Nuts About Therapy
The Monthly, September 2005

Start talking about therapy at any Bay area dinner party (as far too many people do) and you’re likely to find your dining companions falling into three categories: those who are in therapy, wondering if they’re getting their money’s worth; those who aren’t, wondering if they should be, and those who wonder why all those whiners don’t call off the search for their missing inner children, give up their daily doses of Dr. Phil, fire their individual, family, couples, and aura therapists, and get over themselves already.

But it’s not that simple, is it? Not here. Not now. Nowhere on earth are human beings as obsessed with psychotherapy as Americans are today; even our favorite TV Mafioso has his shrink on speed-dial. (Note: we’re talking in this article about garden-variety neurotics, not people facing serious life crisis or mental illness–in Hollywood terms, Tony Soprano, not John Nash.) "Therapy saturation is an American phenomenon," says Oakland therapist Dr. Marny Hall, author of The Lavender Couch, "sort of like pet insurance."

And nowhere in America are people crazier about therapy than we are in the Bay area. "This is the Wild West of therapy," Hall says. "We thrive on ferment. That’s spawned all kinds of experimental therapeutic configurations." "Bay area people put a very strenuous priority on quality of life," adds San Francisco psychoanalyst Dr. Maureen Murphy. "Consequently, no one blinks an eye here if you say you’re seeing a therapist–or two."

Capital of Therapy Nation, home to dozens of psychotherapy training schools, our nine Bay area counties constitute a tectonic Petri dish of personal growth practices and practitioners ranging from the mundane to the arcane to the insane. Synanon and EST are long-gone, now, but you can still re-enact your birth in the pools at Harbin Hot Springs, soothe childhood wounds in a SomatoEmotional Release workshop at Esalen, or have your aura healed at Berkeley’s Psychic Institute. Just like smoothies, health clubs, and methamphetamines, many types of therapy have started here as fringy fads, then spread throughout the hinterlands.

There’s no way to know, exactly, how many of us partake of the Bay area’s myriad therapeutic offerings, but here are a few salient facts. The majority of California’s licensed psychologists–whose ranks increased 30% in the past decade–practice in two places: Los Angeles, and the Bay area. Statewide there are about 30 psychologists per 100,000 residents; in Marin County, there are 144. And a quick perusal of Bay area phone books reveals a plethora of mental health professionals in each county: 22 pages of Marriage and Family Therapists, Psychologists, Psychotherapists, and Social Workers in Contra Costa, 17 pages in Alameda; 14 in San Mateo, 13 in our second-smallest (and unsurprisingly most-shrunk) county, Marin. Uncounted among these numbers are the many unlisted, unlicensed unprofessionals who practice outside the yellow pages–and the licensing boards, and the law. If you’re reading this magazine, chances are you know more people who have been in therapy and/or practice it than people who haven’t.

So what good, exactly, is all this head-shrinking doing us? Are Bay area therapy devotees narcissistic navel-gazers, or truth-seekers on the cutting edge of enlightenment? Both? Neither?

"The Bay area is the place where a lot of this stuff began: crossing therapy with spirituality, social activism, new age ideas," says Ethan Watters, San Francisco co-author of Making Monsters and Therapy’s Delusions and author of Urban Tribes. "We’ve even got something called ‘ecopsychology’ now. A lot of people look at that and say, "What a wonderful place we live in." I look out into this wilderness of ideas and say, "They’re offering everything under the sun. But are they offering anything real?"

Watters wonders, also, if what they’re offering helps or hurts. "This cacophony of therapies shows a profession grasping at straws. People are searching for meaning in their lives, for relief from anxiety. To try and give them that, therapy has to compete with everything from religion to literature to medication. But there’s a fundamental problem that pervades the dynamic. Patients come to therapy looking for a story to explain their lives. Therapists come looking to confirm their own psychological theories–repressed memories of abuse, the shadow mind of the unconscious, whatever. They do that through the process of influencing their patients, who then learn to frame their stories within the therapist’s belief system.

"As we saw in the 80s when you had therapists–in the Bay area first, then elsewhere–claiming that all their patients were satanic cult survivors, this dynamic gives therapists tremendous power to impose their narratives on vulnerable patients." Watters sighs. "Hardly what you’d call therapeutic."

Kim Chernin–a Berkeley eating disorders expert and author of several best-sellers including The Hungry Self and The Obsession–agrees. After 25 years as a psychoanalytic therapist, Chernin joined what she calls the "underground movement" of therapists who are troubled by their profession’s excesses and abuses, but reluctant to throw the inner child out with the bath water. "People know the culture of therapy now, and they don’t like it," Chernin says. "So we’re challenging the hierarchical power dynamic and the rigid rules: the client mustn’t ask the therapist about herself, the therapist mustn’t disclose, the client tells the therapist her life experiences and the therapist interprets them for the client.

"The first thing I tell people who come to see me is, "I’m not an expert, you’re not sick, this isn’t a treatment. Interpretation is the foundation of traditional therapy, but I don’t do it. I won’t deprive you of the meaning of your own experience by putting my own spin on it. What I can do is listen to you in such a way that things become clear to you."

Chernin also rejects the notion of a cure. "Suffering is a normal part of human life," she says. But she does offer one very Bay area-esque prescription for self-improvement: replacing self-absorption with activism. "The most natural way to alleviate one’s own pain is to help other people," she says. "Going through a deep process of knowing oneself frees up the part of the self that wants to do that." When the war on Iraq began, Chernin encouraged her "people" (she doesn’t call herself a therapist; she doesn’t call them clients) to act on their anxieties. "Several of them went to demonstrations or wrote letters expressing their opinions. Doing that helped them. It wasn’t a valid therapy move," she acknowledges, "but it was a therapeutic move."

I ask Chernin if any of her clients would be willing to talk to me, and she breaks another therapy rule: she says yes. I meet twenty-year-old Liz Maxwell at a College Avenue café. "I started seeing Kim a year and a half ago for my eating disorder," Maxwell tells me. She gets positively starry-eyed, recalling their first session. "I’d never been to therapy before, so I didn’t know what to expect. But I felt comfortable right away. Kim’s office is nothing like that cold, sterile office on the Sopranos! It’s in her house. We curl up in cozy chairs facing each other–not the classic ‘lie down on the couch so you can’t see your therapist.’ It’s like talking to a really wise friend."

At $105 per session (paid out-of-pocket by Maxwell’s well-to-do parents), why not talk to a real friend instead? "I tried that," Maxwell says. "I tried my mom. I tried a nutritionist. Nothing worked till I started seeing Kim. It was embarrassing to tell her about the roots of my eating disorder–stuff I’d never told anyone. But she doesn’t judge me. She doesn’t try to fix me. I hope to keep seeing Kim for a long, long time."

When asked how her parents feel about subsidizing her relationship with Kim for a long, expensive time, Maxwell says they see it as an investment in her future–one that’s already yielded a major life decision. "Kim helped me find my calling," Maxwell says. "I always thought I might want to be a therapist. Kim helped me verify that I’m good at listening to people, that I can make a career of that." Maxwell muses for a moment, then adds emphatically, "But I don’t want to be like the Sopranos therapist. I want to do it the way Kim does."

• • •

Therapy will undoubtedly still be with us by the time Liz Maxwell orders a New Yorker subscription for her waiting room, but it may look quite different then. Pressures on the industry are mounting from without as well as within, its greatest threat in pill form. As recently as 1987, fewer than one percent of Americans were being treated for depression, one-third of them with medication. By 1997 nearly four times that many were being treated for depression, 75% of them with drugs; many with drugs alone. Today, twenty million of America’s three hundred million men, women and children are on anti-depressants, a treatment that’s quick, effective, and cheap–an increasingly compelling factor now that fewer and fewer health insurance plans cover outpatient mental health services, and fewer people have either the insurance (15% of Americans have none) or the income to foot a long-term therapy bill.

Should we rejoice or rue these challenges to therapy as we’ve known it? Like Liz Matthews, most past and present clients are satisfied customers–a claim borne out by the only large-scale study of therapy’s effectiveness, conducted by Consumer Reports in 1995. The vast majority of the study’s four thousand respondents reported feeling "significantly better" after therapy. Although they found psychotherapy more effective than medication, 40% also received psychiatric drugs. Those who entered therapy feeling the worst ("I barely managed to deal with things") reported the greatest improvement.

The therapy industry heralded these findings, of course, but not all therapists take them at face value. "Sometimes therapy makes people feel better because it gives them the cover they need to justify their behavior," says Dr. John Nickens, director of clinical services for a San Francisco mental health organization and a therapist in private practice. "Whatever the question or critique is, the answer is "I’m in therapy." It’s like a get-out-of-jail free card–sometimes literally.

"As mental health professionals we have to ask ourselves, have we made a liar or a cheater or a wife-beater "better" when we’ve helped him understand why he does it? Or have we given him cover so he can continue that conduct?" Nickens says. "Too many therapists will see a man twice a week for a year while the man keeps beating his wife. The idea that it’s always an unconditionally supportive relationship–I have trouble with that."

Nickens has trouble, too, with therapy’s lack of quality control. "If you open a can of Campbell’s soup and it’s bad, they say, "Here’s your refund; try another." Therapy is the only industry that can get away with not doing that. I know people who’ve been going to therapy twice a week for ten years, and I quite honestly feel they ought to sue their therapist for breach of contract. If I’ve been seeing someone for a year and I don’t see change happening–in their understanding of the issues, yes, but also in their behavior–I tell the person, "You need to quit, or you need to see someone else." Therapists should share responsibility with the client for the success or failure of the change effort."

But how can success or failure be defined, when a therapeutic process that looks like a failure one week might produce an epiphany the next? And when the process is deemed successful, how can we know what made it so? Would the passage of time alone, or an hour plus a hundred dollars spent each week on a class, a massage, a donation to MoveOn.org have yielded the same or even better results?

Marcia Gelt, a 45-year-old Oakland health educator, has reason to hope not. For the past seventeen years she’s been seeing the same psychoanalytic therapist first once, then twice, then three times a week. "When I think about how much therapy I’ve done," she says with a wry grin, "I feel like Woody Allen." But Gelt has no regrets. "All my life I had a tape in my head questioning every single thing I said or did. I had no sense of self-confidence. I was worried about everything all the time. I needed more than a six-month crisis intervention. I wanted to make an essential change in who I was. And I got lucky. I found a fabulous therapist to help me do that."

Over the years, Gelt says, she’s taken a lot of ribbing from friends and family, most of it about the ten thousand dollars a year she’s been spending. "What’s good about the Bay area is that therapy isn’t so stigmatized here. What’s bad about it is, people are so jaded about therapy that they get cynical." Gelt got a bit cynical herself the day she saw her analyst drive up in a new Mercedes. "I told Jane, ‘I see I bought you a new car,’" Gelt says, laughing. Then she turns serious. "Sure, I could have had some clothes I wanted or a few vacations instead of doing all that work with Jane. But then I would have been walking around unhappy on vacation. Who needs that?"

For the past two years, Gelt has been talking to Jane about quitting. A month ago they set a date for her last session. "It feels really good and really scary to leave Jane. She knows me more than anyone could." Gelt chokes up, takes a breath, recovers. "But it’s time. I finally feel like I’m happy in my life. And when I’m not, I can handle it without Jane’s constant support.

"I used to beat myself up about staying in therapy so long, spending all that money. Then I realized that if someone had said, "Write me a check for ten thousand dollars this year and I guarantee you’ll be happier next year," I’d do it in a second. And that’s exactly what happened.

"There’s no Donna Reed family anymore. Everyone’s family is dysfunctional; everyone has to recover from that. So why would anyone turn down a little help? I think if more people could afford therapy and more people stuck with it through the hard parts, a lot more of us would be cured."

• • •

Despite therapy’s frailties and foibles, in the face of bank accounts it has emptied and needs it has filled, the Bay area remains a bull market for therapists wise and woo-woo, therapies conventional and cuckoo. "My friends and I joke that everyone you meet at a Bay area party is either a therapist or a client or both," says Dr. Natalie Porter, Vice President for Academic Affairs at San Francisco’s California School of Professional Psychology. "But it’s actually close to the truth."

Is our obsession with self-awareness-for-hire teaching us to know ourselves better, and behave better, I ask Dr. Porter, or reinforcing the very narcissism we’re hiring all these trained professionals to cure? "There are some negative consequences of Bay area people being so preoccupied with themselves and so reliant on therapy," she answers. "There are people here who can’t rely on their own gut, people who are junkies for self-growth. Being overly therapized can cause an individual to have a narcissistic view of the world, instead of understanding social causes of problems and seeking group solutions. I have a friend who teaches at Esalen. I asked him why he didn’t start a workshop called ‘Volunteering in Somalia’–get all those seekers to go do something with their lives, instead of just looking for the next kind of therapy.

"On the positive side, Bay area people do a pretty good job of integrating personal growth with social involvement. Other parts of the country use therapy less, but they’re also less involved with social change. People here have high levels of education and disposable income. Spending it on your own well-being, whether it’s yoga or organic food or psychotherapy, is better than spending it on a mink coat."

I pose one last question to Dr. Porter. If all that therapy were worth all that time and money we’re putting into it, shouldn’t we all be cured by now? She thinks, smiles, winks. "We are the most evolved people in the world," she says, with more than a hint of sarcasm. "So it must be working."