“Phoney” Therapy

“Phoney” Therapy? “Phone therapy is phoney therapy” A very experienced and adept psychoanalyst made this acid remark, quoted approvingly to me by a psychiatrist who holds him in the highest esteem. More than a decade ago, I had a patient who had had a very hard time both inlife and in therapy. I was by no means her first therapist. I practice in Baltimore and she was offered a plum job out west. She wanted to take it. One of the major areas of work in our therapy was to help her see just how talented she was and to stop apologizing for it and colluding with the theft of her ideas by co-workers. While she he wanted to take the job, which represented real recognition for her and a real and useful boost in income, she did not want to stop her therapy, feeling that at last she had found something like an emotional home. She proposed that we continue once or twice each week on the telephone. She said she would fly back to the east coast from time to time to see me. I dithered. It was not something I had done before. Previously the therapy I had done had involved both participants breathing the same air alone together in the same room at the same time. I told her that I needed time to think about it. Why couldn’t she find a competent therapist where she was going? Probably she could, but she and that therapist would not share the years of accumulated context that she and I had together. She was very interested in... read more

Do You Get What I’m Talking About?

“Do you get what I’m talking about?” is one of the most difficult questions that a patient can ask a therapist. It is difficult because it goes right to the heart of the enterprise of therapy. It is also slippery. Just what is the import of the question? Does it mean something like, “Do you wholly and without reservation not only understand what I’m saying, but resonate with it and agree one hundred percent with me?” In thinking about the slipperiness of the question, it helps to keep in mind that so many of a child’s complaints that “it’s not fair” really are complaints that the child has not gotten his way. Of course, it is not simply children who reason this way. Also, what are the criteria for a therapist’s knowing that the therapist “gets” what the patient is saying? If the therapist feels that the therapist “gets” what the patient is saying, if the therapist is passionately of a mind that the therapist “gets” what the patient is saying, does that mean that the therapist “gets” it? Any experienced therapist knows that it is possible both to be convinced that he or she “gets” what the patient is saying and to be quite wrong. “I would never go out with a person like that. It’s a bad fit and it just wouldn’t work. I’ve explored it enough in my own mind. It’s all wrong. Do you get what I’m talking about.?” This young woman was very convincing and her therapist was not bothered by the fact that she was too adamant and so agreed that he “got”... read more


Patient: “Tell me what to do. You have to tell me what to do.”Therapist: “But I can’t.”Patient : “Are you sure that it’s not that you could, but you won’t?”Therapist: “I’m sure. These are your decisions and they are precious. I don’t know what you should do.”Patient: “I know these decisions are mine and that this is my life. I own it or it owns me, but I don’t think these decisions are precious. I think they are torture. It’slike choosing between one life or another. Either way one life gets killed off. I’m not real happy about being backed into a corner where whatever I do I’m turned into a murderer.”Therapist: “I know that’s how you feel.”Patient: “….which is why you should tell me what to do. Don’t you have any responsibility in this? You should take some. It’s cowardly not to.. Some times I think you just sit there and take pleasure in how mixed up I am, how I’m a human traffic jam.”Therapist: “…which is why you keep coming back?”Patient: “I keep hoping. I don’t even know what I hope, but it’s something. You know I think about quitting every day, but maybe it’s something as pathetic as that I’m not alone when I come here. I can’t stand my own company. I never have been able to stand it and when other people say I’m so much fun and have such a great sense of humor, I have no idea what they’re talking about.”Therapist: “But you listen…”Patient: “I listen to everybody about everything, which might be why I’m so messed. up I listen to everybody... read more

Costs Of Psychotherapy

“I’m not sure I can afford therapy but I am more or less sure that I can’t afford not to do therapy.” I have heard a number of patients formulate this quandary in roughly these words. Psychotherapy is a developmental input. It works on conflicts that have not yet achieved full definition or recognizable shapes as well as on those which are painfully present, perturbing and pervasive. It is about achieving conflicts at least as much as about resolving conflicts. Psychotherapy works to help the patient delineate the past, discover how it works in the present, know the present in depth and detail and imagine and intuit as well as realize possible futures. Psychotherapy is a dynamic disordering of past, present and future in the service of producing refinements or revolution in the approach to each one. Psychotherapy is often a form of basic research. Many patients come into therapy in search of themselves. They have agony of one or another flavor and also an inkling of who and how they might wish to be on the other side of the interior gulf.. The first emotional cost of psychotherapy is saying, “I need this.” This can be a very high cost if a patient’s character is built around the denial of need, even the repudiation of need. Need-shame is a common and difficult problem. Some patients come to therapy so sealed against their own needs that any effort to help them approach their needs produces great upset. There are patients who come to therapy saying that they are just curious about therapy, that they have a friend who seems... read more


About twenty-five years ago, when managed care was threatening to pull psychiatry up by its economic roots and to toss, if not all of it, away, certainly to get rid of relationship in treatment and long term psychotherapy as a cultural practice, I ran into my friend David Lamb, also a psychiatrist, at Eddie’s supermarket in the late afternoon as each of us was picking up just a few items for our families. “Robert” he asked me in a rushed nearly agitated way at the checkout counter, “do you think that we will still have jobs?”“I hope so,” I replied, ”of one kind or another.” We didn’t linger, but the exchange had plenty of intensity. Three weeks later, under the same circumstances, I ran into David again. This time he was much more sanguine. “I’ve got it figured out, “ he said, “People will always be willing to pay for gurufication. It is not a luxury. It’s a necessity.”“Gurufication?” I echoed. a bit bemused, because I could make some headway in construing the term, but not really enough to constitute understanding.“People need gurus in the midst of the confusion of life,.” David said. “There’s nothing formally religious about it and, yet in the practical sense, there is everything religious about it.”“So what does that have to do with us,” I asked. “We’re doctors, applied scientists, artfully trying to help our patients feel better and do better. We don’t sit under lotus trees and meditate. We don’t have revelations. We’re really ordinary people.”“That’s all true, “ David rejoined. “We are doctors and we are ordinary people. We’re not going to... read more
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