Magic in Psychotherapy

I have a colleague who really does real magic in his work. The work where he does his magic, however, is not in the counseling office. Dan is not only a psychotherapist, he is also a professional magician. He has performed his magic in various venues, and sometimes uses his magical skills in a demonstration of certain psychological principles. An important aspect of professional magic is deception. Dan is an expert at deceiving an audience when he performs his magic as he works to deceive the audience by various techniques. He can also make magic by moving the attention of the audience away from his magical skills. He is fun to watch. I have not had the opportunity to see him perform in front of an audience, but he has entertained his friends with a few magic tricks. I have also had the opportunity of seeing him do his work of psychotherapy once or twice, and have come to respect his skills as a therapist.

 While Dan does magic on the stage when he is performing, he doesn’t do magic when he does psychotherapy. There isn’t any magic in his therapy, but there is plenty of skill. To the person who is unfamiliar with psychotherapy, however, it might seem like he does magic when he is with a patient. There is a mystique about the profession of psychology that suggests that we psychologists do some kind of magic when we engage in psychotherapy. In fact, we psychologists never do magic when doing psychotherapy but the process can look magical, and sometimes patients say that they feel magically changed or improved. Therapists often hear from their patients that they feel “magically changed” when they find success in psychotherapy. There can be a kind of magic when a person recovers from a lifelong depression or when their long standing marital dysfunction is resolved into a loving relationship. It is a joy to see such things, but there is no magic in it. Success in psychotherapy comes from the combination of skill of the therapist and hard work from the patient.

 Most people are not aware of the complexity of the human mind, much less human relationships, and think there is some kind of simple answer to personal and interpersonal difficulties. The origins of the belief that there is magic in psychotherapy lies in its history augmented by a more modern view that there is some kind of magical diagnosis which in turn leads to some kind of magical treatment which finally leads to some kind of magical cure. Let’s examine all four of these elements that seem like magic and find a way to replace the idea of magic with skill and hard work.

 The origins of magic in psychology

The modern roots of psychotherapy lie with Sigmund Freud who was the first well established psychotherapist about 100 years ago. In fact, he followed a colleague named Bleuler and others who preceded him in the late nineteenth century. Yet Freud remains well known partly because he proposed the first comprehensive system of understanding the mind. While Freud was the first well known “modern” psychotherapist (100 years ago), there is a stream of understanding of the mind (and heart) stretching at least 2500 years in Western civilization and possibly several more thousand years in Asian and African cultures. All religions had some psychological origins as religions attempt to make sense of the world of people, how people should organize and treat one another, and mature. Philosophers in early Greek society made conclusions of the three basic human psychological elements of thinking, feeling, and action by espousing theories and philosophies that spoke to how people engage in these same three basic elements of living successfully. Perhaps the best known early Greek philosopher Galen proposed a system of personality assessment, namely that there were four kinds of personality, a system that has survived up to and including the present day in temperament theory. In Galen’s theory these four temperaments were the result of more or less activity of something he called the four basic “fluids” or “humors” in the human body. Galen’s theory was certainly not the first theory that integrated psychological and physical structure, function, and health. He had both predecessors and successors who attempted to understand human psychological functioning by identifying certain physical elements in the body. Freud himself used this physical-psychological connection to identify what he called the “hysterical personality disorder” by suggesting that this primarily female condition was related to a “wandering” or overactive uterus from which the term hysterical comes.

 From Freud, Galen, primitive societies, Greek and Asian philosophers, and religions we came to understand that there is an interaction between things physical and things psychological in the human being. Some of these societal, philosophical, and religious theories have turned out to be quite true, while others have come to be seen as completely inaccurate. While many of these early theorists had a genuine interest in understanding human psychology, they often fell into simplistic analyses of the physical-psychological interaction. One such theorist suggested that psychological functioning could be determined by examining bumps on the head. There were also tragedies in the application of these theories including bloodletting by physicians who believed that such a procedure drained “bad blood” from the system. The Inquisitors of the Catholic Church believed that torture of the human body drove out “unclean spirits” that had infected the alleged heretic’s thinking or faith. These things we now certainly know were a kind of magical thinking of how to rid the body or mind of disease of dysfunction. As society came into the 20th century and beyond this magical thinking continued in different forms.

 The Magic of a diagnosis

People love certainty, almost any kind of certainty. Many people prefer certainty to reality. Sometimes they even know that they are preferring certainty to reality, and they choose to believe in the certainty. Certainty gives a sense of safety and direction in life. People who have a terminal illness usually ask the doctor how much time they have to live. They don’t want to die, but they want to know, if at all possible, how many days they have to live. This gives them a kind of safety, even if the doctor gives an approximate time of death. It is hard to live with uncertainty. It is easier to live with the knowledge that something awful will happen than worrying about whether or not something awful will happen. This desire for certainty, even if we can almost never be certain about the future, remains the basis for people’s belief in the magic of a diagnosis.

 The reality of a diagnosis, particularly when it has to do with psychological disorders, is never certain despite what many people believe and many practitioners purport. Some diagnoses are clearer than others, and some are more accurate than others. I have heard from many people that they have some kind of idiopathic disorder. This could be idiopathic pain, idiopathic cough, idiopathic heart rate, or other idiopathic physical disorder. The term idiopathic means that we don’t know what the disease is, don’t know the cause, and probably don’t know the cure. The terms comes from Latin words, idios that means unique, odd, or individual, and pathos that means problem. Interestingly, however, pathos also means emotion or passion. It is not by chance that the word idiot comes from idios. Idiopathic is not a term that is commonly used these days as we now have more elaborate ways of saying that we don’t know what the cause, the progress, or the cure is for something that ails us. Most recently, we hear of Chronic Obstructive Pulmonary Disease (COPD), which essentially means that the individual has a cough of unknown origin (and unknown cure). There are many other diagnoses that have no exact origin and usually no exact cure. Fibromyalgia, Irritable Bowel Syndrome, and Multiple Chemical Sensitivities are among these diseases that are not well understood. The truth be told, there is no medical symptom or condition that falls exactly into a diagnosis because every physical body reacts differently to the physical problems that we have. We can diagnose cancer, but not the cause, and in many cases, not the cure. Some people do well with a certain cure while others do not. More importantly, we do not know the true cause of cancer because cancer is essentially cells reproducing beyond the value or reproduction. We don’t know how cancer starts because we really don’t know why and exactly how a cell reproduces in the first place.

 If many physical illnesses are not well understood, especially the origin of these diseases, we know even less about psychological disorders. Depression, which is the most commonly diagnosed psychological disorder, is not well understood and not particularly well treated and cured. Not only have there been several categories of depression available to psychologists (although this is changing as we speak), depression can be a side effect of another psychological disorder a side effect of another medical disorder, or the primary symptom that the patient presents to the doctor. It is generally assumed in the psychological community that depression is probably over diagnosed. Women are more likely to be diagnosed with depression, but four out of five suicides are committed by men. There are also several different diagnoses of anxiety (although this is also changing in the diagnostic codebook), making it difficult to accurately diagnose a patient given the plethora of diagnoses that are anxiety-based. Despite the complexities of diagnosing anxiety or depression, people are fond of using these diagnoses with seeming clarity and certainty.

 While depression and anxiety are the predominant psychological diagnoses that are rendered, there have been several other psychological diagnoses that have become “popular” in recent years. The most popular diagnoses in recent years are Attention Deficit Hyperactivity Disorder (ADHD), Learning Disabilities (LD) (there are at least seven different kinds), Post-traumatic Stress Disorder (PTSD), Bi-polar Disorder BPD), and Asperger’s Syndrome (AS). I am not longer surprised by hearing from the mother of a perspective patient that her son or daughter has one or more of these disorders. I have come to believe that it gives parents a sense of certainty to render one of these diagnoses to their children who display some combination of psychological and behavioral difficulties. Frequently, parents bring their children to me in order to complete psychological testing to confirm or disconfirm one of these diagnoses. Interestingly, there is no test that accurately diagnoses ADHD, LD, PTSD, BPD, or AS with any certainty. Diagnoses of these disorders are always approximate and completed with “clinical observations.” This means that the psychologist believes the patient has one or more of these disorders given his/her clinical judgment in conjunction with various psychological tests. When I administer these tests, however, I sometimes find that a very disordered child shows symptoms of all of these disorders or none of these disorders. Parents are often disappointed when I cannot render a diagnosis with some kind of certainty.

 The certainty that parents want, or the patient him/herself wants, would suggest that there is an exact treatment for this patient. Exact treatment is conceived as being based on exact brain dysfunction, and brain dysfunction is the result of (1) a portion of the brain that is not working correctly, or (2) a “chemical imbalance” in the brain where there is an insufficient production of a chemical in the brain or an excess production of a chemical. The introduction of pharmaceutical treatment for most psychological disorders is based on this notion of chemical imbalance. The evidence of extensive research, however, indicates three important things: (1) medication does not cure these disorders, (2) successful treatment of psychological disorder often does well with some combination of medication and psychotherapy, and (3) most of these disorders somehow evaporate over time, especially if the patient is aware of the disorder.

 While so-called chemical imbalance is the prominent theme among people who think that the brain is not working right when we have a psychological disorder, there is increasing thought that certain portions of the brain are not working right. Predominant among the possible culprits of brain dysfunction is the prefrontal cortex (PFC). The PFC is the apparent housing in the brain of “executive functions,” or planning and executing behavior. Dysfunctionality in the PFC has been considered the culprit for ADHD, AD, LD, and PTSD in addition to Psychopathic Personality Disorder. A good deal of research suggests that some kind of functioning or dysfunction of the PFC causes or contributes to these disorders, but the research is less clear as to the cause of this apparent brain dysfunction, much less the possible treatment of the dysfunction. Nevertheless, people feel somehow comforted being told that the reason for their psychological distress, or that of their child, is the result of a brain dysfunction of some kind. Few clinicians note that there are at least an equal number of people who seemingly have the brain dysfunction but not the psychological dysfunction. It is comforting to have an exact diagnosis, which suggests an exact cause but we have no certainty in either of these arenas.

The magic of treatment

If we have an exact diagnosis and an exact origin of a disorder, it would seem reasonable that we might then be able to recommend or prescribe an exact treatment. Unfortunately, treatment is even less exact and certain than diagnosis, especially for psychological disorders. Interestingly, many psychological disorders improve or disappear without any treatment, whether psychological or medical. Furthermore, some disorders do not seem to improve with any sort of treatment. And we don’t really understand why the psychological disorders that some people have seem to be so resilient to treatment compared to people for whom the very same regimen of treatment is quite successful. Understandably, practitioners, whether medical or psychological, are not particularly forthcoming about the fact that treatment for psychological disorders is not an exact science.

The magic associated with treatment of psychological disorders persists because of the need people have for “certainty” even if that certainty is…not certain. Furthermore, there is a kind of mystique or magic, about the profession of psychology and psychotherapy. It remains mysterious to most people how we therapists go about our trade, a trade that amounts to what Freud called the “talking cure.” It is mysterious to the public, and it is somewhat mysterious to us therapists. Sometimes I think that I am doing very well in my work with a particular patient only to find that my work has not yielded any kind of meaningful improvement. I have seen an older couple for six years, seeing them together and seeing them separately, with no particular improvement in the psychological of either of them or the state of their relationship. But they continue to come back to my office, and I work diligently to make progress with these people. I think they are looking for magic, the magic that a therapist seemingly has by saying the right thing or giving the right direction, even though I obviously haven’t done either in these six years. I continue to see them because I seem to be their only hope after they have “failed” with three other therapists. I certainly haven’t succeeded with them, but perhaps I have given them some kind of hope for some kind of cure. I remain amazed every time they come to see me that they say essentially the same thing, that I say essentially the same things, and that they do the same thing…which is remaining unhappy separately and even more unhappy together.

The magical appearance of psychotherapy gives people hope, which can be very good for them. There is good psychological research that suggests that when people have hope, they are more likely to be physically and psychologically well. People do better in life even when their hope is seemingly misplaced. There is some kind of interaction, not well understood, between the psychological mechanisms that are released from hope that eventually affect the physical mechanisms of the body. The life expectancy from people with hope is far greater than those without hope even whether the people being examined are ill or healthy. Thus it is important for therapists to help people find hope in their lives as well as in the process of psychotherapy for them to recover from their disturbances and dysfunctions. The magical appearance of psychotherapy is not related to hope per se. People can never have too much hope. They can, however, have too much belief in the magical hope of psychotherapy.

The mystique and magical appearance of psychotherapy is related to a gross misunderstanding of what psychotherapy is. It is not truly magical although some results of psychotherapy may seem almost magical. Indeed, it does seem magical when someone overcomes a long-term depression or recovers entirely from an early life assault. It even seems magical when a couple actually learns to communicate effectively and hence maximize their love for each other and minimize their dislike for each other. But the process of psychotherapy is not as mysterious, magical, or mystical as it is scientific and natural. There is some science about how to go about doing good psychotherapy, albeit not much. Some scientific research into certain modes and methods of psychotherapy can lead a good therapist to becoming more effective in the work. More importantly, however, there is a natural element to psychotherapy: friendship. Most of the men who come to see me admit that they do not have any friends. During the last hour I heard from a man of 56 that he has had two friends in his entire life, both of them from high school, and neither one has he seen in 25 or 30 years. If I eventually help this man, I will need to become a good friend, perhaps his best friend for a while. Friendship is not magical; it’s just hard to find, especially for men and for older people. The “professional friendship” of psychotherapy looks magical because the patient probably doesn’t have anyone else in his life who can be a good friend. In fact, friendship is natural if we allow friendship to develop naturally.

The magical cure

Much of science seems magical and mysterious. It seems mysterious that a feather and a cannonball will fall to the earth at the same speed if there is no interference from air. Newton proved this with his famous apple experiment. It seems mysterious that time slows down when we are traveling at any speed, and it seems even more mysterious that time apparently stops when we reach the speed of light as Einstein proved. There is much in science that we really don’t understand including the gravity that pulls the same on a feather as a cannonball, or what time really is. We as yet do not understand how and why a living cell grows or why it has a certain life and then dies. If we understood these things, we would be able to cure cancer, which is the unabated growth of cells, or prevent death with is the seemingly natural death of cells.  Even though we don’t understand growth, gravity, time, and many other factors in science, we have a certain trust that these things operate in some sort of scientific fashion.

Because physical illnesses have a lot to do with growth and death of cells, it is often hard to find a cure for diseases like cancer. While we understand much of the progress of physical diseases, we don’t fully understand the causes of these same diseases. Science and medicine has progressed immensely over the past 100 years and moderately over the previous centuries. But we still don’t understand the causes of many diseases and don’t have cures for them. We have treatments for most diseases that for the most part abate the continuation of the disease, but we usually only reduce the symptoms and delay the progress of diseases. I just heard that there has been an evident cure for AIDS in a child although the report is fresh at this time and will certainly be examined in the days and years to come. However, we have seemingly not found a cure for AIDS despite the fact that we now do have treatments that forestall the progress of the disease. We do look for more treatments and more cures for physical diseases.

The situation is very different in the field of psychological treatment. Because psychotherapy is somewhat scientific, somewhat artful, and somewhat mysterious, we therapists are not in a position to suggest that there is a cure for psychological distress, despite Freud’s comment about the talking cure. Psychotherapy is very challenging, and because of that fact many therapists “burn out” of the business, usually because they have not examined themselves enough to avoid the tendency to work too hard with patients or work to simplistically with patients. It is fair to say that psychotherapy never cures disorders and distress. Rather, good psychotherapy (which is hard to find, by the way) helps a patient think, feel, act, and relate in ways that are more productive, creative, and honest in life. Psychotherapy looks like magic and it looks mysterious because it is seen as a cure. Most of the people who come to our offices want us fix them, which is tantamount to curing them of what ails them. We therapists know that we cannot cure them magically because there is no magic in treatment and there is no magic in diagnosis, so there most certainly is no magical cure.

So if there is no magical cure for psychological distress and disorders, what can psychotherapy provide for a person who seeks it? Psychotherapy can be life changing and life enhancing. It can turn people around so completely that they themselves and the world around them in a very positive light. Psychotherapy can improve personal, interpersonal, vocational, private, and public lives dramatically. But good psychotherapy requires both a willing practitioner and a willing participant in the process. It is rare that these two ingredients are present at the same time. Psychotherapy is not magical and it provides no magical cure. It can provide something that is very good, but this good something is not a magical cure. It is a transformation due to hard work on the part of the therapist and even harder work on the part of the participant.

If a person comes to my office asking for a cure or asking me to fix what ails him, I tell him that I cannot cure him or do magic, but we could possibly work hard to find a transformation in his life so that he can enjoy life and bring joy to others. I do not cure people’s depression or their dysfunctional relationships. I help people understand themselves so that they can like themselves. If they like themselves, they will be true to themselves and adequately communicate themselves. If this happens, they will love and they will be lovable. When this happens, something seemingly magical happens: they forget about themselves. They can forget about themselves because they know their strengths (first) and their weaknesses and be unimpressed with their strengths and unashamed of their weaknesses. They become true to themselves, true to others, and begin to live truth. If there is any kind of magical cure for psychological distress, it certainly lies in people finding truth and generating truth in others just as they become better at loving and being loved.

 The magical cure for the other person

The magic that people seek from psychotherapy usually applies to the other person. This other person is a spouse, partner, child, parent, co-worker, supervisor, or friend. Psychological diagnoses are so popular these days that it seems everyone has some kind of magical diagnosis and is engaged in some kind of magical treatment. It is so much easier to look at what is allegedly wrong with the other person than look at myself that most of these magical diagnoses are rendered for the other person. Since autism and Asperger’s Disorder (AD) became so popular recently, I have had many mothers bring their children to me firmly convinced that their kids had Asperger’s Disorders. Another recently popular diagnosis is bi-polar disorder (BPD). In previous years these mothers would believe that their children had some kind of learning disability (LD), and ADHD, but now I hear mothers convinced that their children are AD and BPD. Then they can believe that I can do some kind of test to confirm the presence of these disorders despite the fact that there is no known test that adequately diagnoses an individual with either of these disorders, nor for that matter ADHD or LD. I have seen kids who have diagnoses with all four of these “popular” kids’ diagnoses, sometimes at the same time. Oh, if it were so easy to diagnoses any of these disorders, much less differentiate a clear diagnosis from the dysfunctional families that they often come from or from the school systems that do not recognize different learning styles, personality styles, or different kinds of intelligence that all people have.

If mothers are eager to have exact diagnoses for their children so that they can have exact treatment and an exact cure, it is even truer of adults. If all my patients were accurate in their diagnoses of their spouses, it would seem most of the women of the world suffer from bi-polar disorder, and if not that, certainly from major depressive disorder. I frequently hear something like, “She is so depressed lately that she must be suffering from depression,” or “She is so changeable in her feelings that she must have bi-polar disorder.” I just had a session with a couple who diagnose each other with these diagnoses: one allegedly suffers from depression and the other from bi-polar disorder. Neither of these diagnoses is accurate. Granted, the wife is quite unhappy in her relationship and the husband is quite inconsistent in his expression of feelings. But these are normal feelings in marital discord and not a call for a magical diagnosis that will somehow lead to a magical cure. At this point, however, each of these marital partners are so postured in their belief that the other person has a diagnosis that they can’t do the real work of self understanding that breeds understanding of the other person that in turn breeds good communication and good love.

While the majority of people believe in the magic of diagnosis, treatment, and cure…usually for someone else, there is a minority of people who disparage psychotherapy entirely because of what they see as an unduly complex and indulgent treatment of behavior that should be simple and directive. A basketball teammate once said something like, “Don’t you think that most of these so-called mental disorders amount to lack of motivation and laziness?” It was a bit hard to respond to his rhetorical question because there is, indeed, some truth in the fact that many people are not properly motivated to do what it takes to be successful and happy in their lives. People who take this simplistic view of emotional, relational, and behavioral difficulties understand that there is a magical belief in the effectiveness of psychological treatment. They probably see the indulgence of parents and practitioners seemingly treating disorders that might not really exist. But these critics of psychotherapy have thrown the baby out with the bathwater. People with this simplistic assessment of personal difficulties usually tell people something that begins with, “All you have to do is….” There is no “all you have to do is” in psychotherapy. It is just as simplistic to suggest that people just need to do something to fix what is wrong with their lives as it is to suggest that there is a magical diagnosis and a magical cure.

If psychotherapy is not magic, what is it?

It doesn’t work to have a simple diagnosis that heads to a simple treatment and cure. It doesn’t work to make a judgment about another person that s/he is lazy, and you have the answer to what s/he needs to do. Good psychotherapy contains the elements of good skill on the part of the therapist, hard work on the part of the patient, utilization of the self understanding acquired, and time. The central feature of this process is the combination of the feelings, the thoughts, and the behavior of the patient. Some people feel well but do not think or act; some people think well but do not feel or act; and some people act well but do not feel or think. A few people are able to do two of these things: feeling and thinking, feeling and acting, or thinking and acting. But no one does all three of these ingredients in developing a happy and successful life. Psychotherapy should bring to the person the understanding of their strengths, whether thinking, feeling, or acting, and then helping the patient develop the other two elements. This is hard work. Generally feeling-based people do not think clearly, thinking-based people do not feel clearly, and acting-based people do not think or feel clearly.

It is hard and work and it is painful to develop skill and capacity to feel, think, and act. It is hard work because no one is skilled in all three of these areas, and when a person enters the arena that is unfamiliar, that person will feel insecure and inadequate. It takes time to develop the arenas of life that we are not skilled in. The “work” is mostly practice. Practice, whether it is in thinking, feeling, or acting, is difficult because the area that needs practice is not developed. It is childlike. It is embarrassing to do something that I am not good at doing. A good portion of the work a patient must do in psychotherapy is courageously and regularly engage in doing something that is unfamiliar and awkward until that area becomes more familiar and the behavior of thinking, feeling, or acting becomes more fluent.

Not only does it take work to develop the second or third area of life, but it takes time and it is painful. It is painful to do the work of developing the second and third areas of psychological functioning, but it is even more painful to govern one’s strength. Governing means managing the strength, using the strength with care, and avoiding using the strength instead of one’s inherent weakness. A feeling-based person will be inclined to feel when he needs to think, and a thinking-based person will be inclined to think when he needs to feel. It is painful to leave thinking to the arena of life that benefits from thinking; and it is painful to leave feeling to the arena of life that benefits from feeling; and it is painful to leave acting to the arena of life that benefits from acting. So if one’s first tendency is to use one’s strength, a patient who is “working” to develop himself or herself will govern the use of their strengths so as to develop their abilities in their lesser developed areas of psychological functioning.

Psychotherapy works when a patient finds a depth understanding of him/herself, when s/he accepts and values their strengths, when s/he governs these strengths, and when s/he learns other ways of operating in life. Psychotherapy is work, it is painful, and it is usually long. But it is not magical.