Couch is a series about psychotherapy.
âIâm meeting my boss later,â my patient said. âIâm worried sheâs going to tell me Iâm not pulling my weight, and that I should volunteer to work more hours to show my commitment.â
This tension had been building at her job for months, and she feared that there would be a tacit threat in this meeting: work longer hours, uncompensated, or we will push you out. She was already finding it hard to spend so much time away from home. But she couldnât afford to risk unemployment.
âWhat am I supposed to tell my children?â she asked, breaking down.
My stomach knotted. Such worries among my patients are becoming so common, so persistent, that I find myself focusing less and less on problems and neuroses that are specific to individual patients, and more and more on what is happening to the fabric of daily life.
As a psychotherapist with a private practice in Manhattan, I see a lot of early- and mid-career professionals coping with relentless email and social media obligations, the erasing of work/life boundaries, starting salaries that remain unchanged since the late 1990s. I see âagingâ employees (30 and up) anxiously trying to adjust to a job market in which people have to change jobs repeatedly and cultivate their âpersonal brand.â No one uses all her vacation days. Everyone works longer hours than he would have a generation ago.
Credit Kiyoshi Ota/European Pressphoto Agency
Typically, therapists avoid discussing social and political issues in sessions. If the patient raises them, the therapist will direct the conversation toward a discussion of symptoms, coping skills, the relevant issues in a patientâs childhood and family life. But I am growing more and more convinced that this is inadequate. Psychotherapy, as a field, is not prepared to respond to the major social issues affecting our patientsâ lives.
When people canât live up to the increasingly taxing demands of the economy, they often blame themselves and then struggle to live with the guilt. You see this same tendency, of course, in a variety of contexts, from children of divorce who feel responsible for their parentsâ separation to the âsurvivor guiltâ of those who live through disasters. In situations that may seem impossible or unacceptable, guilt becomes a shield for the anger you otherwise would feel: The child may be angry with her parents for divorcing, the survivor may be angry with those who perished.
This is no different at the social level. When an economic system or government is responsible for personal harm, those affected can feel profoundly helpless, and cover that helplessness with self-criticism. Today, if you canât become what the market wants, it can feel as if you are flawed and have no recourse except to be depressed.
Over the last 30 years, I believe, these changes in the workplace have been slowly taking a psychological toll, though in a more diffuse, less detectable way than with any one traumatic event. To a degree that they may not be aware of, people feel less hope and more stress; their self-regard is damaged; they believe they are fated to take what they can get; they exist in a state approaching learned helplessness.
There comes a time when people canât take it anymore, when too much is being demanded of them. How much blame can people tolerate directing at themselves? When do they turn it outward?
My sense is that psychotherapists are playing a significant role in directing this blame inward. Unfortunately, many therapists, because they have been trained not to discuss political issues in the consulting room, are part of the problem, implicitly reinforcing false assumptions about personal responsibility, isolation and the social status quo.
If the patient describes a nearly unbearable work situation, the therapist will tend to focus on the nature of the patientâs response to the situation, implicitly treating the situation itself as unchangeable, a fact of life. But an untenable or unjust environment is not always just a fact of life, and therapists need to consider how to talk about that explicitly.
This is, in ways, an old quandary in psychotherapy. Should therapy strive to help a patient adjust, or to help prepare him to change the world around him? Is the patientâs internal world skewed? Or is it the so-called real world that has gone awry? Usually, itâs some combination of the two, and a good psychotherapist, I think, will help the patient navigate between those two extremes.
When therapists make the dialogue only about their patientâs life narrative, without including a frank discussion of social and economic hardships, they risk reducing psychotherapy to a tool of social control. That might sound overly polemical, but consider a government proposal in Britain last year to put psychotherapists in jobs centers to offer counseling for the unemployed, with the unemployed possibly facing a reduction in benefits if they declined treatment. In such a situation, therapy could easily become an arm of the state, seeking to âcureâ listlessness or a reluctance to work, potentially limiting social and political awareness among those it is intended to serve.
Too often, when the world is messed up for political reasons, therapists are silent. Instead, the therapist should acknowledge that fact, be supportive of the patient, and discuss the problem. It is inherently therapeutic to help a person understand the injustice of his predicament, reflect on the question of his own agency, and take whatever action he sees fit.
When I am in this situation with a patient, I will introduce into our dialogue the idea that what is happening is unfair. This opens an opportunity for us to explore how my patient reacts to the notion that he is being mistreated, which can be revelatory and vital to the therapy.
I once had a patient who had reached a breaking point with the situation in the startup where she was employed. In her therapy, she had been struggling for two years with the idea that it was possible to have authentic communication in relationships. Our therapy helped her hone her anger into a courageous, well-considered and pointed group email that resulted in nearly half of her co-workers supporting her and prompting direct labor negotiations with the chief executive.
The supportive role therapy plays in such events may strike some people more as social work or organizing than as mental health treatment. But that would be wrong. Therapists need to consider such political interaction in the consulting room as inherent to the therapeutic process. Patients become motivated to change the world around them as a solution to what had become internal stressors. This is an experience of not just of external but internal change, bringing new confidence and a sense of engagement that becomes a part of the patient’s character.
You would be surprised how seldom it occurs to people that their problems are not their fault. By focusing on fairness and justice, a patient may have a chance to find what has so frequently been lost: an ability to care for and stand up for herself. Guilt can be replaced with a clarifying anger, one that liberates a desire â and a demand â to thrive, to turn outward toward others rather than inward, one that draws her forward to make change.
Richard Brouillette, a former community organizer, is a psychotherapist in New York.