BENJAMIN KOVITZ, M.D.*
This paper offers the novice psychotherapist a general orientation to the experience and problems of conducting individual psychotherapy. An implicit but clearly humanistic philosophy is presented through pragmatic and time-tested general observations and a number of specific guidelines and cautions. The patient-therapist relation is treated in a way designed to optimize the outcome for patient and therapist alike.
1. GENERAL CONSIDERATIONS
People who want help with their difficulties in living often put their hopes in psychotherapy. In undertaking to work with such patients you confront a confusing choice of theories and methods, all supported by claims of success but giving less attention to failures. Whatever your theoretical assumptions, it is worth reviewing certain guidelines that have proved their value in practice. Neither guidelines nor theories will answer all your questions, however. Psychotherapy is not a science but an experimental collaboration that cannot be reduced to a purely mechanical or technical process. It is, however, a strictly professional transaction and not, as a catchy subtitle once put it, "The Purchase of Friendship."1 At best it offers the patient a unique opportunity to be listened to and understood without having to maintain a protective screen of deception and self-defense. The challenge for therapists is how to respect the need of patients for that screen while investigating its deleterious effects on their way of living.
Patients have the task of taking conscious responsibility for what they are doing with their lives. They learn to ask not only "What are others doing to me?" but "What am I doing to them?" and "What am I doing to myself?"
In psychotherapy both the problems and the efforts to correct them are deeply personal, often involving the core of the personality and the extraordinarily sensitive issue of self-esteem, equally in the person who seeks help and the person who offers it. The value of biological treatment cannot be denied, but the biological, pharmacological, and psychological approaches are not in competition. Critics who think of psychotherapy as just another drug are missing the point. Psychotherapy fills an irreplaceable role, because it deals with the meaning of the patient's experience; people want to make sense out of their lives.
The Significance of Insight
The goal of therapy is not insight for its own sake but the more effective living that insight makes possible. Valid insight is more than verbal, and the therapist cannot "give" it; patients achieve it as they discover the difference between what they think they are doing and what they are actually doing. Harry Stack Sullivan2 defined psychiatric cure as that state in which "the patient as known to himself is much the same person as the patient behaving with others." Cure is in any case a problematic concept. What matters is the increasing ability of patients to discern more constructive possibilities as they become more honest with themselves and more realistic about their living. Since emotional growth seldom keeps pace with intellectual analysis, the value of purely intellectual insight is easily overestimated. If insight remains a mere verbal exercise, therapy becomes little more than a travesty or a game.
The outcome depends on what patients really feel and really want. Unlike the behavioral therapies, insight therapy promotes self-knowledge as its chief therapeutic tool, but self-knowledge is useful only as it awakens genuine feeling and leads to useful action. What patients do with insight is nevertheless for them to decide; the therapist cannot live for them. Patients have to live with their decisions, and they are the ones to make them. Decisions are to be taken out of the hands only of those who are grossly incompetent or dangerous to themselves or others.
Not everyone is ready or able to profit from insight therapy, and judicious selection is essential. …