What's psychotherapy for?

Psychotherapy is used in basically two situations. The most obvious of the two is to reduce symptoms, such as symptoms of depression or anxiety. The model in people's minds is the medical one: to return the patient to a previous state of health. In this model depression and anxiety are seen as abnormal processes with at least theoretically a genetic predisposition and with a biochemical base. Psychotherapy and medication are ways to re-normalize the symptomatic patient and make them well. For most such illnesses, we can predict reasonably well what kinds of treatment work, and how long they will take, on average, to produce the desired return to health. Medical insurance is designed to work well with these parameters, since expense is fairly easy to anticipate.

But many people have an underlying sense of unease and unhappiness that doesn't add up all the way to depression. Sometimes we call it dysthymia, if it comes to medical attention at all. Mostly it doesn't come to the attention of a professional person. The person may simply accept discomfort as "the way life is". Most people tend to assume that there are no better options, that life simply is more unhappy and disappointing than it is happy.

The second purpose of psychotherapy is dealing with this problem. Clearly does not appear to fit with a "medical model", as does the symptom-reduction paradigm. People in this state of mind tend not to have much fun, to have limited creativity, limited capacity to engage whole-heartedly in relationships, to have recurrent patterns of mild (or extreme) failure. They experience repetitively unsatisfying jobs or marriages. Unpleasant things seem to happen over and over again, to a greater extent than other people experience. They have "bad luck" and they expect to have "bad luck".

While people who live like this are not "mentally ill", therapists who treat such problems and who want insurance reimbursement must have a diagnosis. We may call the patterns "personality disorders", but that's misleading. A personality "disorder" is way of life and pattern of values that is dysfunctional to the degree that the person is actively inconvenienced or harmed. The same pattern of choices and values that does not interfere with one's life is called a personality "trait". Personality traits are what recognizably distinguish us from one another. For instance, we like surgeons who are meticulous and precise. We like teachers who are funny and "show-offy".

The definition for the difference between personality "traits" and "disorders" is the degree of dysfunctionality, but that's a very relative and personal thing. Who isn't (at least sometimes) dysfuntional? and what does that mean, anyway? Dysfunctional by whose standards? Some of the definitions the psychiatric textbooks offer refer to their negative impact on others; other definitions refer to unhappiness of the individual or even to the individual's unwillingness to live up to the standards of society. If the surgeon described in the preceding paragraph spent hours obsessively counting sponges until the patient bled out we would consider his meticulous and precise traits as dysfunctional, or at least, the patient would.

Personality traits are simply our preferred styles of operating in this world. Different families and family circumstances produce different personality styles in their children, although there is considerable evidence for innate temperamental differences among neonate children. These styles are simply preferential patterns of behavior, and they are not problematic unless they are so rigid or so limited that they interfere with normal functions. At what point they become "disorders" is not at all clear. For instance, with "borderline personality disorder" there are many criteria which can exist in varying degrees and combinations, so there may be (using "official" criteria) as many as 84 different ways one can be "borderline".

For a psychotherapist working to reduce symptoms (the first type of psychotherapy described) an accurate diagnosis is very important. A variety of techniques exist to quantify the type and severity of the many symptoms associated with the many disorders. Criteria exist to separate "normal" symptomatology from "clinical" disorders. However, in working with unhappy people, people with limiting or even dysfunctional personality traits, diagnosis is not very important. In fact, to lump people in this category with "mental disorder" or "mental illness" is inappropriate in the extreme.

Psychotherapy with people who are mildly but persistently unhappy or who are dysfunctional in some very circumscribed ways is a very different operation requiring very different skills than those skills required when engaging in symptom reduction. Clients in this category may be highly successful in many ways; they typically have problems only in very specific areas. A brilliant academician might have difficulties with intimacy; an entrepreneur running several companies might find themselves chronically bored; an entertainer, loved by many, might find it impossible to respond lovingly to any one person. The newspapers are full of examples.

These people do not fit within the medical model. There is no "normal" state to return them to. There may be few or no symptoms to reduce. There may be no predictable time-frame for psychotherapy. There may be no clear "cure" or point at which therapy should terminate. (Freud addressed this issue in an article published in 1937, entitled "Analysis Terminable and Interminable). Insurance companies hate this kind of"treatment" because it's hard to label, hard to predict, has uncertain outcomes when outcomes are measurable at all. When can one say they are "done"?

I do not believe that medical insurance companies should be liable for payment for treatment of this kind of disorder. Most people who suffer chronic dissatisfaction and unhappiness don't ask for help. Much of the time they don't even realize that it is their choices and values that are causing the problem, and they may assign blame to others or society, not because they are somehow "irresponsible", but because they don't see the connection between their choices and their lives. Do they "need" therapy? No. They can live their lives out without ever changing the things that contribute to their unhappiness. Could they benefit from psychotherapy? Unquestionably, if they're willing to make the changes they will need to make. Usually they don't ask for psychotherapy until their difficulties become intolerable and unavoidable. In a later note I will post some thoughts on how this kind of therapy works (or doesn't work).