Path and Pathology: Some Philosophic Aspects of Psychotherapy

A 3 Quarks Daily essay

Note: This essay was originally published at the fabulous website, ‘3 Quarks Daily: science, arts, philosophy, politics, and literature,’ where I write a monthly column. As always, I welcome comments and questions. If you like this, you can subscribe to my weekly note for free. Thank you for reading.

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I came to psychotherapy from philosophy, starting therapy in my forties while on sabbatical from St. John’s College. I was struck by therapy’s transformative power—so struck that I ultimately resigned my tenure and returned to graduate school to train as a therapist. But I’ve hardly left philosophy behind. Freud reminds me of Nietzsche. Socrates’ fingerprints are all over the motives and methods of psychoanalysis. Donald Winnicott and Erik Erikson bring to mind Hegel, and the list goes on.

Philosophy and psychotherapy (and humanism generally) see our lives as developmental journeys. In the spirit of Socrates, they view self-exploration as essential to self-actualization. This may seem obvious, but like a lot of obvious things it’s easy to miss. For instance, many academics don’t believe being a “philosopher” need include examining themselves. Yet, how could it not? After all, philosophy means the love of wisdom, and who would say of a true philosopher what Regan said of her father, King Lear, that “he hath ever but slenderly known himself.”

It’s also remarkable that the Socratic spirit is often absent in therapists, in their own lives and in their work with clients. A variety of forces (not least insurance companies) lead many therapists and clients to focus on techniques and tools for reducing symptoms. This draws attention away from the person as a whole. There is nothing wrong with focusing on symptom-relief, as much advertised “evidence-based” “solution-focused” therapies like CBT and EMDR do. People vary in what they want and need from therapy, so we should welcome experimentation and a variety of approaches.

That said, if therapy is to encourage deeper self-exploration, it needs to go beyond symptoms to the whole person suffering them. Thus “psychotherapy” as I mean it here is curious about the patient’s history—about who they are and want to be; about their gifts, passions, loves, hopes, fears, and aspirations. We typically call this sort of approach depth therapy. The depth comes from sustained attention to early childhood experience, unconscious processes, and larger questions of meaning and significance. Psychoanalysis and Jungian analytic psychology are prominent examples.

Depth therapies are criticized for being inefficient and expensive, for lacking “evidence-based” methods and results, even for encouraging years of navel-gazing without tangible results. One might agree with some of these points and still conclude, as I and many others do, that they nevertheless offer the best approach for those seeking to get to know themselves and to make lasting personal change. Depth therapy is vulnerable to such criticisms in part because self-exploration and characterological change are complex, gradual processes that can be effective, but are irreducible to simple methods and measures. In contrast, it’s relatively easy to observe and measure progress when the goal is limited to evidence of immediate symptom-relief. (It is not clear that short-term “solution-focused” therapies bring lasting relief or change.)

It’s easy to see what’s philosophical about depth therapy. Some years ago, a bright, sensitive 21-year-old started a session one day by saying, ‘I don’t think I’m going to deal with my addiction until I figure out what I want for my life….and to do that I’m realizing I first need to figure out what I think it means to be a good person.’

My eyes welled with tears, I was so heartened to hear this. For a year I’d been hearing how depressed and lonely he was; how painful (and sometimes fun) it was to get high all the time; how disagreeable his parents were being. But today he had turned toward a larger existential question. A question directed not to his symptoms, but to a search for meaning.

I thought of how Aristotle begins the Metaphysics: “Human beings naturally yearn to know.” My patient yearned to know, not from philosophical curiosity or academic interest, but because he was stuck. Having thoroughly surveyed his stuckness together, he posed a real question. It’s not that if he answered this question all his problems would be solved. But now, at last, he was asking his own question—an existential one that put his challenges in a larger, non-pathologizing perspective. (Like Socrates, depth approaches emphasize providing conditions for self-discovery rather than teaching subject-matter.)

As he started exploring what he might want, his view of his addiction shifted. Now instead of being a bad shameful part of himself, it appeared to him more as an obstacle. He was heartened when I wondered if his substance use could be seen as a way he’d been trying to relieve his symptoms, but now it wasn’t working so well for him. Re-frames like this made it easier to examine parts of himself he’d been avoiding, since now he saw them more as misguided than bad.

I was also glad for him because it’s easier to face difficulties when you know where you want to go. Obvious, right? Yet, how many of us really know where we want to go? Even when we do know, it is easy to lose sight of the big picture and find ourselves preoccupied with our immediate situation and problems. It’s easier to be motivated when we have a positive, specific, and informed vision of the good we want.

In the course of my years as a teacher, students would occasionally point out, quite rightly, that many people sure don’t seem to “desire to understand,” and that this made Aristotle’s claim seem naïve. But the contradiction dissolves when we add the “in principle” or “for the most part.” Aristotle means that learning and growth are natural, provided conditions are favorable. This is as true of acorns and amoebas as it is of people. In the actual world, conditions are at best favorable “for the most part.”

As I often tell my patients—and the patient in me—even when conditions are favorable, there will be difficulties, pain, crises, traumas, loss, and grief. This needs emphasizing; otherwise we risk pathologizing normal life experiences by taking ‘favorable conditions’ to mean ‘absence of resistance'. Conflating these fuels the harmful tendency of some parents to overprotect their children from difficulties and failure—as if these forms of resistance were a hindrance, rather than a necessary condition for growing up.

Philosophy and psychotherapy agree that challenges and mistakes are essential to growth—part of the path. In his influential account of psychosocial development, psychoanalyst Erik Erikson observed that our lives are characterized by a series of crises. In the first 18 months of life, for example, the crisis concerns trust vs. mistrust. Are conditions favorable for developing a trusting disposition, a secure attachment style? Good-enough parenting helps the child pass through this stage and internalize trust and hope.

Erikson’s crises remind me of Hegel, who described the development of consciousness as a “highway of despair.” That’s not all it is, otherwise who would keep traveling down the road! For Hegel, the despair comes from questioning and, if necessary, abandoning familiar beliefs and opinions and ways of being, for the sake of better knowing ourselves and the world. Similarly, psychotherapy includes feeling the despair, anxiety, fear, and grief that can come when facing our defenses. By reckoning with these, as my patient was doing, we can face parts of ourselves that we’d prefer to avoid, but which are in our path—for better and worse. As Jung noted, what lurks in the shadows, disowned, is often a powerful part of us.

For all their likenesses, psychotherapy diverges from philosophy. I started therapy because I felt stuck in a state of pervasive dissatisfaction. Everything was fine, but…. I saw my problem as personal, and of course it was; but until therapy I hadn’t grasped the extent to which the help I needed would come through the relationship with my therapist, rather than insights or practices she offered. I had assumed, in true Socratic fashion, that in therapy I’d find an ally who’d help me get to the root of my dissatisfaction. And I did find this. But the transformative power came from an unexpected source. Not from insights and techniques, valuable as these can be. It came from the accumulated experience over many months of my therapist’s steady, reliable, warmly intelligent caring attention.

She didn’t offer much in the way of advice or tools; she knew (better than I did) that this wasn’t really the help I needed. Instead, she provided the sort of thing that distinguishes psychotherapy as a path: keen attention to the therapeutic alliance—to providing favorable conditions for self-exploration. Especially of those pained, traumatized, ashamed parts of my self that stood in the way of knowing myself better, and growing. In short, I hadn’t expected that the alliance itself would be key to the help I received. Yet this is exactly what happened. (Later I learned that research confirms that the quality the alliance is the biggest key to effective treatment.)

I could have told my patient what I thought he should do, and what tools would help. And sometimes, despite myself, I did. But this was the philosopher and teacher and anxious-to-help part of me getting in his way. But as a psychotherapist I prioritized listening, and learned something about the specific conditions favoring his growth. I knew, for instance, that he had high-powered overbearing parents who had been advising and cajoling and trying to rescue him for years. If what he had needed was information and advice, and evidence-based tools he’d have been thriving!

What he needed, though, was precisely what those who loved him found so hard to give: space, time and encouragement to ask his own questions, and explore what he thought and felt about his life—without having to defend against constant criticism from anxiety-driven parents pressing him to do what (they thought) was best.

I remember aspiring to do for him what my therapist had done for me: provide the favorable relational conditions that would allow him to give to those wounded, ashamed parts of himself the same warm regard that I was doing my best to give him.