Is Psychotherapy Sustainable in the Internet Age?

Every treatment requires a cultural context that will sustain it. For example, for a very long time, doctors could not practice medicine in a culture that forbade patients from taking off their clothes. Similarly, the intimacy in real psychotherapy is forbidden in many subcultures.

Many people live in situations that prevent them from attending regular appointments. It was certainly a great advance in mental health care when psychologists started thinking about what can be accomplished given the patient’s life constraints rather than always starting a therapy they knew couldn’t last (Horowitz et al., 1984). It was not an advance in psychotherapy, however, to insist that the few sessions being offered were as good as the ideal, open-ended treatment (Nordmo et al., 2020).

Core Factors for Success in Psychotherapy

The psychotherapy outcome literature has long settled the debate over what helps in psychotherapy (Norcross & Lambert, 2019). The problem is that there is no way to monetize these findings with new-sounding acronyms. Successful therapy needs a mutual understanding of what’s wrong with the patient, and a mutual agreement that the cause is psychological—typically, a pattern of behavior or expectations that were once adaptive and are now maladaptive. There must be a mutual, sensible understanding of how therapy can help—typically, with a case formulation that highlights the way patients treat themselves and the utility of bringing all the selves (or all the interpersonal response repertoires) into the therapy by speaking freely. (If the problem is the way other people treat the patient, then those other people must be included in the therapy.) Finally, relational bonds must be nurtured and maintained—bonds of the collaborative sort, not of some other sort such as nurturance, cheerleading, or preaching.

The analogy to physical therapy helps here. If you want to get in shape, improve your athletic performance, or live longer, consult a trainer, coach, or instructor. If there’s something wrong, consult a physical therapist.

The contemporary culture in many parts of America forbids concluding that there is something wrong with the patient. Instead, everyone is perfect in their own way. This attitude is promoted by an internet that will offer every person an online community in which their behavior is normative. Psychotherapy requires an understanding that the patient must adapt to reality; the internet readily adapts to the person.

Changes in Therapist Training and Identity-Based Approaches

Training programs at one time emphasized what was wrong with the student—what psychological patterns and expectations kept the student from fulfilling the demands of the role of therapist. This idea has become so toxic in many graduate programs that they no longer construe the students as needing to be trained (except in record-keeping). The only de facto requirement is that the therapist should once have suffered as the patient has. A patient with some identity element or some sort of pain doesn’t need a well-trained therapist; they need a therapist with the same identity element or the same sort of pain. The analogy to seeking an internet community that avoids rather than resolves conflict is obvious.

In a culture that moralizes as much as ours does, therapeutic neutrality reads as complicity with injustice rather than as offering a place to resolve internal conflict. The very idea of internal conflict seems counter-revolutionary. Therapists are pressured by the culture to stand up against injustice, even when the injustice is perpetrated by patients against themselves. The popular culture is currently bent towards victory over peaceful resolution between parties in conflict, and this extends to the psychology of the patient, where it is currently not only unfashionable but also fascistic to suggest that the part of the person who hates himself and the part of the person who is hated can learn to get along.

The patient’s task in psychotherapy is to take off the social mask and reveal what lies beneath. The therapist’s task is to create a space where it is sensible to do so. Neither of these is possible in a culture that insists that both parties immediately denounce every injustice. Instead, therapy in such a culture teaches the patient to adopt a new social mask, one of moral purity. In that way, we are as puritanical about politically incorrect impulses, feelings, and fantasies as the Victorians in Freud’s day were about sex.

Effects of Anti-Patriarchal Attitudes and Expertise in Therapy

Finally, it is impossible to create a collaborative alliance around working together in a culture that treats all frustration of the patient as patriarchal—and further insists that all patriarchy be denounced. Before the internet undermined expertise by making everyone with a phone feel like an expert, therapists were expected to be experts in psychology and in psychotherapy. Nowadays, claiming expertise is suspiciously patriarchal. The cure for suffering that was caused by mishandled power differentials is not to avoid all power differentials; it’s to get involved in power differentials that are not mishandled. This is not possible in a culture that assumes that all power differentials are evil.

My new novel, The Last Therapist, explores the challenges of providing psychotherapy in a culture of righteous purity and fear of acknowledging internal conflict.

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