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For a hundred years, it was pretty clear that psychotherapy was a relationship between a change agent and a person seeking change. The two parties would meet to decide if the patient’s problems arose from psychological conflicts and, if so, they would proceed to change the patient’s psychology, partly by understanding it (because much unproductive behavior depends on a lack of self-awareness and self-acceptance) and mostly by letting it play out in the room and responding to it differently.
Then came the internet.
Many of the internet’s drawbacks have to do with the way young people can skip certain Eriksonian stages of development. For example, during the school-age years, children in our society generally face the crisis that Erikson called “Industry vs. Inferiority.” The idea was that school and community created situations where kids have to apply themselves to tasks or feel inferior. This includes learning arithmetic, swimming, and manners, among a host of other tasks. In a wired household, kids can sidestep this crisis by engaging in tasks such as gaming where they either succeed or switch to another, easier task. The result is that kids can skip feeling inferior without really learning how to do anything.
In the adolescent crisis of “Identity vs. Confusion,” teenagers try out various roles in social groups and either integrate the ones that seem to work into a sense of who they are or drift into confusion about themselves. The internet allows us to change situations so quickly that people can find environments that support the roles they are trying on for size rather than making them adapt to situations that don’t. There is no growth, but also no confusion.
Similarly, the crisis of “Intimacy vs. Isolation” is bypassed when young adults don’t learn how to be intimate with a romantic partner but don’t suffer isolation as a result. The internet provides a buffer to isolation that reduces the motivation to learn how to make a partnership.
Lastly, George Vaillant’s longitudinal studies led him to posit another crisis of young adulthood that he called “Career Consolidation vs. Self-Absorption.” This doesn’t refer merely to the label associated with one’s vocational life, but also to the question of whether that purpose links to one’s culture and community to provide what Ecclesiastes called finding enjoyment in one’s toil as opposed to chasing after the wind. It’s not the novelist who spends years learning a craft while waiting tables that Vaillant is warning against self-absorption; it’s the waiter who says they’re a novelist but doesn’t actually write anything. It’s also the businesswoman, the lawyer, or the graphic designer who doesn’t enjoy her toil but spends the day checking boxes and watching the clock, while thinking of Happy Hour.
Whatever one does for a living, the internet allows us to find a social environment that makes it seem like a career, and that furthermore makes it seem like one is already good at it. Everything becomes a matter of “likes” and little becomes a matter of corrective feedback, improvement, and growth.
Skipping industry, identity, and intimacy has created a generation of therapists who by and large think it’s a matter of checking boxes and watching the clock, following a manual and dragging the patient through its lessons. It has also created a generation of patients who by and large think they are already perfect just as they are and that the world has to change to suit them.
This used to be the heart of Dialectical Behavior Therapy, the dialectic between the borderline patient’s needing to change and feeling insulted by the idea that they need to change. Now, many patients feel that way, and, worse, many therapists do as well. The master clinicians I know all think, “I’m finally getting the hang of this” or “Until five years ago, I really didn’t know what I was doing in therapy.” The younger generation has many, many therapists who think, “There’s nothing to it!”
One of the major foci of box-checking is diagnosis. With the advent of DSM-III (we’re now on DSM-5), diagnosis stopped being a matter of pattern recognition and became instead a matter of checklists and “meeting criteria.” Therapists search for a label rather than for a case formulation, and the label they search for has little to do with how the patient treats the therapist and much to do with how the patient reports behaving out in the world.
Further, the criteria that the therapist checks are all generic: “Requires excessive admiration.” This leads to a consideration of how often and to what extent the patient requires admiration rather than an exploration of a particular, meaningful instance where the function of seeking admiration can be explored. (Was the admiration, for example, heartwarming and appreciated or avoidant of feeling insignificant and taken as one’s due?)
It also diverts focus from particular, meaningful instances that arise in the therapy relationship toward a focus on numerous and excessive moments outside of the therapy office. But it sure is easier to evaluate and offer advice about packaged stories about the patient’s work than it is to make sense of and intervene in patterns as they unfold in the therapy exchange.
I’m not blaming psychotherapy’s death rattle entirely on the internet. Others have been eloquent in blaming the chemicalization of the human condition, Big Pharma, and health insurance companies. But I think the internet also has something to do with it, as it has helped produce patients who don’t think it is necessary to adapt to reality and therapists who agree with them.
There are a few important implications for therapists. Conflicts are not to be avoided nor crises averted; they are to be resolved and mastered. Patients are in therapy to change, and only therapists who see themselves on a growth curve of their own can induce growth. Checklists may (or may not) help beginners, but real mastery involves pattern recognition and improvisation. Finally, just as the internet can be an escape hatch from life, talking about the patient’s life like a coach, friend, or gossip is an escape hatch from therapy.
