On the couch

Your problems, your solutions...

Your problems, your solutions...   | Photo Credit: Photo: Rajeev Bhatt


Though there are different approaches, psychotherapy is mainly about getting a deeper understanding of your self and arriving at your own solutions to perceived problems.

When introduced to me, the first thing that comes to many peoples’ minds, whether they express it or not, and a good many do express it, is some gag or the other about the couch. And when clients visit me for the first time, they usually look around, surreptitiously of course, for the couch. After all, how good can a shrink be, if he doesn’t have a couch? The couch has come to be thought of as one of the tools of a therapist’s trade and some of my clients look a tad disappointed when they can’t spot a couch in my office. It’s almost like seeing a doctor who doesn’t own a stethoscope.

So, is a couch really necessary for the process of psychotherapy? Actually it is not. The couch came to be used in therapy when, around the turn of the last century, Sigmund Freud, the much-maligned genius, invented psychoanalysis or the “talking cure”. Freud used hypnosis in the early stages of the development of psychoanalysis and, therefore, a recumbent posture was considered more desirable. Even after he abandoned the use of hypnosis, the couch continued to play a role, as he believed it caused the client to be in a state of relaxation when exploring unconscious conflicts. Also, the recumbent posture gave the analyst the opportunity to sit behind the client’s head, out of the client’s view, so that the analyst’s physical presence did not disturb or distract the client. Even today, psychoanalysts use the couch as an integral part of their interventions. But, all psychotherapists do not.

Different approaches

The difference between a psychotherapist and a psychoanalyst is much more than many people may believe. An analyst uses a very stringent theoretical framework and very specific tools and processes such as “free association” (a technique whereby the client is asked to state each thought as it comes to his mind without censoring it and allowing the analyst to interpret the thought) and dream analysis (the client or “analysand” is asked to describe his dreams in graphic detail, thereby giving the analyst an opportunity to analyse and interpret them). The framework that an analyst uses would depend on the school that s/he is affiliated to. Thus, you have Freudian analysts (who follow the theories of Freud), Jungian analysts (who follow Jung’s teachings), Rankian analysts (Otto Rank), Kleinian analysts (Melanie Klein) and so forth. All practising analysts would have undergone a period of personal psychoanalysis with a qualified analyst as part of their training and for a few years when they first start practising, are usually supervised by a senior analyst. The process of psychoanalysis can take from anything between one and five years and clients usually meet their analyst once or twice a week during this period. Psychotherapy developed as an offshoot of psychoanalysis to counter the criticism that analysis seemed too long-drawn out and time-consuming, and therefore, often unaffordable. However, it’s important to realise that psychotherapy is not an abbreviated or “instant” version of psychoanalysis. Also, the therapy-seeker needs to know that there is a wide range of psychotherapies available in the market today, some better known than others.

First off, you have Psychoanalytic Psychotherapy which is very close to psychoanalysis but is a little more focused on the immediate problem that the client has and not necessarily all her/his unconscious conflicts, although some generic conflicts are addressed. It’s generally shorter than classical psychoanalysis and could last for up to a year or two. Then you have what are referred to as the Psychodynamic psychotherapies. These too use some of the theoretical foundations of psychoanalysis although the process and techniques vary. The focus is on arriving at insights into the impact of unconscious and unresolved past issues on the individual’s present life and could last between six months and a year. The Brief Dynamic Psychotherapies usually follow similar principles as psychodynamic therapies in either an anxiety provoking (produce insights by inducing stress) or an anxiety-reducing format (produce insights by reducing stress). Such interventions usually last for about 12 to 18 one-hour sessions. Then there are Rational-Emotive Therapy that appeals to rational processes in the mind of the client to help overcome whatever issues the client faces, and Cognitive Behaviour Therapy, that is based on the theory that negative cognitions (ideas and beliefs) cause emotional problems and therefore attempts to substitute negative thought processes with positive ones. Aside of these there are other psychotherapies — such as Psychodrama (uses drama as a method of exorcising unresolved issues) or Gestalt therapy (based on the well developed Gestalt psychology) and other Humanistic therapies such as Client-centred Psychotherapy that seek to shift the focus on to the human beings or clients, rather than the problems they experience. Needless to say there are a lot of esoteric psychotherapies as well.

Effective treatments

On the face of it, going by the list of psychotherapies described, it may appear that the psychotherapies are really more whimsical than scientific. Nothing could be further from the truth. There is growing research-based evidence confirming the effectiveness of these different psychotherapies. However, the research literature is not too voluble on which of these is better than the others. One important reason for this is what is often called the therapist variable. There seem to be some therapists who, for a variety of reasons, are very gifted and deeply empathetic in the way they approach their clients. Obviously the results produced by such therapists would be far better than another less gifted or empathetic counterpart even if both administer the same sort of psychotherapy. The notable exception to this is Cognitive Behaviour Therapy which, by virtue of being a highly standardised method, does not depend as much on the gifted therapist as do the others. The research literature is also clear that judicious combinations of medication and psychotherapy produce better results than either does individually. In the final analysis, it is the relationship between the therapist and the client that produces consistently successful outcomes.

In India, most psychotherapists use what is referred to as an “eclectic” orientation to their psychotherapy. The term usually means, “a bit of this and a bit of that”. However, it is not as capricious as it sounds. A fairly distinctive form of “Indian psychotherapy”, for want of a better word, seems to be evolving over the last couple of decades that takes the best of all worlds and, like most good therapies, is based on a relationship between the client and therapist. Even though many Indian therapists are eclectic, they would invariably lean towards one of the classical psychotherapies, based on their training and experience.

Nothing formidable

The experience of psychotherapy from a client’s perspective need not be a formidable one at all, if one understands when one should take help and what one should expect of the therapeutic process itself. You should seek therapy not when you become ill, but when your life seems to be at cross-purposes with you and you don’t feel as composed as you would like to be. The therapeutic process itself, regardless of which form of therapy your therapist is oriented to, is exceedingly simple: you just sit in an armchair or across a table and talk to your therapist for about an hour or two a week about the issues that are bothering you and the therapist helps you understand these issues from a slightly differently perspective so you can empower yourself to make considered choices. The most important criterion that needs to be satisfied is that you feel comfortable with your therapist. Also try and remember that psychotherapy is not about getting advice or solutions to your problems from a professional. It is about your obtaining a deeper understanding about yourself and arriving at your own solutions, with some professional nudging. It’s your mind. You own it. As you do your therapy.

The writer is a psychiatrist, columnist and author. His latest book, The 24x7 Marriage, is due out in late 2008. He can be contacted at >

A fortnightly column on mental wellness.

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