Some ideas about therapy show up so often in fiction I find myself wondering how many writers are using them deliberately and how many just don’t realize they’re inaccurate. Here are six of the most common, along with some information on more standard current practice.
1. You lie on a couch
Reality: Therapy clients don’t lie on a couch; some therapists’ offices don’t even have couches.
So where did this come from? Sigmund Freud had his patients lie on a couch so he could sit in a chair behind their heads. Why? No deep psychological reason — he just didn’t like people looking at him.
There are a lot of reasons modern therapy clients wouldn’t be happy with this. Imagine telling someone about difficult or embarrassing experiences and not only not being able to see them, but having them react with silence. Why on earth would you want to go back?
The ideal therapeutic setup, and they actually teach this in graduate school, is to have both chairs turned inward at about a 20 degree angle(give or take about 10 degrees), usually with 8 or 10 feet between them. Often the therapist and the client end up facing each other because they turn toward each other in their chairs, but with this setup the client doesn’t feel like s/he’s being confronted.
Even if there is a couch in the room, the therapist’s chair will almost invariably be turned at an angle to it.
2. Therapists analyze everyone
Reality: Therapists don’t analyze people any more than the average person, and sometimes less often.
Ironically, only people trained in Freud’s make-the-patient-lie-on-the-couch-and-free-associate-about-Mother approach (aka psychoanalysis) are taught to analyze at all. All other therapists are taught to understand why people do things, but it takes a lot of energy to figure people out. And to be very frank, while therapists are usually caring folks who want to help their clients, in day-to-day life they’re dealing with their own issues and don’t necessarily have the time or space to care about everyone else’s problems or behaviors.
And the last thing most therapists want to hear about in their spare time is strangers’ problems. Therapists get paid to deal with other people’s problems for a reason!
3. Therapists have sex with their clients
Reality: Therapists never, ever, ever have sex with their clients, or the friends or family members of clients, if they want to keep their licenses.
That includes sex therapists. Sex therapists don’t watch their clients have sex, or ask them to experiment in the office. Sex therapy is often about educating and addressing relationship problems, since those are two of the most common reasons people have sexual problems.
Therapists aren’t supposed to have sex with former clients, either. The rule is that if two years have passed and the former client and therapist run into each other and somehow hit it off (ie this wasn’t planned), the therapist won’t be thrown out of professional organizations and have licenses revoked. But in most cases other therapists will still see them as suspect.
The reasoning behind this is simple — therapists are to listen and help without involving their own issues or needs, which creates a power differential that’s difficult to overcome.
And truth be told, the roles therapists play in their offices are only facets of who they really are. Therapists focus all of their attention on clients without ever complaining about their own concerns or insecurities.
When people think they want to be friends, they usually want to be friends with the therapist, not the person, and a true friendship involves sharing power, and flaws, and taking care of each other to some extent. Getting to know a therapist as a real person can be disenchanting, because now they want to talk about themselves and their own issues!
4. It’s all about your mother (or childhood, or past…)
Reality: One branch of psychotherapeutic theory focuses on childhood and the unconscious. The rest don’t.
Psychodynamic theory kept Freud’s psychoanalytic belief that early childhood and unconscious mechanisms are important to later problems, but most modern practitioners know that we’re exposed to a lot of influences in day-to-day life that are just as important.
Some therapists will flat-out tell you your past isn’t important if it’s not directly relevant to the current problem. Some believe extensive discussion of the past is an attempt to escape responsibility (Gestalt therapy) or keep from actively working to change (some types of cognitive-behavioral theory). Some believe that the social and cultural environments we live in today are what cause problems (systems, feminist, and multicultural therapies).
5. ECT is painful and used to punish bad patients
Reality: Electro-convulsive treatment (in the past, called electro-shock treatment) is a rare, last-resort treatment for clients who have been in and out of the hospital for suicidality, and for whom more traditional treatments, like medications, haven’t worked. In some cases, the client is so depressed she can’t do the work to get better until her brain chemistry is working more effectively.
By the time ECT is a consideration, some clients are eager to try it. They’ve tried everything else and just want to feel better. When death feels like your only other option, having someone run a painless current through your brain while you’re asleep doesn’t sound like such a bad idea.
ECT is not painful, nor do you jitter or shake. Patients are given a muscle relaxant, and because it’s frightening to feel paralyzed, they’re also briefly placed under general anesthesia. Electrodes are usually attached to only one side of the head, and the current is introduced in short pulses, causing a grand mal seizure. Doctors monitor the electrical activity on a screen.
The seizure makes the brain produce and use serotonin, norepinephrine, and dopamine, all brain chemicals that are low when someone is depressed. Some people wake up feeling like a miracle has occurred. Several sessions are usually required to maintain the changes, and then the individual can be switched to antidepressants and/or other medications.
ECT is no more dangerous than any other procedure administered under general anesthesia, and many of the potential side effects (confusion, memory disturbance, nausea) may be as much a result of the anesthesia as the treatment itself.
6. “Schizophrenia” is the same thing as having “multiple personalities”
Reality: Schizophrenia is a biological disorder with a genetic basis. It usually causes hallucinations and/or delusions (strong ideas that go against cultural norms and are not supported by reality), along with a deterioration in normal day-to-day functioning. Some people with schizophrenia become periodically catatonic, have paranoid thoughts, or behave in a disorganized manner. They may speak strangely, becoming tangential (wandering verbally, often in a way that doesn’t make sense to the listener) using nelogisms (made up words), clang associations (rhyming) or, in extreme cases, producing word salads (sentences that sound like a bunch of jumbled words and may or may not be grammatically correct).
Dissociative Identity Disorder (formerly multiple personality disorder) is caused by trauma. In some abusive situations, the normal defense mechanism of dissociation may be used to “split off” memories of trauma. In DID, the split also includes the part of the “core” personality attached to that memory or series of memories. The dissociated identity often has its own name, traits, and quirks; and may or may not age at the same rate as the rest of the personality (or personalities), if it ages at all.
Therefore, referring to oneself as “schizo” or “schizoid” or “schizophrenic” when one means one has an alter ego or contradictory personality traits makes no sense (and is guaranteed to make the psychologically savvy wince)!