The Messy World of Psychotherapy

If you ever read a paper about psychotherapy, you probably noticed that it was rather neat. Whether an empirical presentation or a theoretical discussion, things tend to fall into place. Psychodynamic interventions work in resolving unconscious conflicts, cognitive and behavioral techniques significantly reduce symptoms, and our theories explain to us precisely what it is we’re encountering in terms of psychopathology. Problem is, it’s not how therapists, perhaps especially beginners who are more attuned to truth rather than dogma, experience their work: They experience it as messy and chaotic.

The dissonance between the papers, the classrooms, and the actual treatment room has always troubled me. On a typical day in graduate school I would learn in the morning about affect research, about a creative short-term dynamic intervention, about a smart cognitive technique, about a new therapy (one of more than 300(!) available)—only to sit in the afternoon with an actual human being, scrambling in embarrassment in front of him as I tried to offer something of substance.

People rarely have a distinct diagnosis or problem that are receptive to a particular intervention. Usually it’s a mix of things: some depression, some anxiety, some shyness, a lot of self-doubt—life. In my experience, you try one thing (interpretation) and it doesn’t really work, you try another (cognitive restructuring) and it also doesn’t, you try something else (humor, something about yourself, another dynamic interpretation) and maybe it works a bit better.

But this is not how psychotherapy is typically presented.

For many years, we have been taught to cherish the multitude of approaches, and their uniqueness—CBT is really not like IPT, that has nothing to do with DBT, that is distinctly different from TFP that is such a revolution of psychoanalysis. The idea that a specific intervention works for a specific problem has been presented as an axiom: This is psychotherapy. The challenge was just learning the thousands of approaches and their application.

However, in recent years this idea has been put under serious scrutiny. First, the evidence for the uniqueness of approaches and their effectiveness has been questioned by researchers; the current consensus seems to be that the differences between the interventions have been exaggerated. More people talk nowadays about the unifying factors of psychotherapy while it seems that the distinguishing factor that predicts success is the therapist not the therapy. Second, clinical experience calls for that unification, for the blending of approaches and their creative (rather than rigid and fragmented) use. Basically, it calls for the one thing that has been missing in our field: nuance.

In the past few months, together with four other therapists, I have been involved in opening a new treatment center for youth in Jerusalem. We've been receiving referrals for a few weeks and so far have about 20. Each and every one of them calls for a different intervention—typically more, many more, than one at the same time. Their diversity is exciting and life affirming: no one is quite the same as the other. But mostly they need creative, flexible therapists who can fluently use theory, technique, and themselves.

There is a teenager with behavioral problems at school who we thought needs mostly family work because we felt that this is the only available gateway to his experience. There is a 20-year-old with mild OCD who we treat with behavioral exposure, not forgetting about the unique transference he has been developing in the room (because why not both things if they are true?), there is a girl who calls for dyadic work with her mother, but we're also trying to figure out ("dynamically") how her school performance is a symptom of rebelliousness, or a cry for independence.

Because our center provides short-term treatment, it pushes us to be focused, and to constantly question what, if anything, we can give the people we work with. And it turns out that it is completely different from person to person. Calling ourselves a "CBT center" or a "DBT center" or a "psychodynamic center" would be a joke: We are neither of them, and we are all of them. Modern therapy, I believe, should be like that—nimble, nuanced, non-rigid, personalized. What works for some, doesn't work for others, and typically it is a messy, chaotic blend that works.

This is psychotherapy.

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