Randall C. Wyatt: Any interesting cab experiences?
Owen Renik: Oh, many, it was a wonderful job.
Driving a cab is kind of like being a shrink, except that you sit in front of the patient.
Driving a cab is kind of like being a shrink, except that you sit in front of the patient. You know what people are like; it's like strangers on a train, people open up. It was a different New York then. There was no plexiglas between you and the customer. You flipped the arm down and you split the paid miles with the owner of the medallions and after about 10 o'clock at night it was all making deals about going to Brooklyn. I drove anywhere in the city then—not without fear—but without restraint.
RW: Let’s start, Owen, with the story that has circulated around that you drove a cab to pay your way through medical school; some people wonder if that’s how you got your start in therapy.
OR: I drove a cab in New York for several years while I was doing what we called post-bac or pre-med requirements. When I got out of Columbia I didn't have any of those requirements. And, no, no, I knew I wanted to be a shrink before I drove the cab. When I went to medical school, I stopped driving a cab and I missed it. For years, if I came into New York, like on New Years' eve, and nobody could get a cab, I would go with my date and pick people up and take them where they wanted to go, actually play cabbie for a while.
RW: There’s a reality TV show on cab rides where the customers tell the cab driver all kinds of things.
OR: Oh yeah, I saw an episode. This lesbian couple gets in the cab and one of them says, "This is my girlfriend, and this is the toy we use in bed ," and so on. Wild.
RW: When there’s a little distance people will tell their stories. And they really don’t expect the cab driver to tell anybody because who is the cab driver going to tell?
OR: It's anonymous. One doesn't give names. It's a cash business. It was a lot of fun.
Don’t be a schmuck, go to medical school!
RW: You were trained as a psychiatrist and a psychoanalyst. What first stirred your interest in psychiatry and psychoanalysis?
OR: Well, I began by wanting to be a therapist. I was going to get my PhD in psychology and was accepted to graduate school. They gave me some scholarships but I didn't graduate from college on time so I couldn't go that year. There were a few glitches. I was not wrapped too tight in those days. So, I took a job at Paine-Whitney, a freestanding psychiatry hospital in New York as a psych. tech, midnight 'til 8 am, to see what the deal was working with very disturbed patients.
I saw immediately what the pecking order was at the hospital and I figured I wouldn't last thirty seconds taking orders from some schmuck with a stethoscope.
I saw immediately what the pecking order was at the hospital and I figured I wouldn't last thirty seconds taking orders from some schmuck with a stethoscope. I saw what the realpolitik was.
RW: Were you interested in psychoanalytic thinking yet?
OR: No, I was not interested in psychoanalysis because the little contact that I had with the New York psychoanalytical community was, you know, these people were undertakers. I mean they were like the walking dead. I couldn't imagine it. I went to medical school to become a psychiatrist.
RW: Let’s go back a few steps, how did you end up in med school?
OR: At the time I didn't think I could sit still long enough to get through medical school. When I say I wasn't wrapped too tight, I really wasn't wrapped too tight. I didn't know what to do and I didn't know anybody to ask. You know, my mother graduated high school and my father dropped out of manual trades high school after two years. Nobody in my family had been to college, let alone medical school.
So I looked up Rose Franzblau in phone book; she wrote a psychology column for the New York Post, that for the liberal and the Jewish community was the paper. It's now a rag, but in those days everybody worshiped it. The publisher, Dorothy Schiff, was like the Virgin Mary. So I called Rose up and said, "Look, I'd like to talk to you about going to graduate school in psychology versus medical school. Could you see me? I know you from your column. " And she said, "No, you don't want to talk to me. You want to talk to my husband, Abe. He's Chair of Psychiatry at Mount Sinai Hospital." So I called him up the next day and he says, "Oh, yeah, Rose said you were going to call. Could you come over this afternoon to see me?" So he cuts me an hour and a half out of his day.
Abe was a sweet guy, real caring, a mensch. I go over there and after talking with him for an hour or so, he says "Go to medical school. Don't be a schmuck."
Abe was a sweet guy, real caring, a mensch. I go over there and after talking with him for an hour or so, he says "Go to medical school. Don't be a schmuck." (laughter all around)
RW: That would be hard to refuse.
OR: I said, "Yeah, but I'm not," He interrupts me, "It's not so hard. Don't worry. You'll get there." So I went 'cause Abe told me to go. (laughing exuberantly) But, anyhow, that's how I got involved in all of this stuff.
I went to the upstate medical school in Syracuse. Then I did my psychiatry internship at Denver General Hospital, a real knife and gun club, you know, real down amongst 'em county hospital internship which I enjoyed thoroughly.
RW: Then, how did you end up in San Francisco?
OR: I visited friends in California in the late 60s and I loved it. I wanted to go to the Stanford residency psychiatry program, which would have been a hilarious mistake for me. Irv, pace Irv. (laughter) I didn't interview with Irv. It was Khatchaturian I was speaking to then. I liked the place and the people that I met. But I had no idea how research-oriented it was. And I don't need to tell you how different being in Palo Alto is from being in San Francisco. But Stanford couldn't tell me yet whether I was accepted and Mount Zion in San Francisco had offered me a place. I had no idea what I was stepping into; it turned out to be a great, great department. I wanted to be in San Francisco, so I came. That's where it was happening. But this was 1969, the summer of '69.
RW: That was quite a time, the ’60s in San Francisco was thriving place to be.
OR: Yeah. I thought I died and went to heaven. (laughter from all)
RW: You started getting interested in psychoanalysis then?
OR: Yeah! Because of the people I ran into at Mount Zion. I came out here just to be a psychiatrist. And I ran into wonderful people like Eddie Weinshel, he died recently, Vic Calif, and Bob Wallerstein, and Norm Reider. They're all mavericks who thought for themselves and they were real people. I became interested in psychoanalysis through them.
RW: And what did you notice about changes in psychology and psychoanalysis then?
OR: But I was not sophisticated, Randy. It's not as if I was aware of the changes at the time. I didn't know beans about it. I had read Freud in college and the idea of becoming a shrink seemed great to me.
How therapy saved Renik’s ass
RW: Had you been in therapy yourself yet?
OR: I'd had therapy in New York that had saved my ass, really, with an analyst, although that did not convince me that analysis was worthwhile because I didn't think she was being very psychoanalytic.
RW: You said that therapy “saved your ass.” How so? And you said she was quite an analyst. What do you think she did to help you?
OR: Yeah it did. I didn't think she was being very analytic per se yet what she did was extremely helpful to me. It's not always so easy to be able to put your finger on how a treatment helps you, but, in this case, I really could. She permitted me to understand something and that made an enormous difference in my life. When I say I wasn't wrapped too tight, I mean from a very early age I was really scrambling in life because I felt very guilty about not being able to help my mother. And, eventually, when I left the family in order to survive, I felt really bad about that.
RW: Your mother was quite ill and depressed.
OR: Yeah, she was, very. My understanding of it up until I had this therapy was that her physical illness had been the cause of it. She had a very bad case of myasthenia gravis, which is a terrible illness when it's not treatable; it was the very early days—they didn't know much about it then.
Victor Yalom: What was the illness again?
Owen Renik: Myasthenia gravis. It's a neurological illness. It's essentially a disorder of the way the nerves innervate the muscles. You become weak, atrophied, even flaccidly paralyzed. It was horrible. But I recognized and learned, with my therapist's help, that the real problem had been my mother's reaction to her physical illness. She could have made a much better life for herself and for our family had she had a different attitude. She didn't cooperate with the medical treatment. It was catastrophic. Realizing that was enormously liberating for me. Years after my mother died, I was eventually able to confront my father about this. And I learned from him that she had been psychotically depressed prior to ever becoming physically ill. I had screen memories that came from having been shipped out of the house for months before I was two years old, while my mother was in the hospital getting shock treatment. So, it was an enormously important therapy for me. I have sent many, many patients to my therapist, Hanna Kapit, in New York. And we remain friends to this day.
VY: In what way wasn’t she psychoanalytic?
OR: Well, she did not fit the stereotype of a psychoanalyst that I had in my mind at the time. She was personal. She was friendly. She was not lowered by a string into the session, in a lotus position.
Well, she did not fit the stereotype of a psychoanalyst that I had in my mind at the time. She was personal. She was friendly. She was not lowered by a string into the session, in a lotus position. (laughs) I remember once, and by the way, we're going back forty-five years now, guys…
RW: We’re going through the screen.
OR: Well, you know, when something is important, it sticks. I remember I was feeling very humiliated about having feelings for my therapist because I couldn't imagine that she had feelings for me. I'm not even talking about sexual desire. I'm just talking about loving feelings. And she said, "What makes you think I don't have feelings about you?" Oh, it was a big revelation for me.
VY: And why shouldn’t the therapist reveal those feelings?
OR: Right. Well, all I knew was the stereotype and Hanna didn't conform to it. She's a good example of why psychoanalysis has lasted, despite a really pretty cockamamie theory.
There are really good people who are analysts, who, despite the theory, they find a way to be helpful to patients.
There are really good people who are analysts, who, despite the theory, they find a way to be helpful to patients.
RW: Can you isolate it a little more? What are you saying that she did that helped?
OR: Well, the one that stands out for me is helping me realize that my mother was not simply the helpless victim of this physical illness, but that there was some kind of choice there. That it was a psychological problem. I don't want to over-dramatize it but the psychology that I was suffering from was essentially that of, like, the child of a holocaust survivor. You've got a parent who is a completely helpless victim, without any choices, of this external thing. It changed my whole view of my parents and my relationship with my parents, and myself, essentially. I calmed down enormously, actually. I was less anxious and therefore less defended against anxiety. And my defenses against anxiety had been quite costly for me. I mean I was really out there and moving pretty quickly.
RW: So, you came out here to San Francisco, became a psychiatrist, and then got trained as an analyst. Where?
OR: I got my training at the Institute (The San Francisco Psychoanalytic Institute).
RW: And when did you first become disillusioned with traditional or orthodox analytic practice? Do you remember what set you off?
OR: It didn't happen like that, Randy. I didn't become disillusioned since I never had illusions to begin with. It's a little bit deceptive, because I had such a successful career within the ranks. I have all the merit badges. I was Editor of the Psychoanalytic Quarterly for 10 years and Chairman of the Program Committee of the American Psychoanalytic Association, etc. But it was never because I bought in. I was always thinking for myself about what seemed sensible and what didn't. I never drank the Kool-Aid, but I was respectful of what I was taught. And I didn't just decide sittin' in the armchair. I mean it was after doing analyses for quite some time and seeing what seemed to be useful or not that I reached my conclusions.
So, it was really a gradual evolution that I moved farther and farther away from standard psychoanalysis. I just questioned more and more and more things, as time went on. The way I see it, I evolved during the thirty or so years after I graduated, while psychoanalysis remained at a standstill. It's not that I became disillusioned, I was always wondering.
RW: People call you a maverick analyst or a rebel, unorthodox. You’ve heard these terms.
OR: Oh, sure, sure.
RW: And what do you think people mean by these things they say about you?
OR: These terms only apply if you have an orthodoxy. In science, which is what psychoanalysis began as, and ought to have remained, which it did not. In science, there's no such thing as being anti-, there is no such thing as being a maverick or a rebel. You're not only entitled to question even the most basic assumptions of the discipline, you're encouraged to question the most basic assumptions. So, the term, maverick, or rebel, in itself contains the answer to your question. It's because psychoanalysis is a faith-based movement, at this point; it's a sect. It perpetuates received wisdom which is not really, despite claims to the contrary, open to question. Psychoanalysis is no longer a scientific enterprise. So people who, for whatever reasons, don't hew to the established received wisdom, are labeled as heretics. That's the reason I'm called a maverick, and a rebel.
Many of the best and the brightest were really excluded from becoming analysts because they were sorted out in the admissions process. Or they took one look at the orthodoxy of it and did not run into the few, sort of exceptional people that I did, and then said, "Who needs this?"
The crux: Self-awareness and symptom change
RW: So what are some of the key ingredients of the orthodoxy, the traditional psychoanalysis that you challenged?
OR: Jeez, it's so much, at this point that you can dip in wherever you want. First and foremost, the clinical method is really screwy, in my opinion. It's very self-deceived. And, without realizing it, it's at the patient's expense.
I would say the most fundamental problem is that psychoanalysis, the professional community, has drifted away from and has essentially abandoned symptom relief as the criterion for whether treatment is working. Freud never did, by the way. That was Freud's criterion, right up till the end. Freud only considered treatment to be working when symptoms got better, when there started being a therapeutic benefit. He often warned against therapeutic zeal saying he was a researcher and not a healer. But, as a scientist, he recognized that you need to have a dependent variable to track this that is separate from the hypotheses being tested. All this stuff that psychoanalysts now prize as evidence of good treatment, Freud recognized as unreliable—the patient's insight, increased self-awareness. That's all stuff that is shaped by the analyst/patient dialogue. Using it as an outcome criterion gets circular because you find what you believed to exist a priori.
Even when interesting new material comes to the fore, if the patient's symptoms are not changing, there's something wrong. Why do we have these twenty-year-long treatments during which the patient's life isn't really changing very much? The only way for an analyst to square that for himself or herself is to have outcome criteria other than symptom relief.
That's the fundamental issue. When you're no longer submitting your hypotheses to systematic empirical investigation then you can cling on the basis of conviction to any old method that you like that you get married to in your mind.
RW: The term, symptom relief, which is bandied about in different ways, can you describe that more? Because it could be from, on one end, a narrow view of symptoms, meaning panic and depression, all the way out to meaning and life and relationships and satisfaction with relationships, expanded choices, a sense of self, which gets more abstract.
OR: Right, right. Well, that's a crucial question, Randy. What I mean by symptom is something about the way the patient functions, which bothers the patient, which leads the patient to be distressed, which the patient identifies as something troublesome. The patient decides, not the analyst. An analyst can decide that something is all screwed up about a patient. If the patient doesn't experience it as being screwed up, then it can't be treated. So, of course, depression, impotence, hand-washing compulsions, bridge phobias are symptoms. But, for example, somebody walks in and says, "I have not been able to maintain a romantic relationship in my life." That, per se, is not a symptom. That is a complaint that may indicate a direction that needs to be explored in order to identify a symptom. But the patient and the therapist need to understand what, if anything, it is about the way the patient operates that seems to have led to the inability to maintain a relationship. Is it, for example, that the woman who is complaining of this really has an anxiety that she won't be satisfactory to the kind of man she'd really like to be with? So she keeps picking guys that are sort of damaged goods—and then, lo and behold, she becomes unsatisfied with the relationship and has to dump him? If so, then that way of operating and that anxiety become her symptoms. So, not infrequently, the patient's view of what his or her symptoms are evolves in the treatment.
And, often enough it's really pretty straightforward. Somebody comes to see me because they're depressed—they don't want to get out of bed in the morning, they're not enjoying anything, they want to kill themselves. I don't care about how self-aware they get. All I care about is: Do they feel like getting up in the morning now? Are they enjoying things? Do they not want to kill themselves? I've seen too many treatments, my own and other people's, in which—what do they say?—greater choices, awareness, insight, and so on, has blossomed, and the symptoms have not been changed. And I have seen too many treatments in which the symptoms have changed and no self-awareness has arrived. The truth is that we're not really very clear on the mechanism of action of psychotherapy. And we're not going to get clear if we cling to received wisdom about what's supposed to be the mechanism of action.
RW: Certain research on psychotherapy outcomes has put change into three phases: First, symptom relief is the relief of symptoms, and change in the basic things, depression, mood, energy, panic, and so forth; second, increased coping, skills, where people are more resilient to face their problems the next time around and; third, personality or character change, transformation of the self, resolving underlying conflicts and wounds, the more amorphous abstract things. Certainly the latter are more difficult to measure. What do you make of all this?
OR: Symptom relief, that's something that can be measured independently of theories. I don't care what your theory is. If the patient wants to get up in the morning, that observation is not related to any theory. Coping mechanisms? Insight? How do we judge those, exactly? Who was complaining of them being absent? Those are all constructs by the therapist. If they turn out to be steps in a process that leads to symptom relief, fine. But, if not, and the patient's symptoms are gone, we have to consider that treatment has worked in a way we don't necessarily understand. Then it's time to ask: "Do we need to continue the treatment any longer?" If the patient says, "I don't know if I have enough coping mechanisms to make sure that these symptoms don't come back," the therapist can answer, "Well, let's see. Let's stop for the moment, and we'll find out how things go. Let's keep in touch about it…"
RW: Ok, certainly it’s easier to measure symptom changes compared to personality change, but I think strides have been made with coping and resilience, but that is debatable. Well, let’s take that a step further. Let’s think in terms of an analogy from physical illness, like a muscle problem or hurting your knee. I go to the physical therapist after I hurt my knee. They can give me some medication and tell me to ice it to reduce the swelling, some pain medication for the acute pain. But I haven’t built up the muscles around it. So I go to a sports medicine doc and physical therapy. They help stretch it out, give me some exercises, I lift some weights, and I build up the muscles around it to prevent re-injury. I can cope better, I am more resilient and I have learned some things as well.
OR: That's true. That's right. That's a very apt, I think, analogy, and it goes to the heart of the matter. The difference there is if you scrub your ACL (the anterior cruciate ligament) and you get arthroscopic surgery, and then you need to rehab and strengthen the quadratus muscle in order to stabilize the joint, there are objective measures that indicate whether that's happening. You know, it's how many leg presses you can do, how many repetitions, and so on.
If we had those kinds of measures about coping, resiliency, all the rest of it, we could do that in therapy. I mean, you're very to-the-point, Randy. Let's say I come to you, and we're just complaining about, "Hey, I don't, I can't maintain romantic relationships." You and I dig into it and we discover that actually I have a big performance anxiety, so I've been picking these ladies that I feel secure with but who are never going to satisfy me. And we get into this and we find out that my father was really a very overpowering figure and I never could live up to him. And now I feel a lot better about myself and I don't have the performance anxiety. Now, the question is: am I going to be in shape to deal with a relationship? And how do we judge? Well, should I keep being in treatment with you until you decide or I decide that? I mean we wait and we keep in touch and when I get into a relationship, or if I meet some lady that scares the shit out of me cause she's so hot, the heavy-hitter of the world, and I'm nervous and I can't ask her out, then I'm giving you a phone call. Well, if I do ask her out, and I feel like I'm stepping on my dick every time I talk to her, I'll give you a phone call.
VY: Someone might want to stay in treatment until they are in a relationship and are able to be in a successful relationship.
OR: That's right. Those are interesting judgment calls, Victor. And I don't think that it is so easy to decide, because sometimes, that's an extremely constructive game plan. And, other times, it's a hideout and making a career out of therapy. And how do you decide that? As long as that question is really on the therapist's mind and the therapist is not clinging to some kind of Procrustean bed that he is forcing on the client, that's fine with me. It's not like I'm saying this is a perfect and easy-to-apply system.
RW: Well, in grad school, we were trained fairly psychoanalytic, and it was rare that that…
OR: Which school?
RW: CSPP, Berkeley (California School of Professional Psychology, now in San Francisco). It was rare that in supervision, which was often psychoanalytic for the most part, that anybody would say, “You know, the patient is ready to go.” The client would come in, and say “I think I’m done” and the supervisor and therapist would think of ways of getting them to stay in therapy: “Maybe they should be in therapy longer, there are still some things to resolve” instead of “Well maybe, let’s talk about it. Let’s think about it.” We would jump to the ideas that it was a premature ending. Most of my colleagues reported the same thing when they went for their own therapy or analysis. We even had terms for it which still persist like dropouts, flight into health, and acting out, which was not always the case in retrospect. In group meetings, it seemed it always came to an assumption, that there was a resistance in the client and they did not know what they were talking about.
OR: That's right. That's exactly the point of view that I think has resulted in the demise of psychoanalysis.
VY: And, usually, it seemed, a successful therapist is seen as someone who is able to keep their patients, which has a mixed meaning as well.
OR: You bet. I don't nail my patient's feet to the floor as you can see but I don't have any problem keeping a full practice. There is a hilarious irony, because when you stick a straw into the patient's vein and continue to drink as long as you can, but they are not getting better, it becomes an ever more convoluted and unsuccessful way to do treatment and attract new referrals.
RW: How long do you mean? What is long for you may not be for someone else? We’re talking about an analyst who was seeing people four times a week for years versus many therapists who see people one time a week for much briefer periods.
OR: Well, first of all, I don't see anybody four times a week anymore—not for the reasons that analysts see people four times a week. Actually, the only people that I think need that kind of treatment are people who are very disturbed and/or in a crisis and need the contact. I see lots of people once a week, once every other week, whatever it is. And there's a huge range. I mean you read the book (Practical Psychoanalysis), there are people I see one session! And then, people who may come for years. But in terms of what Victor was saying, I think it's in batches, very often. In the book, I try to give some feeling for this. Somebody will be in treatment and it's sufficient unto the day and then they come back if they need to.
RW: I have heard it called intermittent therapy across the lifespan, a phrase I like. Freud spoke of analysis as interminable versus terminal in that he suggested people come back in for tune-ups.
OR: Yeah, or not.
RW: Or not, of course. I think the key to what you’re saying—to avoid becoming polarized between the question of people staying too long in therapy or not staying in therapy long enough—is that you focus on the dialogue between therapist and patient and taking the patient seriously, having the patient as a main player in the conversation. I think this shift of focus is profound in its implications.
OR: That's very true. I think that is right, Randy. But, when you do that, very few people don't stay in long enough. Impatience has not been a problem that therapists have suffered from, because, after all—think about it—it is correctable. If, indeed, somebody goes too soon, he or she can turn around and come back, whereas, if you keep somebody around too long, you can't give them back that time.
VY: Usually, the way I think of it with people I work with is not so much whether their symptoms are there or not, but are they benefiting in concrete ways from continuing to come? People can stay in therapy to make positive gains, as well as to get rid of problems.
OR: Yeah. Right. That becomes a semantic matter since you could also describe that from the point of view of what they feel unable to achieve. As long as it's the patient who makes that call. In other words, people certainly come for one purpose, hopefully achieve it, and develop other purposes—
so long as those are purposes relate to the patient's judgment about his or her own well-being and not some bill of goods that they're sold by the analyst based on the analyst's judgments or theories.
so long as those are purposes relate to the patient's judgment about his or her own well-being and not some bill of goods that they're sold by the analyst based on the analyst's judgments or theories.
RW: Let’s say there’s an idea that the analyst or therapist has about the patient from their own judgment. “So, you’re not depressed anymore, and you’ve developed a healthier relationship, but you haven’t really worked things out with your mother. And that’s really going to get in the way in the future.”
OR: I think the point here, for me, Randy, is I think that dialogue of that sort can be useful depending on how it's done. I think the question of this patient's state of well-being is fine for that to be a dialogue into which the therapist has input. I think that the kind of judgments that you're describing are, in the main like: "I see a dynamic issue with you. I see something psychological in you that isn't worked out. It's going to cause you trouble even if you don't feel like it's causing you trouble now." I think that's 99%-100% of the time bullshit.
I think if the analyst sees something that the patient appears to be denying or overlooking that pertains to the patient's state of well-being, that's fine. Here's a classic, right? Let's say the patient, in God's eye, is getting very uncomfortable because they're attracted to their therapist and they want to get the hell out of therapy because it's a very threatening situation. So, the patient says, "Well, I'm fine. I think it's time to quit now." And the therapist says, "Really? I mean, you know, it's true that when you came in you were washing your hands 200 times a day and now you're only washing them 100 times a day. But is that really a satisfactory outcome to you?" That's fine to say.
But, for the analyst to say, "You know, I think your conflicts over your homosexual feelings are unresolved and I'm not sure that you've really touched those yet." "And your relationship with your sister, you know, I don't think we've really gone into that sufficiently." The person is going, "What the hell can I tell you? You know, we're not that close, but it doesn't bother me."
RW: This reminds me of a supervision I had in post-grad training. The supervisor told me, “You’ve got to assign some homework to this patient, a reading assignment about what is going on with her.” And I’m all for homework when it fits the patient and makes sense so I talked to the patient about it. She was hesitant but agreed to do it. She came back the next week saying she had not done it and was not really into it. My supervisor said with exasperation, “She’s being resistant. She’s not following the treatment plan and she is being non-compliant. So, you’ve got to go in and tell her this, it’s a real problem.” And I did this, foolishly. The client was just beside herself: “Well, I didn’t want to read that book. I didn’t think it would be helpful. I looked at it. I didn’t like it.” And I pursued it. The client quit therapy. My supervisor was no help saying okay, so be it. She ended up writing me this brilliant letter criticizing what I had done. I called an old supervisor, Sohan Sharma, a wonderful psychologist, mentor and friend, who said, “She’s right on everything she said. You’re putting your stuff on her, you should call her and tell her.” I called the patient back, admitted everything.
OR: And you apologized to her.
RW: Yes, and she called me in a few weeks, came back in and we ended up having another good round of therapy which was much more beneficial for her.
OR: Yeah. Good. I agree. You know, I need not tell you what has been pointed out so many times by so many people.
The concept of resistance is itself flawed because of that problem. The concept of resistance presupposes that the therapist has a superior knowledge of what is going to be good for the patient, that trumps the patient—which is disastrous—rather than constantly negotiated for the best in a dialogue between patient and therapist.
The concept of resistance is itself flawed because of that problem. The concept of resistance presupposes that the therapist has a superior knowledge of what is going to be good for the patient, that trumps the patient—which is disastrous—rather than constantly negotiated for the best in a dialogue between patient and therapist. A therapist may have brilliant ideas and have a lot of expertise but it is one contribution to the dialogue. You know, as you've pointed out, the crucial thing is that it is, after all, it is the patient's treatment, and that the patient's voice must be given full authority. The concept of resistance essentially already, from the get-go, denies that.
What makes it Practical Psychoanalysis?
RW: You have made it a point to say that psychoanalysis should not be defined by its techniques, but a way of looking and understanding people, and indeed you are quite critical of the traditional analytic approach to the relationship with the patient.
OR: The concept of analytic neutrality, or anonymity, the use of the couch, free association. These are all tools, all techniques. And their validity, or their utility, should be measured by their ability to produce effective treatment. Once you don't have a scientifically honest methodology, a way of evaluating treatment, then you can perpetuate this stuff and convince yourself that it's very important and the basis of treatment; that is what goes on at psychoanalytic institutes. The reality is that that stuff doesn't work, which is why people don't come for psychoanalysis worldwide; it is a movement that is in decline. And when they do come to analysts, many analysts don't practice what they're taught in the institutes. They do what's known as psychotherapy. These theories of psychoanalysis actually don't work. That's what is going on.
VY: So in your approach you are not only distinguishing from traditional psychoanalysis, but also from much of traditional psychotherapy, in terms of some of your egalitarian ideas.
OR: Yes, I think that that's true, Victor. One way we can look at it, and you might ask, why did I, hey, hey look at these guys [seeing the window washers out the 9th floor window], why did I call the book Practical Psychoanalysis? Well, what's psychoanalytic about it? One of the distinguishing features of psychoanalysis historically, and it has remained true, is that it is a treatment method that places a priority upon the most thorough and searching examination of the treatment relationship itself. Cognitive-behavioral therapy, Dialectical Behavioral Therapy, are interesting and very useful treatment methods. They have protocols and methods that are applied to the treatment that the patient is asked to comply with. And, at least in principle, it's not a negotiation. Now, in fact, if you look closely at it, the way it's applied and the way it's done, the best of these therapists do, in fact, practice in a flexible way.
Yogi Berra is reputed to have said, "In theory, there's no difference between theory and practice, but in practice, there is."
Yogi Berra is reputed to have said, "In theory, there's no difference between theory and practice, but in practice, there is." In practice, many of these therapists and analysts, in fact, are very sensitive to the relationship, and are very interested in the patient's input, and don't just try to override it, and do take it into account. But, as you say, those therapies, in the theory of treatment, do not allow for the patient determining, in a lot of ways, how you're going to proceed—that there is a priori a way to proceed that is understood by the therapist. That, of course, is a killing flaw in traditional psychoanalysis. Because the way to proceed that is in the theory, it's not only that it's doctrinaire, but it's also not a particularly good way to proceed.
RW: Well, the difference between the analyzing the transference from on high versus it being part of the dialogue, part of the relationship, which you encourage, is quite different.
OR: Analyzing the transference suggests that you can somehow separate yourself from what's taking place and identify what is going on inside the patient, and that is a presumptuous error. If I come to see you as a therapist and I find you overbearing and critical, and you feel like, "Come on. I like this guy, and I'm just trying to be nice to him." And you say to me, "You're experiencing me like your father. You're hearing perfectly innocent remarks that I make as putdowns of you, 'cause that's what your father did to you." That's called analyzing the transference.
Now, in reality, all we can decide is: does that interpretation on your part help me? Do I then find myself more comfortable with you? Am I not getting into arguments with my boss at work? It's not like that establishes, in fact, the truth that you weren't putting me down and I only experienced this because of my father. Who the hell knows? You could have been putting me down. You could have been competitive with me in subtle ways that you were unaware of.
VY: How would you be more likely to articulate your feelings in a situation like that?
OR: Well, the difference between the way I would articulate them, and the way the traditional psychoanalyst would articulate them, is that it would be abundantly clear to the patient that I was only expressing an opinion. I might say to the patient something like, "You know, I gotta tell you, my experience of it is that I don't feel like I'm critical of you. In fact, I like you. I mean it's always possible that I'm being competitive or something in some way I don't understand—but my experience of it is that you're really hypersensitive here. Unless I'm outright telling you you're great, then you feel like I'm looking to put you down. Now, that's my experience of this. And I can't help but think that you're expecting me to be the way you describe your father having been." That's the distinction; it's not necessarily that I wouldn't be looking for what we could call transference.
I would recognize that transference is not something that can be definitively identified and separated from the relationship; it is a hypothesis based on one subjective person offered to another subjective person.
I would recognize that transference is not something that can be definitively identified and separated from the relationship; it is a hypothesis based on one subjective person offered to another subjective person.
VY: A couple of differences I hear between that and a more traditional analytic interpretation is that you are stating it as a hypothesis, emphasizing my experience, not the definitive experience.
OR: That's right.
VY: And you’re also willing to share, “Hey, I like you.”
OR: Yes. Those are two very crucial differences that bear upon a number of the concepts that Randy alluded to before that are traditional psychoanalytic concepts, neutrality and anonymity, the whole position of objectivity. Those are all called into question through exactly what you put your finger on.
Playing your cards face-up
RW: One point related to what you are saying, it’s a quote from your book Practical Psychoanalysis, which I’m sure you know.
OR: Let's hope so.
RW: You’re talking about playing your cards face-up and subjectivity: “The only thing an analyst really has to offer, and the only thing a patient can really use, is an analyst’s account of his or her experience—especially an analyst’s account of his or her experience of the events of the treatment.”
OR: Yes that's very apropos. That's bears exactly on what Victor was just talking about. That's what it means. That's why you say, "This is how I feel about your experience of me as critical of you. It's that my experience is different from yours. I'm offering you my experience. The traditional analyst says, "You are distorting reality. You are seeing me as critical, when I'm not. I'm the arbiter of reality, and therefore free of distortions." And, by the way, this is a critique that is shared by many analysts and therapists, although I think there's a lot people who even make the critique and yet don't follow through on it and take it to its ultimate implication in their technique.
The therapist has no right to say, "I'm not criticizing you. That's a distortion of reality." The therapist can only say, "Well, let me tell you what my experience of this situation is. From my point of view, I experience it totally differently than you do."
VY: From your writing, you’re saying not only is it important to phrase it this way if you make a process comment, or a comment about the relationship, but that it is fundamental to the therapy.
OR: Yes.
VY: Everyone says, yes, the therapeutic relationship is important. Research has shown that out. But I think it’s still fairly radical or not fully understood how to really work in the here-and-now in a way that is central to the therapy.
OR: I agree with that. I agree completely with that.
VY: Can you summarize how you see the therapeutic relationship being central to the therapy in terms of the goals of therapy—symptom-relief?
OR: It is an omnibus question since it touches on so many issues. I think it is the ultimate question. Let's take one example. There is a traditional concept of analytic anonymity that says, I, the analyst am not going to tell you, the patient, how I experience anything because you need a blank screen upon which to project yourself.
Well, the typical contemporary analyst says, "No, no, no, no, no, no—we realize that it's not a process of projecting onto a blank screen." Meanwhile, they're still, to a great extent, reluctant to be revealing.
Well, the typical contemporary analyst says, "No, no, no, no, no, no—we realize that it's not a process of projecting onto a blank screen." Meanwhile, they're still, to a great extent, reluctant to be revealing. They worry about it, "Yeah, I'm not a blank screen, but how much should I reveal? I don't know. I don't know."
Whereas, as you say, if you really look at it as a dialogue, then self-revelation is not the issue. Reveal whatever the hell seems appropriate to reveal. Categorically, self-revelation is not a problem. It doesn't mean you free associate. It doesn't mean you walk in and the patient goes, "Hi, how are you doing?" And you answer, "Oh man, you can't believe what happened to me this morning on the way to work." The same rules apply as any ordinary conversation. You say what you think is useful. You ask about self-revelation, and how that relates to the goal of symptom relief. There's a mediating step there in our understanding and that has to be addressed. I mean, namely, how does treatment achieve symptom relief?
RW: Yes, how does it?
OR: In order to say how a particular technique contributes, we have to ask, well, what is the mechanism of action of therapy? And I think I have to say this at the onset that I think we should regard this matter as a work in progress. I would say, to my mind, on of the most important concepts we have, and I try to touch upon this in the book, is that of a corrective emotional experience. So that, one answer to your question, if the treatment works by actually providing for the patient salutary experiences with the therapist, whether these are recognized and discussed explicitly or not, then we need to create conditions in which these experiences are most likely to happen. And, if the encounter is an encounter between two subjective individuals, then
the best prospects for negotiation of the corrective emotional experience occur when the subjectivity of the therapist and the patient is, as far as possible, placed in the center of the table for examination, so that running repairs can be made. To the extent that the analyst retreats to a position of pre-ordained authority, the analyst is not available to negotiation.
the best prospects for negotiation of the corrective emotional experience occur when the subjectivity of the therapist and the patient is, as far as possible, placed in the center of the table for examination, so that running repairs can be made. To the extent that the analyst retreats to a position of pre-ordained authority, the analyst is not available to negotiation. It diminishes the likelihood that they will be able to negotiate a corrective emotional experience. I would say that is one way of thinking about how what we're talking about contributes to symptom relief.
Turning it upside down: Therapist self-disclosure
RW: Let’s talk more about the items you talked about earlier, therapist self-disclosure, for one. A lot of people think there is some room for that. And then the question is: what, when, and how much? But you take the position that advocates much more self-disclosure about your own subjective experience of the treatment. What guides you? And can you give any examples of how that works?
OR: You know, Randy, this is an issue that really comes up only because of traditional psychoanalytic theory, which touted analytic anonymity.
RW: The blank screen, the anonymous analyst.
OR: Yes. Otherwise, the answers to the questions would be obvious. I tried to take this up in the book. Actually, I would say two things that bear on your question. One is that the relationship between therapist and patient, in many ways, is no different than any other relationship. In fact, the whole idea to make it precious and special is really very destructive and takes it away from its utility. What makes the therapeutic relationship distinctive is that the patient is asked to pledge to an unusual degree candor. Well, if you're going to expect that from the patient, the best way to help that happen is for the therapist to be equally candid.
The other thing that can be said about self-revelation by the therapist is that the guidelines are not matters of analytic technique; they're matters of common sense. In other words, I may arrive to the therapy session being really annoyed with my wife. I'm not going to start telling the patient about that, because it's not to the purpose. Or a woman patient may walk in and she may look sensational. I may not tell her that she's looking hot. Why? Because I calculate that the effect of the remark is likely to be one that I would not like to have happen. These are common-sense judgments.
VY: Some common sense should be part of what determines it, as well as tact.
OR: Right. That's right. It's not a technical rule. The other thing I have said in the book is about what to do when you reach an impasse in treatment. I know there are all kinds of reasons for impasses and it's not one-size-fits-all. But if there is any generalization that could be made about working with impasses, in my opinion, it is that the situation could benefit from the therapist being as candid as possible and turning all his cards face-up. I gave some examples of that in the book.
RW: Can you give us one now?
OR: Yes. There was one patient—I was really pissed off at him. He had two previous treatments that ended disastrously. He was really dishonest and slippery, and couldn't get pinned down about anything. And he would lie and double back on himself and bullshit. That was ultimately very frustrating for the therapists he saw. When the therapists would try and pin him down he would get into a fight with the therapist instead of seeing that the therapist was trying to help him see about, how he was operating in his life. And after awhile, I'd finally had it with him about that too. I told him he was really getting' up my nose and he kept coming back to me with, "We'll you're being narcissistic?" I said, "Maybe. But I don't think it's our main problem."
RW: That’s a separate issue. (laughter)
OR: It may be, what can I tell you man?! Ultimately, it wound up very well, because he felt like as long as I was swallowing that stuff and trying to keep it out, he knew I was not being authentic.
RW: You were just BS-ing him as well, so to speak, until you began telling him how he was affecting you.
OR: That's right. In essence, that's right. In terms of what Victor said, there is tact.
VY: One obvious difference in a therapeutic relationship is that in other relationships you’re out there trying to get your needs met in addition to being sensitive to others. Whereas the primary focus as a therapist is the patient.
OR: Oh, that's absolutely right. That is of fundamental importance, that the therapeutic relationship is for the benefit of the patient. And that it's the therapist's duty to try and keep his or her needs subordinate to that. Absolutely.
RW: At the same time, attend to your own feelings. For example, traditionally, countertransference is seen to be something you notice, it is the therapist’s own feelings triggered from the patient, from your life, your past, buttons pushed, and so forth. You try to analyze yourself, or with your colleagues, your supervisor, consultants, and keep it out of the work. Some of it may be helpful and help you understand something about the patient. But, for the most part, you don’t share much of it. You’re turning that upside down and saying, “Sure, keep your junk out…”
OR: To the extent you can, yes.
RW: To the extent you can, keep your junk out, but also, that not sharing yourself in the therapy may very well be hurting the therapy.
OR: That's right. And you gotta be very careful, because it's very difficult to keep your junk completely out of the therapy.
RW: Okay.
OR: So if your junk is in there, when it gets in the therapy, then you gotta cop to it. You gotta be aware of the fact that your junk can always be getting in, in ways that you would not prefer, in ways you're not readily aware of, and cop to that. As you did with your patient, Randy.
It was, as it goes, rather innocent junk, it was misdemeanor junk, you were obeying the orders of your supervisor and doing a dumb thing.
It was, as it goes, rather innocent junk, it was misdemeanor junk, you were obeying the orders of your supervisor and doing a dumb thing. And eventually you call the patient up and brought her back and say, "Hey, look, I'm sorry. I did a dumb thing, it was a mistake." In many little ways, that happens all the time.
In the example Randy was asking about before —and there are many examples in the book about this— "Look, I'm not aware of being competitive. What can I tell you? I understand your point, but I don't think I'm being competitive with you. You know, maybe I'd be the last to know." You gotta acknowledge that possibility. That's another aspect of what's called countertransference. The problem of countertransference as a concept is the same as the problem of transference. It implies that there are personal aspects of the therapist's relationship that can somehow be identified and separated from the non-countertransferential aspects of the therapist's functioning, which can then be left relatively countertransference-free. In reality, every moment of every session, and everything that the therapist does is saturated in what we call countertransference. That has to be taken into account in our principles of technique.
VY: Back to my question a while ago, the purpose of this intense examination of the therapist-client relationship is a corrective emotional experience. And, I guess, another way to think about it is it’s a corrective interpersonal experience.
OR: Yes. Right. It's a vehicle for the corrective experience. As we've been saying, Victor, I mean it's for the patient, so it's the patient's experience and the benefit that accrues from it that counts. But the vehicle for that is certainly, as many people have recognized, the relationship. I'm not advancing this concept of the mechanism of action of therapy as a perfected and all-inclusive formulation. I think we should regard this problem of understanding how therapy works and what kind of technique is going to optimize therapy working as a work in progress.
VY: I think you’ll agree that many therapists, not only analytically trained but therapists trained in other orientations as well, have great difficulty in really working in a transparent, here-and-now fashion.
OR: Well, do you mean, why is that?
VY: Do you think it’s true and why?
OR: Yes, I think it's definitely true. I think that there are, in broad strokes, two kinds of reasons. One is you cannot overemphasize the influence of what has been taught—that whole misguided idea of the therapist's objectivity—and still is taught.
Even though there are disclaimers and caveats issued, that dogma is still a tremendous influence and impediment to effective work with patients.
Even though there are disclaimers and caveats issued, that dogma is still a tremendous influence and impediment to effective work with patients. It's like Catholics who claim to no longer be believers and practitioners. At the same time, come Friday, "Man, I don't think we should have the roast beef. I think it would be nice if we had some salmon, you know." (laughter all around)
The other thing, and maybe the more important thing, is that to really get in there with a patient is a perilous business. You're presenting yourself as somebody who can be helpful and you're charging money for that. Now, that means you gotta deliver. It's very threatening to feel like you might not be able to deliver. Traditionally, one way of protecting yourself against that threat is to retreat to a position in which your accountability is diminished, and in which you are personally not so exposed. You've got a group of people, therapists and analysts, who have their own struggles, and undertaking a task, which, in principle, requires a great deal of personal courage and skill.
RW: Well, maybe, until a person becomes self-aware enough, you have to be a little more careful about what is shared of a personal nature. And that is one of the growth things in therapists, becoming self-aware, self-reflective—as much as possible. So that when you do share more, you can own your own stuff, you can speak for yourself. Speaking for yourself as a person, let alone as a therapist, I think, is an accomplishment that takes work.
OR: Truly. But it doesn't work to begin by being anonymous. I mean you don't get better, you don't learn to swim outside the water. You learn to swim in the water by trying your best.
Flying blind and the corrective emotional experience
RW: In your book, you emphasize that we don’t know everything that is going on within the patient, that we can’t have a total plan: “As far as the corrective emotional experiences are concerned, an analyst never knows ahead of time exactly where he or she needs to go or how to get there. In that sense, an analyst is always flying blind.” Can you say what you mean by flying blind and give an example?
OR: Flying blind, that you don't know where you are going in the terms that we have just been discussing. If you hypothesize that the purpose of the treatment is to provide corrective emotional experiences for the patient, you don't know what they consist of. The term corrective emotional experience fell out of favor and has gotten a bad rap. Alexander and French were the first to promote the concept, and, later, Hal Sampson and Joe Weiss, in Control Mastery theory. Control Mastery is sort of a derivative of the corrective emotional experience and there are many great things about it. They agree that the purpose of therapy is to provide a corrective emotional experience for the patient. But the problem with those approaches was they went an extra step and diagnose what kind of corrective emotional experience is required, and then attempt to provide it. Alexander and French did this in a very rudimentary way, and Hal and Joe in a much more sophisticated way. But both approaches suffer from the same problems, which are, number one, that to think that you cannot fly blind, and think that you can diagnose what kind of core issue the patient is facing: "Your father was very cold to you, so I'm going to be warmer in each session".
RW: Or “If you have a fear of abandonment, I’m not going to abandon you.” But deciding it a priori is your point, right?
OR: Deciding it period. The therapist deciding it is presumptuous. A priori, or three-quarters of the way into the treatment, it's a presumption. That's one problem. And, then, the therapist providing it is an artificial. Therapist role-playing it is an inauthentic, disingenuous thing. And, by the way, analysts recognize that. That's why Alexander and French's ideas were originally dismissed. Too bad 'cause they had a very good theory of how things work. The proposed technique was not so great. So we need to have the theory which takes into account that there is no way of knowing, that the therapist does not decide what the patient needs. And there's no way to provide that that isn't artificial.
You have to find a way of bring it into dialogue, just what you were emphasizing before, Randy, of giving the patient full voice in working out with the therapist, conjointly, the treatment method. You gotta acknowledge that you're flying blind. Otherwise, you'll be presumptuous.
RW: Acknowledge to who, yourself, the client?
OR: Both. Obviously, if you don't acknowledge it to yourself, you won't acknowledge it to client.
RW: Obviously. (laughter)
OR: Well, but that's what happens. Even people who think they're acknowledging it may not be.
There's a lot of, "Yes, I believe, oh, I believe in the patient having a voice. Of course, anonymity is passé, we've given that up." But the patient says, "Do you have any kids?" and the therapist says, "Well, why are you asking that?"
There's a lot of, "Yes, I believe, oh, I believe in the patient having a voice. Of course, anonymity is passé, we've given that up." But the patient says, "Do you have any kids?" and the therapist says, "Well, why are you asking that?"
RW: “Why are you asking me if I am married? What would it mean if I was or wasn’t, and why are you asking?”
OR: "Have you ever been depressed? You're telling me about my depression and what you think. Have you ever been depressed?"
RW: You answer in a straightforward fashion?
OR: Sure. Now, if I get the feeling that the patient is just feasting off it for whatever reason and finding out about me, I say, "Listen, I don't understand what all this is and how this is helping you." Or, "I certainly hope you're not trying to be me—because I haven't told you about the other parts of my life yet." But, seriously, basically, yes, I answer them.
VY: It’s easier, in retrospect, to say when you were depressed in the past, and then you can talk about it. It’s hard while stuff is going on. What happens if you are going through a divorce, or you’re depressed right now? What do you say?
OR: Well, for example, I did go through a divorce while being a therapist, and as you can imagine, I had many patients that came in who knew I was going through a divorce and wanted to talk a great deal about it, and had ideas about it. It turned out differently with each patient that brought it up, but first of all, for example, I might say, "Well, look, I'm happy to tell you whatever is going to be useful. But I think we should think carefully about what that is. What would you like to know?" and I would tell them.
At a certain point, and this gets to another thing Randy mentioned before about your own junk and keeping it out. There are certain things that I decline to tell the patient, not for the patient's good, and I didn't hide behind it, but for my own reasons. A patient would say, "Well, why did you blah-blah-blah?" I'd say, "Look, that gets into my view of Lisby (my ex-wife) and she's not here to speak for herself. So, I don't really feel comfortable giving you my thoughts on that without her being there. I'm sorry. I understand I'm not saying that this is for your good." There may be limits about what, for example, you are willing to disclose to a patient that's got zip-all to do with the patient. You don't hide behind it and say, "Well, for the good of the treatment, I think."
RW: You are not advocating that you must reveal because you can reveal.
OR: Yes. "Look, I'm not going to tell you what my favorite sexual position is. I don't feel comfortable doing that. You know, it might be very helpful to you. I don't know. But I'm sorry, I'm not going to tell you." (laughter)
RW: In this era of the Internet and everything, therapists are freaked out—”Oh my God, they’ll know something about me!”
The much talked about APA plenary speech
RW: I know we don’t have much time but I want to get to a few more questions.
OR: Okay.
RW: I know you spoke at the plenary of the American Psychoanalytic Association meeting in 2003. This talk has been published in the journals and is widely referred to. You said what some consider to be challenging things about psychoanalysis and training. Yet, it has been reported to me by a friend in attendance that you received a five minute standing ovation and it was quite well-received. How do you make sense of this, you are a maverick and your ideas are well received, yet not necessarily accepted?
OR: There are a couple of things that I would say about that, candidly. First of all, these issues that I'm touching on, many analysts and therapist are very conflicted about them. They have questions, and they appreciate a chance to dialogue about them. And they're good people. Even people I disagree with fundamentally are very nice people. The other thing is I think, for myself, I'm not in this to put other people down and to say, "I'm smarter than you, and you're such a jerk." I've got a lot of friends that I disagree with completely about this stuff and I love those people!
RW: I have one last question. What do you enjoy most in your work with patients? And what keeps you alive and vital in your work?
OR: Oh man, it's been the same thing since day one, which is the whole reason I began as a therapist and became an analyst: If I can help people. You know, despite these treatments, I really wish I could have saved my mother.
To the extent that I could help anybody who comes in feeling terrible and walk out feeling great, it makes my day. And that's what I'm in business to do. So, that's what I love.
To the extent that I could help anybody who comes in feeling terrible and walk out feeling great, it makes my day. And that's what I'm in business to do. So, that's what I love. That's what it's all about. That's why I continue to work. I mean I'm not that interested in speaking any more, and I'm not that interested in writing anymore. But what I do, and will do as long as I am able, is work with patients. That's what keeps me going. Helping others in therapy, that's always been the engine for me. And that's it, still. So, gotta go guys. Thank you very much for taking the time.
RW: Well, thank you Owen.
VY: Thank you.
OR: Oh, yeah, a pleasure! Say hi to your dad. I haven't seen him in a while.
VY: Alright.
