Can Psychotherapy Make You Selfish?
Deborah Y. Park, MD, MS, Brigham and Women's Hospital, Boston, MA; and John Peteet, MD, Brigham and Women's Hospital, Boston, MA
Medication, surgery and psychotherapy are interventions which can be lifesaving, abused, and/or a source of harm. Are there features of psychotherapy like potentially habit-forming medications, that can lead to inappropriate dependence? Are there, analogous to “chemical copers” focused on medication, certain individuals who more vulnerable to depending on therapy as a substitute for life? Can psychotherapy’s focus on one’s own wants and feelings promote an inappropriate preoccupation with the self?
Sigmund Freud believed that by exploring the deep layers of a patient's unconscious thoughts, feelings, and memories, a psychoanalytic therapist could give one’s ego greater independence from the superego’s restraints upon the id’s urges. However, Freud’s emphasis on unfulfilled and repressed internal desires as the root of neurosis drew criticizism for encouraging a focus on one’s own development and fulfillment as the primary aim of treatment. Victor Frankl argued that such ego-centric forms of therapy are often counterproductive, inviting the neurotic patient to fixate more on their own feelings. Other theorists such as Milton Erickson and Irvin Yalom also emphasized the benefits of turning outwards rather than looking inward for self-actualization. Positive psychologists such as Martin Seligman suggested that other-regarding virtues are essential to full mental health. L. Nique Dworkin contended that post-Freudian, relational models of therapy based in self psychology and attachment theory include an implicit morality based on empathy leading to respect for others. However, religious psychologists such as Paul Vitz continue to express concerns about the failure of secular psychotherapy to take into account the problem of human selfishness.
These historical and theoretical considerations raise the possibility that psychotherapy could contribute to selfishness, but are there clinical contexts in which this is more apt to occur? We suggest four here:
Each of these contexts suggests the need to balance the risks and benefits of supporting the patient’s perspective by attending to the therapist’s and the patient’s core values as they inform the goals of the work as well as what constitutes “healthy selfishness” and a life well lived. This requires conscious awareness of how these values are informed by their worldviews, including their religious and spiritual commitments.
Sigmund Freud believed that by exploring the deep layers of a patient's unconscious thoughts, feelings, and memories, a psychoanalytic therapist could give one’s ego greater independence from the superego’s restraints upon the id’s urges. However, Freud’s emphasis on unfulfilled and repressed internal desires as the root of neurosis drew criticizism for encouraging a focus on one’s own development and fulfillment as the primary aim of treatment. Victor Frankl argued that such ego-centric forms of therapy are often counterproductive, inviting the neurotic patient to fixate more on their own feelings. Other theorists such as Milton Erickson and Irvin Yalom also emphasized the benefits of turning outwards rather than looking inward for self-actualization. Positive psychologists such as Martin Seligman suggested that other-regarding virtues are essential to full mental health. L. Nique Dworkin contended that post-Freudian, relational models of therapy based in self psychology and attachment theory include an implicit morality based on empathy leading to respect for others. However, religious psychologists such as Paul Vitz continue to express concerns about the failure of secular psychotherapy to take into account the problem of human selfishness.
These historical and theoretical considerations raise the possibility that psychotherapy could contribute to selfishness, but are there clinical contexts in which this is more apt to occur? We suggest four here:
- As Kohut has pointed out, narcissistic individuals often require validation over time in order to develop trust, and become open to change. Therapists of such patients may be tempted to offer support rather than challenge them to find what they need in relationships outside of the therapy. Without a conscious focus on the goals of treatment, the effect can be to reinforce their pathology.
- Survivors of trauma, such as those with complex PTSD, often need acceptance from a non-judgmental therapist to feel safe, as well as help establishing appropriate boundaries for dealing with difficult relationships. Therapists who avoid exploring patients’ behaviors out of fear of adding to their feelings of guilt and shame can miss opportunities for them to achieve mature relatedness – at times even enabling the avoidance or “canceling” of others who make them feel uncomfortable.
- Individuals with disordered attachment such as those with borderline personality traits can develop intense transferences focused on what a therapist can do to save them. A therapist who fails to deal appropriately with these unrealistic expectations may be unable to help the patient move beyond a focus on the therapeutic dyad.
- Individuals who pursue intensive psychotherapy to better understand themselves can justify their investment in self-serving ways that have little to do with becoming a better related person.
Each of these contexts suggests the need to balance the risks and benefits of supporting the patient’s perspective by attending to the therapist’s and the patient’s core values as they inform the goals of the work as well as what constitutes “healthy selfishness” and a life well lived. This requires conscious awareness of how these values are informed by their worldviews, including their religious and spiritual commitments.