psychotherapy thoughts

[Adam Blatner]

Dear Colleagues, the following five or six paragraphs are a bit theoretical about the 
nature of psychotherapy today. I don't expect y'all to read it, but if you want to, I'm 
certainly open to feedback!  These ideas are still tentative.

    As you know, I think about stuff, about therapy. Just put a note on psychiatric 
diagnosis on my blog   www.blatner.com/adam/blog/
       Here are a couple of other ideas that I'd like your thinking about:

 1. Therapists feeling stressed by client stress. (I was asked about this by a colleague.)
          a. Could it be that therapists since the 1970s have taken on clients who are 
less neurotic and ego-dystonic (and by that I mean that they feel that their own thinking 
might be the problem) and increasingly a larger percentage of clients who are more 
"characterological" in their problems, their own basic dysfunction being ego-syntonic 
(their thinking and behavior is justified, and why are others reacting, blaming them, 
divorcing them, firing them, etc.?).

        b. More papers and books are suggesting not only more ways to work with the second 
type, the "Personality Disorders," but also hint that such problems CAN be worked with 
successfully by competent psychotherapists. I wonder how true this is in what percentage 
of cases? Perhaps there are more approaches and better ways to work with problem patients, 
but what if there is still a much higher rate of failure. After all, as Fritz Perls 
observed---and I think it applies even more to those who are more characterological in 
their makeup---"Most patients don't really want to stop being neurotic; they just want to 
be better at it."
       c. The raised expectations in journals and from conference presenters---are these 
folks conceding that a fair number of people will in fact resist consciousness and make 
little headway?
              c(2): And those who mix any types of addiction process are doubly 
"resistant"?
                and (c3)  those who have 3 co-morbid features, add trauma, or lower 
intelligence, or bleak social support system, etc., are triply or quadruply more 
"difficult"?   Is this fair to suggest this?

        d. In other words, I am concerned that therapists are imposing upon themselves 
unrealistically high expectations as part of their professional identity.
               d1 this leads to a tendency to fall into collusions of projective 
identification and counter-transference reactions
               d2,  and it is, I suspect, a significant element in "burn-out."
        e. In other words, what if some or much of what is called burn-out doesn't reflect 
some of the more common explanations of causes, but rather relates to a realistic 
frustration that isn't being commented on by enough authorities:
        "It takes a village to raise a child" might also be re-framed, "It takes a 
somewhat intact and wholesome social network and economic foundation to heal, and without 
those therapy is like trying to treat, say, the gum disease of scurvy by periodontia...
 missing entirely the underlying nutritional (more fundamental systemic) problem.

        2. On another point: It seems that many clients have their frustrations, 
victimizations, and trauma addressed, but could it be that many if not most therapists 
don't consider that many clients are also equally suffering from unrealistic infantile 
expectations? (My sympathy for Adler may be glimpsed here.) I am inclined to see this 
throughout the society, reinforced by the consumerist and competitive cultural activities 
and media: It's easy to continue as an adult with no shame or awareness that one is 
entertaining and being largely guided by simplistic and immature attitudes. See ( 
http://www.blatner.com/adam/psyntbk/innerbrat.html  )

      I don't remember encountering much in the psychotherapy or dynamic psychology 
literature that suggests that we take a history of fundamental attitudes of expectation 
the way physicians theoretically should take a sexual history (hah!) or therapists have
> been more recently exhorted to take a spiritual history (double hah!). And in medicine, 
> a rule for diagnosis is that if you don't know the condition exists, or don't think of 
> asking about it, you won't find the signs and symptoms of it.

   The relevance of all this is simple: If a person harbors unrealistic expectations of 
life and of others---and I suspect a significant percentage of so-called adults do---, 
then this fundamentally unstable state will feed into the other kinds of problems: When 
hurt,
 the hurt runs deep, because it opens up a goodly number of unresolved dependency issues.
     And so forth. As I said, it's a bit analogous to trying to treat a wound when the 
underlying nutritional or immunological state is grossly deficient. Treatments that might 
work with healthy people just don't work with these weaknesses.
         What do you think about these provisional ideas?   Warmly, Adam Blatner