed one night, I felt the hair on my neck stand up. After the authors offered a critique of Reagan-era economic individualism, they went on to fault psychotherapists for promoting something quite parallel: expressive individualism, the primary pursuit of fulfilling one’s emotional needs, with the expectation that if I take care of me, others in my life, as well as society itself, will automatically benefit. To highlight this idea, the authors included an interview with a therapist named Sheila, whose religion she said was “Sheila-ism.” The kicker for me was how Sheila answered the question about why she was committed to her children. All she could say is that it was her “thing” to be faithful to her children—that she’d feel badly about herself if she ever abandoned them.

The scary part was that I saw myself in Sheila’s explanation that her moral commitment to her children was just in terms of what felt right to do at this point in her life. The point wasn’t that she lacked fidelity to her children, but that she couldn’t allow herself to articulate any broader ethical values beyond completely voluntary standards of what feels good and authentic for herself. Would I have done any better at this point, with all my liberated rhetoric? I wasn’t sure.

Habits of the Heart was the defining blow to my fantasy that my therapy tribe was always on the side of the angels. Not only had we ignored social pathologies like sexism and racism, but we were promoting an image of the self that was a version of trickle-down psychological economics, a kissing cousin to what conservatives were doing with the economy. In my own practice, what Bellah called “expressive individualism” showed up in how I guided clients through decisions about divorce, and in how I challenged any client who uttered the s-word, should—a sure sign of inauthenticity. My life journey had led me from the stifling communalism of my youth to the excessive individualism of my professional life. I knew I couldn’t stay where I was, or go back, but which way forward?

Fortunately, I wasn’t alone in my discomfort. By the end of the ’80s, the Authentic/Liberated Self was due for reevaluation. Although it’d been a powerful antidote to the post-World War II era of button-down conformity, it now looked out of balance, with too much self-absorption and freedom to manipulate others, not to mention ignorance of institutional forms of oppression. The broader society itself was now mired in identity politics and a conservative backlash against the liberationist movements of the ’60s. Reagan’s election in 1980 ushered in 12 years of conservative political leadership as political liberals struggled to find a way to replace the now-defunct New Deal coalition. Funding was slashed for the National Institute of Mental Health. In this environment of skepticism and retrenchment, psychotherapy lost its confidence as an expression of larger human purposes. Multiculturalism replaced feminism as the leading edge of soul searching among therapists, but it focused more on institutional oppression and what therapists were doing wrong than on ideas for what everyday therapists, most of them white and middle-class, could do in their offices beyond being sensitive to cultural differences and the realities of oppression. It left us with a call to consciousness, but not a call to action or to a new formulation of the self.

In the midst of psychotherapy’s cultural purgatory, a new image of the self was taking hold in the wider American culture: the Consumer Self. As documented by Harvard social historian Lizabeth Cohen in her book A Consumers’ Republic, the consumer culture had kicked into high gear after World War II, when the US government had asked Americans to spend their way out of the aftereffects of the Great Depression. It was augmented by the unprecedented economic boom of that period, when so many Americans moved into the middle class. The psychologically self-absorbed Me Decade of the ’70s morphed into the greed-is-good economic Me Decade of the ’80s, and continued its ascendance in the ’90s.

More and more, I began to see the language and attitudes of the new Consumer Self (homo economicus) in therapy. Clients who in earlier times would’ve just said they weren’t happy in their marriage were now adding something like, “This isn’t the deal I signed up for when I got married.” Therapists began asking whether a marital problem was a “deal breaker” for a client. Consumer images even started invading parenting. For example, the director of a local shelter and therapy center for runaway youth, founded in the late ’60s, told me that the biggest client category in the ’90s had moved from “runaway kids” to “throwaway kids.” Many were casualties of churning stepfamilies, in which they didn’t get along with mom or dad’s new partner, and it came down to who was going to be forced out. The partner brought resources, and the teen drained them.

I’ll never forget a depressed 14-year old girl named Tobi, whose middle-class parents wanted her to be more communicative. The family had come to therapy because of issues with her younger brother, who had a brain disorder, but Tobi soon became the focus of the parents’ concerns. In one session, the father described a family dinner where he and his wife had asked Tobi about her day. She’d responded (like a typical adolescent) with no information, whereupon they’d angrily sent her to her room, saying, “If that’s the attitude you’re going to have, you can eat by yourself.” Then, as Tobi sat silent on my couch, the father asked me a question that sent chills down my spine: “How long do we have to keep giving to this child before we can expect to get something in return?”

I’d never faced a moment like this in my years as a family therapist. I couldn’t decide whether to string up the parents or scoop up the girl, or both. Instead I took a breath and addressed the parents slowly and intensely, barely holding back a tremble in my voice. “She’s your daughter,” I said. “You have to keep giving and giving. What you can expect back is respect and cooperation, but not openness with her feelings, because that’s a free gift.” As the parents took this in, I noticed the girl sit up in her chair.

The father softened and said, “I don’t know how to reach her.”

I responded gently, “I think you both know how to reach her, and I can help.”

Over the subsequent week, I chose to process what had happened not by pathologizing the parents (tempting as it was), but by seeing them as loving people caught up in a consumer culture of parenting, in which disappointments and frustrations are processed via the lingua franca of self-interest. I was nervous about the next session, but the tone was different from the start. Tobi was bright and participating, and the parents said how important the last session had been to them. Choking up a bit, I told them how much I admired them for taking in a pretty strong challenge from me. This wasn’t a miracle cure—together, they had a longer journey to go—but the parents had backed away from entitled consumer parenting, and Tobi was no longer the center of their frustrated expectations for family harmony. In the big scheme, however, this was just a small moral victory in a culture war increasingly being won by the American marketplace of entitled individualism, with psychotherapy on the sidelines.


Psychotherapy Turns Inward

During the ’90s and the 2000s, the psychotherapy profession, now less sure of itself, went through an economic upheaval that further drained its creative energies and set it up for a takeover by the medical model. Previously based on a prosperous middle class and insurers willing to pay for therapy on demand, the economics of therapy had allowed for successful private group practices and training institutes, which were key sources of innovation. (Think of teams and one-way mirrors.) Healthcare spending began surging in the US in 1980, when annual costs were about $1,000, to almost $4,000 per capita in 1995 (a far higher rate of increase than in Europe). With fiscal and culturally conservative political forces ascendant, mental health costs were easy pickings. Facing the trifecta of limited insurance panels, the predominance of DSM-IV in 1994, and the requirement of “medical necessity,” therapists hunkered down as auxiliaries to the medical industry. As the ’90s was decreed The Decade of the Brain (by the first President Bush), many therapists got the sense that the tide had turned against talk therapy.

The Networker took rueful note of this fundamental change in the world of therapy. As Editor Rich Simon noted, “Therapists played the diagnosing game as if the clients they saw suffered from ‘medical disorders,’ treating them according to the equally fictitious ‘medical necessity,’ and by so doing, therapists were admitted into the medical club. The bargain worked well enough for many years, until managed care threw a wrench into the system by not only limiting reimbursement to specific diagnoses, but also accepting as ‘medically necessary’ only those diagnoses that could be cured quickly.”

This leveraged takeover of mental health treatment came through a big push from Big Pharma and its flock of advertising agencies and complicit psychiatrists. We became Prozac Nation after the much-ballyhooed SSRIs were introduced via much-publicized studies and big-league marketing. Never mind that subsequent studies would find that the SSRIs, although safer, are no better for depression than earlier drugs, that they’re not notably effective for the kinds of mild and moderate depression that therapists (and primary care physicians) most often treat, and that they can be dangerous for kids. At this point, all we could cling to was the both/and recommendation of some researchers: medication plus talk therapy. But that’s expensive for insurers.

Of course, therapists didn’t stop producing new ideas and healing practices in the ’90s and 2000s. We rediscovered trauma as not just the product of violence and war, but as a widespread human experience. After the national trauma of 9/11, we got new insight into the sources of human resilience. The neuroscience fields gave us new insights into emotion, self-regulation, and interpersonal attunement. Along with our fellow Americans, we discovered mindfulness as a way to cope with an era of anxiety and social media saturation. Attachment theory, previously the province of developmental psychology, proved to be fruitful for treating intimate bonds. Cognitive behavioral therapy, with its strong research tradition, reached beyond depression into new areas like substance abuse and psychosis.

But for me, even with all these gains, we lost something that had inspired many therapists in the earlier decades: attention to the larger context and a sense that we could make a difference outside the consulting room. We became more focused on individuals and couples, losing sight of families, social networks, and communities. We concentrated on diagnosing discrete disorders and treating specific conditions. We lost sight of public mental health and social conditions. We got small and surrendered any pretense that we offered the world a vision of the healthy, fully functioning self beyond being symptom free. We stopped claiming a place in the big, contentious conversation that every society must have about what human flourishing should look like at a particular time in history, and how to promote it.

In other words, when we turned inward toward economic survival and a focus on the individual, we left culture-shaping work to business consultants, media celebrities, and entrepreneurs, most of whom celebrated the Consumer Self, either in the form of expressive individualism (Oprah’s You go, girl!), or economic individualism (the subtitle of CEO Jack Welch’s book said it all: Wisdom from the World’s Greatest Business Leader). Meanwhile, a tsunami of anger and social alienation was forming offshore. It would soon wash over the land, making our turn inward seem claustrophobic.


Therapy in the Age of Trumpism

Donald Trump was elected president while I was writing this article. Like many therapists, I experienced his election as a kick in the stomach for the field of psychotherapy. In his public persona, he’s the antithesis of what we promote in our work. At a cultural level, he’s the embodiment of the empty Consumer Self. The election laid bare the dysfunction of so many of our institutions and the frayed status of our social fabric. But in a perversely ironic way, the movement that Trump set in motion is forcing the therapy community to examine our own cultural role and our underlying vision of the healthy connection between self and society.

Almost 20 years ago, Robert Putnam’s book Bowling Alone described the gradual decline of American voluntary social organizations, civic groups, local political activities, churches, and sports leagues. A theme in the media in the wake of the recent election is that this decline of social capital and a widespread sense of alienation has gotten worse. What we’ve seen is the decline in real capital—the interlaced phenomenon of rust belt and rural impoverishment—lost jobs, lost unions, followed by the hollowing out and boarding up of cities and towns (including hinterland villages), which in turn means the disappearance of small-scale, locally owned stores and restaurants that used to be busy de facto social centers. Besides the anger and fear for the future, all this breeds a fierce sense of isolation and emotional impoverishment.

In a recent address, New York Times columnist David Brooks stated, “The crisis of our moment is a crisis of social isolation.” He went on to cite statistics that show people trust their neighbors less and have fewer close friends and confidants than ever before, and they experience loneliness and depression at greater rates. “They feel betrayed by institutions and have lost the sense of dignity they once achieved by doing humble but fulfilling work,” he said. “That code of dignity has been replaced in America with a reality TV code that says, ‘If you’re not making it big, and if you’re not famous, then you’re nothing.’ So you’ve got this massive social isolation, this massive sense of betrayal, and people want a change. They’re completely realistic about who Trump is, but they’re willing to stomach it because they feel threatened by the world order.”

Trump’s ascendancy revealed that a large group of people feel that their society is moving on without them, that they’re not valued anymore, that there’s nothing left for them. They’re deeply alienated, and some feel temporarily more powerful by expressing or excusing expressions of racism and xenophobia and sexism. But Trump—with his rock-star persona (whatever you may think of his “music”), his ability to connect emotionally with people, his achievement of wealth in the consumer culture, his projection of at least the appearance of raw power—has brought them together into a movement, given them a common purpose, forming them into a focused community, with, in their eyes, a real moral and ethical point, which is to “Make America Great Again,” or at least to “Make America The Way It Used To Be Again,” when they themselves counted for something. As Clare Malone of FiveThirtyEight.com wrote about a crowd of Trump supporters, “Something inspirational seems to be happening among the assembled—a sense of collective identity being discovered.” And all of this despite the fact that, according to journalists who interview Trump supporters, most don’t take literally what the guy says he’ll do. It’s enough that he’s given them a voice.

It’s clear that multiculturalism in the therapy field has missed this white, working-class group, who are particularly vulnerable because their fall from grace has been so precipitous. Unlike truly poor people and people of color (who’ve always been outliers in American society), the Trump people did count: they were part of respectable, respected, hard-working communities, which saw themselves as America’s backbone. So Trump tells them they still count, that they’ve been betrayed, that they’re part of a great all-American community, dedicated to a great cause, and should rise again. While it’s hard to tolerate a lot of what they say and do when they’re angry and activated by Trump, there’s real pain there, with a belief in a higher purpose. Nostalgia is homesickness, grief for what’s been lost—or, as many seem to believe, stolen—in a world of globalization, immigration, and affirmative action for every group but their own, with the federal government the chief perpetrator and punisher. The kindling was ready for Trump to strike the match, and similar movements are occurring in many of the world’s democracies.

So you could argue that, inadvertently, Trump has issued a challenge to the therapy field, pointed to a new direction therapists need to take. His ascendency is a bugle call that therapists must begin to take seriously, so as to move beyond focusing narrowly on individual mental health problems when the larger social glue is weakening.

At this time of fragmentation and division, we need to recognize that we’re in the glue business. We know something about helping people connect, about how to form a healthy “we” out of self and other. We also know something about how to depolarize conflict. But first our society needs us to recover our conviction and passionate intensity as a profession, our belief that we have something to offer beyond symptom reduction, something that embodies wisdom about what it means to live a fulfilling, purposeful life in healthy families and communities. We need a new image of the self to counteract the Consumer Self of hyper-individualism, which, because the individual alone is impotent in a mass society, easily falls prey to the tribal loyalties seen in the Trump movement and its siblings in other countries.


The Connected/Committed Self

Fortunately, we’re moving past our decades-long embrace of expressive individualism toward a focus on attachment and connection. This shift can be seen in work as diverse as couples therapy (with its emphasis on attachment bonds), trauma therapy (with its emphasis on connection and community in the healing process), mindfulness therapies (in which self-attunement leads to attunement with others), and interpersonal psychoanalysis (which attends to current relationships as well as past ones). New therapy masters like Susan Johnson, John Gottman, and Daniel Siegel teach that bonds of connection can strengthen the individual, rather than diminish or threaten personal freedom. In a world of centrifugal forces, where politicians talk of building walls, our field has a message of engagement across differences. We’re evolving an image of the self in which connection is central.

But we need something more. Although an emphasis on human connections moves us past the Authentic/Liberated Self, it can easily be coopted by the consumer culture. Powerful advertising constantly calls on our sense of connection to sell us things, as illustrated by the classic Coke commercial song “I’d Like to Teach the World to Sing,” which served as the perfect ending of the epic TV series Mad Men, when Don Draper, the empty-self protagonist, wedded the advertising world to the human potential movement.

As law professor Tim Wu points out in his book The Attention Merchants, consumer capitalism is the most creative force in the contemporary world, able to hijack any personal or collective ideal by turning it into consumer desire, in this case by encouraging us to feel entitled to the best possible relationships that require low maintenance and offer high rewards. So the Connected Self must have an ethical dimension. It must embrace commitment, by which I mean sustained investments in something outside oneself, to relationships and causes that transcend us, extend us, challenge us, and require continual struggle to balance and manage. It’s both feet in, not a toe in the water. Dare I say that commitments require sacrifice—a dirty word in my training (forgive me, Fritz Perls). This Connected/Committed Self is an antidote to the Consumer Self that honors no past obligations unless they promise future rewards.

The vision of the Connected/Committed Self as the underlying foundation of therapy is already becoming more and more evident in the therapy field. John and Julie Gottman have begun emphasizing the role of commitment in couples therapy. “Commitment,” they write, “means believing (and acting on the belief) that your relationship with this person is completely your lifelong journey, for better or for worse (meaning that if it gets worse, you’ll both work to improve it). It implies cherishing and reinforcing your partner’s positive qualities and cultivating gratitude.” Michele Weiner-Davis’s work has long emphasized commitment in marriage, often bucking the tide of expressive individualism in the field. Steven Hayes named his model Action and Commitment Therapy, an approach that helps clients access their deepest values about what it means to embrace a flourishing life, and supports them in being committed to live by those values.

Although attachment-based approaches like Emotionally Focused Therapy don’t use the term commitment as a central concept, they emphasize how secure attachment creates the possibility of enduring bonds of connection. Attachment is impossible without a sense commitment, which creates a safe space for vulnerability. And attachment, in turn, can lead to deeper commitment and responsibility to repair the union when it’s broken. As a folk marriage counselor said in August Wilson’s play Joe Turner’s Come and Gone, “You can’t bind what don’t cling.”

The idea of the Connected/Committed Self reflects an emerging conceptual shift to seeing relationships as part of the self, as inherent in the very idea of the self—not self in relationship, but the relational self. This was a core principle of family systems theory that got diluted when family therapy became just one intervention among several to treat DSM disorders. It’s at the heart of interpersonal neurobiology and attachment therapies. It resurrects the premodern idea that the fully separate self doesn’t exist—there’s no I without we—but with a modern twist, which highlights both the complexity and the agency of the individual person and the embeddedness of this person in a web of family, friends, and community. Emphasis on commitment adds the idea that long-term embeddedness comes only when our closest relationships—and our relationships to community—involve a strong dose of ethical commitment.

New therapy ideas usually emerge by rejecting what came before. But I propose doing it differently this time. Embracing the Connected/Committed Self doesn’t mean that we abandon the wisdom of therapy’s previous models of self; in fact, we can claim the enduring wisdom of Freud and humanistic psychology. Starting with Freud’s two major life tasks—love and work—we can see our personal relationships and our work not just as venues for the Consumer Self (how much love am I getting, and what’s in my paycheck?), but as places where we commit ourselves to people and to meaningful tasks, and where our lives become larger. Psychoanalysts have also taught that we’re never without ambivalence in our connections and commitments. Even though we’re always conflicted to some extent, we press on.

Humanistic psychotherapy’s enduring wisdom, for its part, involves authenticity and personal agency. Without these values, connections are superficial and commitments are externally driven and soul-diminishing. But commitment adds an underplayed element in the Authentic/Liberated Self. Therapists have often disparaged commitments that create emotional pain and struggle for the client: difficult marriages that have multiple stakeholders, work commitments that strain one’s personal life, public commitments that are easily framed as distractions from doing the “real” work of self-healing and self-care.

June, a senior family therapist and social activist, once told me that periodically, when she’d entered therapy, she’d been encouraged to see her social activism as a kind of displacement of inner conflicts. So she’d pull back from these commitments while in therapy, only to return again after therapy ended. In retrospect, she resented how her investments in a better world were diminished in therapy that was otherwise good and productive. And it isn’t just June’s therapists. For the most part, psychotherapy has split the public world off from the personal world, with the consequence that most of us don’t know how to support our clients’ civic engagement beyond its being a source of social support for them. What about healing the self and healing the world as twin processes, with synergies as well as tensions between them?


The Road Ahead

In today’s fragmented and polarized world, the ideal of the Connected/Committed Self must involve engagement with community. The link between personal healing and giving to others who have suffered has been well established in feminist-informed therapies for many years, as witnessed in Lisa Goodman’s work with small groups of depressed, low-income women who engage in collective social-change projects as a way to solidify and expand their personal healing. Ramon Rojano’s Community Family Therapy invites those who’ve found their way above water to receive leadership training in their communities. Jack Saul engaged community resilience in New York after 9/11 and more recently with the Liberian community in Staten Island. Alcoholics Anonymous has the 12th step of sponsoring someone newer in recovery. And of course the great religions of the world got there a long time before the advent of psychotherapy: healing the self and healing the world are deeply interconnected.

But the idea of clients as citizens of larger communities, as contributors to their larger world and not just as receivers of social support, hasn’t entered the mainstream of therapy. I had a wakeup call on this some years ago, when I was finishing up work with a couple who’d found their way back from an affair, chronic pain, and struggles over stepfamily life. I can’t recall how the information came up, but I discovered that 20 years before, this couple had been behind the creation of a major children’s institution in our city. They’d been sitting in their kitchen wishing their children had an opportunity (I’m keeping details light to protect their privacy), and they decided that it should be available for all the local children. A dozen years later, with lots of others on board, it happened. I frequently took my own children to participate in it. What struck me was that despite working with this couple for more than a year, I’d known nothing about their commitment to their community. It was deeply relevant to who they were as individuals and a couple, but it had remained hidden from therapy because our focus was on their personal world and on how their near environment (like work) affected them.

I’m sorry to say this experience didn’t make me change how I’d work with clients in the future. I couldn’t see a way to bring a citizen dimension into therapy without “changing the subject” when clients came to sessions with personal concerns or environmental stresses—this despite the fact that in another part of my career I’d been engaging fellow community members in social-action projects. My therapist identity was cut off from my civic-activist identity. Therapy was about personal and relational healing based on the agendas clients brought, not about having conversations about public issues, unless those issues, like racism, were directly impinging on clients. And it certainly wasn’t about how clients could make a difference in the world.

A catchphrase of the feminist movement was the idea that the personal is political. The election of Donald Trump has led me to see the connection between democracy and therapy in a new light. Democracy, as I’ve come to see it in my public practice of community organizing, is about collective agency, the ability of people to work together to solve problems and have an impact on their world. It’s only secondarily about elections and government, because without we-the-people having a sense of joint efficacy, democratic forms of government are hollow and given to authoritarianism and oligarchy. Democracy, in John Dewey’s terms, is a way of life. It’s about ordinary people deliberating across differences and taking responsibility for their future together—before, during, and after electing their public officials.

I see two core links between psychotherapy and democracy. The first is that personal agency, which is necessary for collective agency, is at the heart of psychotherapy— we help people create meanings and act in accord with their aspirations and values. People without a sense of efficacy in their personal lives will have trouble maintaining a democracy. The second link goes in the other direction. Outside of free democratic society, therapists’ ability to foster personal agency is severely compromised, as I discovered when my graduate students returned to countries like China and Vietnam, where they had to be careful about how they encouraged their clients to speak and act in the community. (One therapist led youth-support groups in the woods so as to avoid attention from local authorities.) And of course in the US there have always been antidemocratic, agency-squashing practices (think Jim Crow and more recent civil rights abuses).

The link between psychotherapy and the public domain, I now realize, is through seeing therapy as a form of democratic practice that starts in the consulting room. Our clinical work prepares people to be active shapers of their personal lives and also, if they choose, to join with others—in the Hebrew phrase, tikkun olam—to repair the world.

In truth, this work can be anxiety-producing for therapists, so we need a lot more therapists developing the craft of these personal/public conversations in therapy. When is it therapeutic, and when does it become a way to avoid real work? How and when does the therapist share personal views and reactions to public issues? What happens when the therapist gets triggered by a client’s polar opposite—or even offensive—public views? What resources can therapists provide clients who want to engage in civic action? Since most therapists are on the liberal/progressive side of the spectrum, how do we avoid letting therapy be seen as part of a partisan political agenda? How do we avoid sending messages to clients that our regard for them depends on whether they agree with us politically?

On one hand, all of this reminds me of other big shifts in what we do in the therapy room: at first they seem antitherapeutic, maybe even unethical, as when therapists began to treat marital distress by having both spouses in the same room. On the other hand, feminist therapists and other social-justice therapists have been pushing this envelope in therapy for decades, so it’s not really new. Maybe what is new is the democracy theme, which assumes that everyone has a stake in the public domain, can be affected the public stress (Trump supporters included), and can be part of the solution through personal action (such as talking about issues in their social network) and collective action (by joining with others to work on change).

The realm of public concerns of clients in today’s world is likely to be far ranging if we invite them to share what’s on their minds and in their hearts. These concerns could include local public schools, community safety, the lack of insurance support for mental health treatment, local police practices, threats to the planet, or the influence of the internet and social media on children. Note that these can cut across traditional liberal and conservative lines, but I predict that one of the main public stresses that therapists will be dealing with now is the Trump presidency: how will we deal with the Trump effect on our clients, and how will we address the larger threat to the public mental health and our democracy? Clearly, we have work to do. Each of us will need to decide how far we’re willing to extend ourselves into the world beyond our consulting room.

What’s next for me? After being prodded and challenged by my therapist daughter not to aim low or think small (as therapists have often done since we lost our cultural mojo), I’ve decided to launch Citizen Therapists for Democracy, which I envision as an association of therapists developing and spreading transformative ways to practice therapy with a public dimension, rebuilding democratic capacity in communities, and resisting antidemocratic ideologies and practices wherever they arise. (Okay, a bit daunting, but why not dream big?) It’s for colleagues who are attracted to the idea of the Connected/Commitment Self in personal and civic life and who want to find ways to bridge the divide between the personal and the public dimensions of life in the therapy room and the community.

Though tempered by age and experience, and not expecting cultural transformation in my lifetime, I’m fired up for a new leg of my pilgrim journey. Our world needs what therapists have to offer. We’re connectors, glue makers. We understand the complexity of the human spirit. We know that embracing differences is difficult but life enhancing. If we raise our sights and keep in mind that we’re in this culture and not above it, our profession can contribute to a flourishing democracy, where people can be agents of their own lives and builders of the commonwealth.


***

William Doherty, PhD, is a professor and director of the Minnesota Couples on the Brink Project and the Citizen Professional Center at the University of Minnesota. He is founder of Citizen Therapists for Democracy. His books include Take Back Your Marriage and Medical Family Therapy with Susan McDaniel and Jeri Hepworth. Contact: bdoherty@umn.edu.

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2 Comments

Monday, January 9, 2017 9:17:36 AM | posted by George
In an era where I struggle to retain a core central sense of purpose as to why I continue to strive to be a better therapist, Bill Doherty reminds me that is all about being a better person and that this is something that is not a solitary quest but one that is achievable only through connection and community. I return again and again to Bill's work and his writing and find his words here very timely and very necessary. Thank you.

Monday, February 20, 2017 3:33:02 PM | posted by Cindy Trawinski, Psy.D.
Thank you Dr. Doherty, for this comprehensive contextual perspective on the psychotherapy profession, on your own career and practice as well I expect on many others' professional journey. You may find the work of educator, author, Jungian analyst and physicist, Arnold Mindell of interest. His body of work, often referred to as processwork or process-oriented psychology focuses on the inter-relationship of our inner experiences and identities and our outer experiences in the world. He has written extensively about a concept he calls "deep democracy" -- an attitude that values of all voices as important for the well-being of the whole organism. His therapy paradigm stresses identifying and work intentionally with 3 levels of experience: intrapsychic or individual processes; relationship processes between people, and world processes that impact many of us and that we as individuals also impact. He has developed many powerful methods for addressing inner and outer conflict that can be used with individuals, couples/relationships, families, small groups, businesses and social organizations, communities and even groups of several hundred. You may find these relate to and strongly support your idea of the Connected/Committed Self.