Tuesday, August 10, 2010

My Life in Therapy

I got an email from one of our readers asking for the Shrink Rappers' opinion of an article in the New York Times by Daphne Merkin entitled "My Life in Therapy". My first thought was: "I am sooo not the person to be blogging about this." My clinical practice consists entirely of medication management, occasionally with additional crisis intervention and brief supportive therapy. I know that Dinah will have more to say about this story when she gets back and will probably say it better than I can. Nevertheless, I'll give it a shot.

In keeping with the Dinah tradition, I'll summarize the story and post a couple excerpts, then give my thoughts on it and ask for comments.

Merkin writes about her forty-plus years of experience as a psychoanalytic patient in New York City. Her first therapeutic contact took place when she was ten years old; she writes about her initial ambivalence and resentment of her therapists, what therapy has taught her over the years and also what therapy has cost her in both financial and personal terms. In spite of her professional and successful outward appearance, she suffered from repeated episodes of depression. Therapy helped keep her alive, but also occasionally provoked the symptoms she was struggling to contain:

"In therapy that was more psychoanalytically oriented...I tended to get trapped in long-ago traumas, identifying with myself as a terrified little girl at the mercy of cruel adult forces. This imaginative position would eventually destabilize me, kicking off feelings of rage and despair that would in turn spiral down into a debilitating depression, in which I couldn’t seem to retrieve the pieces of my contemporary life."

Although she knew that therapy would not provide her with a "cure" per se, she travelled from one analyst to the next in the hope of converting her “hysterical misery” into “common unhappiness”. Finally, while looking for her last doctor, she came to a conclusion:

"Now, however, in my 50s, I only felt persuaded that the last thing I wanted was to put myself into Dr. F.’s hands. I realized that I had been carrying a “Wizard of Oz”-like fantasy with me all these years, hoping to find someone who would not turn out to be just another little man behind a velvet curtain. It was not that I found all my shrinks to be impostors, exactly, but it dawned on me that I no longer had the requi site belief in the process — perhaps had never had it in sufficient quantity."

For the first time, she decides to try living a life without therapy: "All those years, I thought, all that money, all that unrequited love. Where had the experience taken me and was it worth the long, expensive ride? I couldn’t help wondering whether it kept me too cocooned in the past to the detriment of the present, too fixated on an unhappy childhood to make use of the opportunities of adulthood."

There are obviously limitations to what Merkin can write about: the only type of therapy she experienced was psychoanalysis, and it was unclear to me whether or not her clinical depression was ever adequately addressed pharmacologically in spite of the fact that all of her analysts were psychiatrists. Setting aside these issues, I was disappointed in the story. Her chronological list of therapist descriptions eventually took on a vacuous, droning tone of endless disappointments. She admitted that in spite of years of experience with treatment she lacked the ability to recognize a good therapist; she judged each new potential doctor based upon their wardrobe, or the office decor. The article appeared to be mainly a depiction of the New York analysand zeitgeist rather than a progressive story of one individual patient.

Frankly, I've heard better descriptions of the therapy experience, descriptions that were deeply personal and more heartfelt, from our readers. Merkin's article lacked poignancy, intensity and warmth and for me it had the feel of an intellectual exercise rather than a personal revelation.

She made one point successfully: that although the unexamined life may not be worth living, sometimes the examination of life takes the place of living.


Alison Cummins said...

“She admitted that in spite of years of experience with treatment she lacked the ability to recognize a good therapist.”

Well yes. I think this is a very common situation for therapy patients to find themselves in.

Fourth-graders often complain that school is dumb, or that math is dumb, or that french is dumb. Parents rarely respond by taking fourth-graders out of school. They may make sure that their child is doing their homework, ask questions to see if the child is behind, talk to the teacher to get the teacher’s perspective, move their child to a different school, volunteer in the class to make sure that the teacher knows they are being watched, or move the child to another school. Most often fourth-graders are coached that they will appreciate their educations later, to be polite to the teacher anyway, and to do their homework so they don’t feel so stupid in class.

Agreeing that math is dumb and that nobody should have to learn it? Not so much. Agreeing that Ms. ___ is a poopy-head and that fourth-graders should hang around in the schoolyard and eat popsicles instead of attending her class? Not so much.

When a mental patient goes to a therapist and responds by thinking “therapy is dumb,” we do the responsible, adult thing by assuming that we are responding like fourth-graders to difficult material. The problem is not therapy; we should be able to learn from therapy even if we aren’t that keen on the therapist on a personal level; the problem is us.

See, isn’t that grown-up and mature of us mental patients? Taking ownership of our own issues? So we continue to see destructive poopy-heads because we don’t know how to decide not to.

Anonymous said...

A post containing some of those "better descriptions" would be wonderful. I'd love to read it.

Anonymous said...

You did a great job!
I read the article and I would have picked different quotes.
Merkin has written in the NYTimes before about her depression and hospitalization, so I think we can assume she's being reasonably treated with medications (I think she was on the verge of starting ECT at one point).
Here's what I was struck with:
--She feels therapy has saved her life, and that is valuable. Titrating exactly how much therapy is necessary to save a life is hard, but whatever.
In her final paragraph, she talks about therapy being a place to process her emotions in a productive way and that sounds useful.
Aside from that, she describes therapy in a self-indulgent way where it developed a life of it's own. She describes an often-non productive, regressive event that lacks the creativity to look and say, "Hey, where are we going with this, is it accomplishing a goal, and if not, should we try something else." There is the assumption here that psychoanalytic therapy done hard and long enough will yield answers and results, even when decades later, it doesn't seem to be getting her where she might want to go ?
Seems like the cheerleader doctor, the one who wasn't so analytic, was the most helpful, and the one who could allow Merkin to quietly stop therapy without feeling guilty or like she was quiting, with the quiet reassurance that she would remain there for her.

moviedoc said...

Do I hear what analysts do best? Blaming the patient for not getting better? It seems like one of these people could have said, "Enough already. This isn't working. Try something else." But that would be too active.

I didn't get the sense that all of these "therapists" were psychiatrists or psychoanalysts. I may have known the guy who went off his roof, and if so I don't believe he was an analyst, though he was a psychiatrist. (I was in the ER when they wheeled him in. ~1980. How many NYC psychiatrists jumped (or fell) off the roof of their house? (How many people in NYC even live in a house?)

Analysts could write tomes about the success or failure of Merkin's "treatment." They can understand anything in analytic terms. What does that mean? And what does it have to do with treating mental illness? Can we measure it? Is it worth the money?

Sarebear said...

Very well done post, Clink! I agree with your conclusions.

There was a part about the therapy interfering with life, or something, that I am currently identifying with, or therapy becoming . . . worsening the problem, yeah that's it.

See, the loss and pain I'd been feeling about LOSING therapy because our insurance ended July 31, is what's triggered my current mania, as well as a whole HOST of other things and issues. I was so desperate to handle stuff that I didn't know how to handle that, despite husband being out of work, I paid out of pocket for a therapy session on Monday.

Ironic, huh, to go to therapy to deal with the loss of therapy . . . . . actually, alot of it had to do with some writing I did last week, that he had recommended that I do, in our last July appt, that brought up alot of baggage that I just couldn't handle on my own, anyway.

More here at my new alternate blog cause my in-laws suck and don't deserve a window into my life My VOX Blog, yet to be officially named.

I've since secured some interim help from my church to pay for weekly therapy short-term, because this manic episode I'm having has the potential to shove me into some life-changing, in a bad way, decisions that are life-wrecking. It's like an episode I had 15 years ago, and it scares me. I'm glad I've got some therapy now to try and help me reign these galloping horses in.

Trying to work on seeing what the psychiatrist can do, gotta get that on board now.

Sunny CA said...

"or something, that I am currently identifying with, or therapy becoming . . . worsening the problem, yeah that's it."

I identify with that comment. This is hard for me to evaluate since my pdoc observed that I have chronically ignored my feelings. Examination of these feelings with him invariably makes me feel worse, but is it better than the accumulation of unacknowledged feelings that get "swept under the rug"? I don't know. Sometimes I wish I'd go back to distancing myself from my feelings.

ClinkShrink said...

Alison: I don't have any doubt that some people continue to see unhelpful doctors (of any specialty) because they don't have the knowledge or the confidence to go elsewhere.

Anon: Some of our readers disclose personal experiences that can't go on the blog.

MovieDoc: Great questions and I wish I had the answers. To some people it's worth paying out of pocket. To insurance companies, not so much.

Sarie: Thanks for the movie trailer link. That may be our next Shrink Rappers' outing.

Dinah: Come back soon, we miss you!

Anonymous said...

Clink did a wonderful job.
I had a very difficult time reading the article itself on Sunday morning. I could not wait for it to end. It was putting me to sleep and I wondered if she had the same effect on her analysts over the years.

Alison Cummins said...

clinkshrink on the realities of therapy: “I don't have any doubt that some people continue to see unhelpful doctors (of any specialty) because they don't have the knowledge or the confidence to go elsewhere.”

clinkshrink on the vacuous, droning tone of endless disappointments:
“She admitted that in spite of years of experience with treatment she lacked the ability to recognize a good therapist.”

I’m wondering why you seem so critical of mental patients who don’t know how to decide that they (who are crazy) are right and the highly trained specialist who works with lots of crazy people is wrong.

It’s an intrinsically hard problem. And blaming people who don’t know how to solve it is not helpful.

Sarebear said...

My new post resulting from the article

I wrote a post relating the article to my life in therapy, a little bit, this year. About something, two quotes from the article that sort of go together, that had struck me.

Sarebear said...


My link didn't work, here's the low-tech copy and paste version, sorry!

Maggie said...

Alison, it doesn't make sense to say that someone who needs therapy should be taking ownership of their issues. If it were a matter of taking ownership of your issues, you wouldn't need the help of a therapist! It sounds to me like you're defending therapists who don't take ownership of their own practices. Not all therapists are very good. Some are outright awful. There needs to be a certain level of responsibility on the part of the patient, but you make it sound as though there are no bad therapists, only bad patients. It doesn't work that way. Some fourth grade math teachers are terrible. And if such a teacher is bad enough that the parent, or a hired tutor, or somebody else, is the one teaching the child the math, then the math teacher isn't doing their job. Sometimes a parent does have to agree "yes, your math teacher is pretty bad, we'd better find you a tutor so that you can learn this." Just because some fourth graders complain about decent math teachers doesn't mean that there are no bad math teachers or that any student can learn from any teacher if only they try hard enough. Sometimes something more is needed.
I don't think ClinkShrink has been critical of patients who can't recognize a good or bad therapist, but rather of patients who have been in therapy for forty years of therapy for neurotic disorders and still can't recognize anything about the quality of a therapist. After nearly half a century of therapy, it's hard to fathom how someone would have no idea what it is that makes a therapist helpful. If anything, what she's criticizing is patients who don't take ownership of their issues by evaluating the effectiveness of different therapies and therapists.

You seem to want to have it both ways, that patients should blindly trust that a therapist knows what's best, and at the same time, take ownership of the issues that brought them to therapy, whether or not the therapist is helping them! That doesn't make any sense at all.

Anonymous said...

Reading Daphne Merkin's account made me extremely sad. Like her, I can say it saved my life. But unlike her, I know how profound that is. I tremble as I write this knowing it so fully. I started out railing, tormented and knowing it was only a matter of time before I deservedly, viciously destroyed the horrible being I was. It took a LONG time, and incredible patience, insight, genuine inquiry and open mindedness, a committed presence, and yes - a kind of love - on the part of my analyst. Oh yeah, on my part too. Not only did it save my life, I am so much of a better human being to all around me able to love and give.

I'm sorry Daphne Merkin did not have this experience. But just because she is "famous" and has a fine platform to write doesn't mean it characterizes all psychoanalytic experiences.

Thank you for addressing this. And for the platform.

Sarebear said...

Anonymous, this part of your comment rings so true for me, despite what I say above,

"I started out railing, tormented and knowing it was only a matter of time before I deservedly, viciously destroyed the horrible being I was. It took a LONG time, and incredible patience, insight, genuine inquiry and open mindedness, a committed presence, and yes - a kind of love - on the part of my analyst. Oh yeah, on my part too."

I cringe at the love part, but a human kind of connection that is very platonic, and more than just a passing acquaintance would have; I feel like he genuinely cares for my well-being, and if I didn't feel that way, therapy wouldn't be as effective. It kind of gets danced around sometimes, but there is a . . . real, absolutely sincere concern and caring that is difficult to describe, that after years I think fits under a certain respectful, distant kind of love that you would have for someone whom you genuinely care about. Not "in love", but . . . he conveys a genuine concern that comes across, and everything anonymous said above.

Of course, all of this is PAID for, and the other day I said, "I have to pay you, to be important to you, "and I noted that he didn't really respond to that, rather he dealt with other aspects, other things I had brought up that I had been substituting in my life for meaning that I was important, which really didn't mean I was important at all, it was the false self trying to gratify that empty hole inside me that will never have enough, that doesn't feel sufficient, that no number of people or attention or any of these dangerous behaviors I'm currently being pulled to that substitute for feeling important, will ever be "enough".

Anyway. A merging of personality disorder with mania is not a good combination, here. Ugh.

Ah well, life sucks, and it goes on. Darn it.

Alison Cummins said...

Sorry Maggie, I guess I wasn't clear. I agree with you completely!

I have seen therapists on and off over the years and usually hated it. I always assumed it was my fault; I assumed I was being like a fourth-grader complaining that math is dumb. Of course I knew that the therapist might be not so great, or wrong for me, but since I was the one who needed therapy complaining that therapy was dumb would just prove that I lacked insight. If the therapist was actually good, carrying the attitude that therapy was dumb would interfere with my ability to make a go of it. Unlike a fourth-grader I didn't have a parent to take an objective look at the situation. So I stuck it out, even when I hated it, even when I thought the therapist was a poopy-head, even when (looking back) the therapist was actively doing me harm.

This is a really terrible situation to be in and I still don't really know how to protect myself against it.
Therapists often tell you that getting worse is a sign that you are doing great work in therapy - therefore that you are actually getting better. If they ever right about this, how is a poor patient supposed to be able to tell the difference between getting worse and getting better?

I have a lot of trouble with therapists/ psychologists/ magazine writers who explain breezily that it's up to the patient to do their homework and choose a good, qualified therapist. And that everyone who has a mental problem can benefit from therapy. But most of all, I have a problem with the general attitude that therapy is risk-free.

Maggie: "You seem to want to have it both ways, that patients should blindly trust that a therapist knows what's best, and at the same time, take ownership of the issues that brought them to therapy, whether or not the therapist is helping them! That doesn't make any sense at all."

That's exactly the point I was trying to make. It doesn't make any sense at all!

I am really sensitive on the topic of blaming crazy people for not knowing how to pick a therapist. If therapy isn't helpful, by this logic it is always the patient's fault. Even if the therapist is dangerously incompetent, it's the patient's fault for not firing them.

So when someone like clinkshrink blames the patient for being dull and vacuous for not knowing how to pick a therapist, I react. It's not helpful.

Maybe she thinks therapy is decadent and is prejudiced against the pampered types who can avail themselves of it; maybe she thinks that anyone who can get therapy has it pretty good and shouldn't be complaining. Fine, if that's true, I can sympathize with that attitude.

But out here in the free world, therapy is part of the culture. We know we're supposed to see therapists when we have mental problems just like we know we're supposed to see dentists when we have tooth problems. Blaming patients for doing what "everyone knows" you're supposed to do is not helpful.

The difference between therapists and dentists is that if your dentist makes your dental situation worse you know you got a bad dentist. If your therapist makes your mental situation worse, you can't know it was the therapist. Even when it was.

Alison Cummins said...
This comment has been removed by the author.
Maggie said...

Wow, I definitely missed the tone of your comment! Actually I think there was a study recently about how some huge percentage of people who correspond online (I think it focused on e-mail or forums, but this is the same gist) believed that they correctly interpreted the tone of what they read, while some tiny percentage actually did interpret it correctly.
I would start by saying that it's the bad ones that take the attitude that you described! If you know that you need therapy, then you really can't be compared to the fourth-grader who says their class is dumb; the comparison would be to someone who has decided to take a class in something that they want to learn. You want to be there, you're willing to put effort into it, and so you have the discretion to say whether or not you're getting out of it what you want to get out of it.
Personally, I consider that "well if you're feeling terrible, the therapy must be working" bit to be, in most cases, nothing but a line to excuse bad therapy. There are exceptions, but for the most part, if you're going to therapy for depression, it's supposed to make you feel at least somewhat better. I'm sure that's not the case for some trauma issues, and maybe less the case for someone who has never been in therapy before and hasn't thought about their issues much, but for the most part, therapy should help.

You're also right about that attitude that therapy is risk-free, and it's one that can be really hard to explain-- especially because I don't quite understand how anybody could be under that impression to begin with. If you admit that past experiences, things that have been said, things that you've been convinced of, have contributed to your problems, how can you say that talking to a person (who may be totally clueless and/or abusive) could carry no risks of doing damage? I never know how to go about explaining something that seems painfully obvious to me, when the other person acts as though they've never even considered the idea. Where do you begin?

BUT.. I would still think that someone who has seen multiple therapists in the past would have some basis to gauge the quality of a therapist or therapy. You should at least be aware of what HASN'T worked, right? Granted, there's an extent to which someone could say "yea, but you don't know why it hasn't worked" but I'd say that if a particular therapy hasn't worked, and I'm looking for a new therapist, I'd go with one who uses an approach I haven't tried before. I would also NOT go with one who dismissed my feelings and beliefs, or who pulled the authoritative thing. If they have some reason to believe something, they can explain it. If they can't even explain something, why should I believe that they understand it themselves, or can help? I'm sure that having studied so much psychology and biology, I have advantages a lot of other people looking for therapists don't have, but shouldn't it be obvious that if a therapist makes you feel belittled and pathetic, they're not going to help you? And therapy is a big expense. You wouldn't spend that much money on anything else without properly researching it first.

Moreover, shouldn't an author with an extensive education and theoretically phenomenal abilities of reason and research be able to judge a therapist by something more telling than decor?

EastCoaster said...

You should read her earlier article about her experience in the hospital. I'm not psychopharmacologist, but it sounded like she'd been on many different meds and cocktails.