Shirah Vollmer MD

The Musings of Dr. Vollmer

Psychotherapy As Art

Posted by Dr. Vollmer on January 27, 2015

“On the day, some decades ago, that I sent off the manuscript of what would become my sixth published book, I was suddenly possessed — there is no other word — by the desire to leave this world, and to do so by stepping in front of an oncoming bus. I walked to the edge of the sidewalk, stepped down, hesitated, let the bus go by, and decided to go home, where, if one of my children, then ages 4, 2 and 1, defied me in any way, I imagined picking that child up and throwing the child against a wall or through a window.”

“I came, slowly, not merely to remember experiences and feelings, but to relive them. And this turned out to be not unlike what I did while writing fiction: I gave myself up to my own life and feelings in the same way that, when inventing characters, I gave myself up to what my characters felt and experienced. By imagining an experience back into existence I came closer not only to what had happened and what I’d felt, but to what I’d forgotten, or had not felt, or not seen, or might have felt. I became lost and frightened the way characters in my novels became lost and frightened, and I found ways of surviving in ways my characters did. Like my writing, psychotherapy enabled me to make sense of a world that often seemed senseless.”

 

 

http://nyti.ms/1yXZ7KV

 

These are quotes from the article for the New York Times blog, entitled the couch. The author, Jay Neugeboren describes the process of psychotherapy as similar to writing fiction. By imagining himself as a character in his book, he could then develop sympathy and empathy for himself. With these feelings comes the ability to feel sad for what he did and did not get throughout his life. This sadness is the journey of mourning, and like mourning the death of a loved one, it is a journey of fits and starts, a journey of waves coming in and then receding, but ultimately with an acceptance of the loss and an ability to re-invest in new relationships. Psychotherapists, psychoanalysts, help people imagine themselves in the third person, and in so doing, the patient can begin to feel his experiences with consciousness and depth, rather than lapse into denial and superficial thinking. The art in the work is that the journey is not mapped out. The journey evolves over time.

 

This critical distinction is why I rail at time-limited therapies, since one cannot put a time on personal exploration, because, as the word implies, it is personal. If we then accept psychotherapy as an art, then we have to accept that there needs to be an open-ended approach in order for it to be deeply helpful. At the very least we should acknowledge that open-ended therapies are the gold standard, and so when modifications need to happen, we need to modify with the understanding of what is useful, is the ability to go on that journey of self-exploration, with a concerned professional, is useful. We cannot prescribe the journey, we must let it unfold. Thank you Jay Neugeboren for articulating my point.

13 Responses to “Psychotherapy As Art”

  1. Ashana M said

    And yet most works of fiction do not unfold in that way. Most novelists do, in fact, outline. They know how the story starts They know how it ends. They generally know what the major plot points are as well. The guesswork is sometimes in how to move convincingly between them, and sometimes they realize that a plot point is not convincing, that given who the characters are, things will never work out that way. The recognize when things need to be tweaked, but would-be novelists who simply meander generally write terrible books and these end up on Amazon as things their friends and relatives feel obligated to read and no one else ever does.

    Structure–a time line, an endpoint, a goal, and ways to assess success along the way–are important in art. They ought to be important in helping people with their mental health as well.

    • Yes, structure is important, and in psychotherapy, that would be the structure of the time and the money. Within that structure there is the art, and hence the flexibility to navigate the waters on an individual basis. Ashana, you remind me about a lecture I read in college (a few years ago 🙂 by CP Snow, titled “The Two Cultures”.http://en.wikipedia.org/wiki/C._P._Snow . Thanks.

      • Ashana M said

        That’s the structure I see here. Teachers show up to class with no specific agenda, no objective, wander for 40 minutes or so, and leave again. And then we’re all surprised that the country is barely literate.

        A repeating time slot is not structure.

  2. Shelly said

    I think you do yourself a disservice by comparing psychotherapy to art. Either psychiatry is medicine and your chosen profession deserves as much respect as say surgery, internal medicine and pediatrics, or it is an art and people will see psychotherapists as such. If you choose to describe it this way, then insurance won’t pay for your sessions with your patients and it can never be ‘open-ended’ as you describe. If, however, therapy goes to a socialistic model and open-ended self-discovery is covered by health insurance, it could work. But the way you are describing it, only the wealthy could benefit and those with less means will suffer.

    • Yes, Shelly this is the major dilemma. Do we seek insurance dollars so that more people can get help, or do we seek private pay in order to maintain more autonomy, but then restrict our services, not just to those with means, but also by doing pro bono work. This is the unending conflict, because, as with many issues which arise in psychotherapy, the ideas are contradictory, but they are both true. We cannot deny the art or the science, and yet how do we talk about the art without being marginalized? This is my mission. Thanks.

  3. georgielizabeth said

    “This critical distinction is why I rail at time-limited therapies, since one cannot put a time on personal exploration, because, as the word implies, it is personal. ” I just wrote about this (and agree to a certain extent). I think though that individual difference need to be taken into account, some people just don’t want or need long term therapy. There is also an argument for not opening up that can of worms…depending on what the person would like to get out of therapy.
    Great post 🙂

    • Hello Georgieelizabeth and welcome to my blog! It is nice to connect with you. I completely agree that the time and intensity of psychotherapy needs to be negotiated with the patient, and not the insurance company. I agree that within these negotiations are considerations of time, money, tolerance for psychological pain, and long-term goals. I agree that short-term work can be useful, both in the short-term and the long-term. My issue is that the dyad needs to draw the map, and not a third party. The collateral issue is that if no one can get long-term psychotherapy, then trainees will never be exposed to that skill set, and hence there will be very few options for relief from mental suffering. Learning long-term work helps the clinician to do short-term work. I very much want to keep saying that. Long term work is both helpful to SOME patients, and it is always helpful to the clinician in that it adds to his skill set. Eliminating long-term work from the mental health world, I am afraid will have dire consequences. Thanks.

      • georgielizabeth said

        Very good point about eliminating that skill set. It is definitely the way the UK is going and thats worrying. The government boast about trainign up over 4000 therapists in evidence based psychological therapies, which on the surface sounds good, but I’m one of them and my training was appalling! Didn’t equip me to do my job much at all. I’m lucky I work for an excellent service and we received a year of intensive supervision, shadowing and in-house training, but most don’t. This has the on-going effect of these bright, young graduates moving on from the role and I’ve heard it so often, out of mental health because the whole experience was so off-putting. We need more long termers, absolutely.

        • Thanks for chiming in again, Georgielizabeth. It is all very bad news, but I am hopeful that if we long termers can join hands on the internet then maybe we can get some traction.

  4. Eleanor said

    Great blog post Shirah. I would like to emphasize that you are also a physician…an MD….and should, as Shelly mentioned, be taken as seriously as any other specialty. In past years I’ve heard respected educated people say things like “all shrinks are crazy” which was intimidating since both my daughter and I were working with MD psychoanalysts at the time. I totally agree that what you do is not only an “art” in the skill, knowledge, sensitivity and intuition it requires, but it is also medical treatment at the highest level. I am familiar with the training post medical school that becoming a psychoanalyst requires ( including a training analysis of ones self) and it is rigorous and lengthly. I recently referred a family with an adult child with spina bifida to the Houston Center for Psychoanalytic Studies in hopes they could get a recommendation for a consult for treatment. They had previously had short term type therapy with poor results.

    High level psychodynamic treatment as you describe, changes thinking and stays with a person for life, making it possible for a person to continue to improve by using those skills learned in therapy. One more thing…there are no shortcuts…nor should there be. As I’ve said previously the human brain is the most complex thing in our known universe and the mind has complex layers that need to be understood and brought to consciousness. Yes the skill needed for this this is an “art”. But it also requires enormous amounts of medical training.

    • Thanks, Eleanor. You and Shelly are both right. As I responded to Shelly, there is a science behind psychotherapy AND there is an art. The “all shrinks are crazy” comment, I always find interesting, because I hardly see how that is relevant to whether or not they can be helpful. Any statement with an “all” in it, is suspect, given that it is unlikely the person saying it has interviewed “all” shrinks, so the comment reflects poorly on the speaker, rather than the listener.
      Yes, you are aware that psychoanalytic training usually comes at the tail of 10 years of medical training, giving the clinician a depth and breath that is unmatched by other mental health professionals. Having said that, there are many other paths to becoming a psychoanalyst besides medical training and the fear is that the mix of trainees will change with a predominance of clinicians that have much less exposure to the range of psychopathology and with much less understanding of the pathophysiology of disease. Thanks Again.

      • Eleanor said

        Yes I agree with you Shirah about the ignorance in the “all shrinks are crazy” comment especially when made by educated, influential people. However when one is in treatment comments like that or similar can create immense shame and vulnerability and the need to “hide” the fact one is, in fact, in treatment. I’ve been there and I felt very “inferior” and unacceptable around my educated “acquaintances” during that time. Treatment is difficult as is and public stupidity especially by folks who should know better, only makes it more problematic. I emphasized the importance of your medical training (tho I realize medical backgrounds are declining in the psychoanalytic community) in addition to the art of therapy because I agree with Shelly’s take on this, insurance won’t pay for “art” unfortunately. It’s difficult enough to get insurance to pay for mental health treatment anyway even with MD’s. (To quote a friend who sells medical insurance, “we need proof on paper, MRI’s, CAT scan, etc. to pay”)……..When my daughter and I were in treatment, the second year we applied for a minimal reimbursement by insurance, the company not only cancelled our policy but also the policy of my husbands entire medical office which we were a part of. It was not until my husband pleaded with the company to reinstate the policy for his office did the company agree to do so, but only if our daughter and I were left off any coverage at all for anything. Pathetic really…..Another difficult experience in the world of psychodynamic treatments.

        • Thank you again for sharing your experience. As you probably know, one of the many motivations for my blog is to de-stigmatize mental illness, and psychotherapy and psychoanalysis. We can “name it to tame it,” meaning that when the words see the light of day, the “craziness” in the field is put into perspective, that like all stereotypes, there are grains of truth, but they do not capture the profession. In other words, you sharing your experience on my posts is one step closer to seeing people, identifying with their struggles and developing compassion for people who try to make their lives better.
          Yes, insurance companies have a lot of power, and they can determine not just what they pay for, but the types of treatment that are administered. This, as you know, is another prompt for my ranting.

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