The Intuition Network, A Thinking Allowed Television Underwriter, presents the following transcript from the series Thinking Allowed, Conversations On the Leading Edge of Knowledge and Discovery, with Dr. Jeffrey Mishlove.

PUTTING PSYCHOTHERAPY ON THE COUCH with BERNIE ZILBERGELD, Ph.D.

JEFFREY MISHLOVE, Ph.D.: Hello and welcome. Today we're going to be analyzing psychotherapy -- putting psychotherapy on the couch, so to speak. Many viewers are interested in whether psychotherapy really works, and if it does work, what type of psychotherapy is appropriate for what particular problems. With me in the studio is Dr. Bernie Zilbergeld, the author of numerous books, including Male Sexuality, The Shrinking of America, and Mind Power. Dr. Zilbergeld is a psychologist in private practice in Oakland, California. Welcome, Bernie.

BERNIE ZILBERGELD, Ph.D.: It's nice to be here, Jeff.

MISHLOVE: It's a pleasure to have you here. You know, in your book The Shrinking of America, you suggest that psychotherapy has basically been oversold to the American population, and probably overused -- that it really doesn't meet up to all the claims that are made for it. Why don't we start there, and look at the ways in which exaggerated claims may be made for therapy?

ZILBERGELD: Well, I think exaggerated claims are made all the time. Part of it is the structure of television; television I think is the real villain. Basically, unlike your show, when a psychologist is on pushing a book or something, which is usually why they're on, or discussing a topic, what's wanted is real short positive answers, and if you want to qualify something you really can't. The interviewers on most shows really don't have any tolerance for that. Plus, you know, we're selling ourselves, and want to put our best feet forward. You put those two things together. So what we talk about are our most dramatic successes, and you would think, if you listened to shrinks on the media -- which is really where they sell themselves; it's the only place where the public comes in contact with them, aside from reading their books, where they do the same thing, and actually being in therapy with them -- you would think you can go from rags to riches in ten minutes, or the sky's the limit, as Wayne Dyer, a popular psychologist, put it. And of course none of these things are true. Dramatic cures in psychotherapy do happen, but they're extremely rare. By and large the research shows that psychotherapy generally does do some good, but very modestly. Now, modestly may be fine, but we're not talking about the sky's the limit, rags to riches, and you're going to go from being a depressed whatever to just a happy-go-lucky person in a few weeks. It doesn't happen.

MISHLOVE: I suppose part of the problem here is that people can often experience a dramatic change in therapy, but they're not able to sustain it, and their previous behavior or attitudes will sort of revert. They'll relapse to that.

ZILBERGELD: Well, yes. I think Mark Twain actually put it well. He said he quit smoking, it's very easy to do; he's done it hundreds of time. A lot of times people will get a sudden insight or a certain surge of energy, and they will be more assertive, less depressed, they'll stop drinking or smoking or whatever. But then it's hard to maintain, and the maintaining of it takes a lot of work. There are a lot of relapses in all the therapies, and for the most part people don't pay attention to this, and certainly therapists don't want to talk about it; they want to put their best foot forward. Basically what has happened is the total psychologization of the world. What we want -- and it's happened, by the way -- the therapeutic has triumphed in the last twenty, thirty years in America. Whatever problems people have now -- I mean, we're talking all the way from biting their nails or being depressed, sexual problems, to being rapists and murderers -- the first question is, "Well, have you talked to anybody about this?"

MISHLOVE: Meaning therapists.

ZILBERGELD: Meaning, "Have you seen a therapist about this?" And it is amazing -- this is a radical change in American life -- in the twenties, thirties, and forties, people who went to therapy were thought to be really cuckoo. But now, anybody with any problem -- "Have you seen somebody about this? I'll get you a name."

MISHLOVE: Well, there's still in some circles certainly a stigma about going for psychotherapy, but I think your point is generally true. I guess the question really is, for anybody who's looking at making a change in their life, is it realistic? Should they try and change their attitudes, change their behavior, or should they try and accept themselves the way they are?

ZILBERGELD: Well, I think a big question has to do with how much you're willing to put into it, and this is often overlooked. Therapy, to make changes of the kind most people want, takes work, whether it's self-help work, therapist work, or however you want do to it. Whether you want to work from a book, you want to come and see you or me, or however, it's going to take effort and time, and often money as well. Certainly if they're coming to our offices it's going to cost money, and even to buy books or tapes costs money. A lot of people don't consider that. They just think if they go, somehow something's going to happen. You know, on the one hand we have things like psychoanalysis, which go on for years and years and years, often three, four, five times a week; and on the other hand you might get a book for a few dollars. But just reading the book is probably not going to do it; that's very rare. Most self-help books, wisely these days, have exercises in them. They're meant for you to do, not just to glance at. You've got to do these certainly weekly, but for most things you're going to have to do them every day. A lot of people are not willing to put in the effort. If you're not willing to put in the effort, why bother? Why not try to accept it and just move on -- accept that you're never going to be real assertive, you're never going to be a millionaire, you're never going to be thin -- and get on with it?

MISHLOVE: Isn't this the job of a therapist? If I want to change my behavior, naturally I have resistance to change, and therapists are supposedly skilled at dealing with resistance, at helping people move past their resistance, in ways they can't do themselves.

ZILBERGELD: Well, I think therapists create as much resistance as they actually help resolve. But why call it resistance? That's like an ugly word. Why not just admit that not everybody can be everything? That's another one of these psychological myths -- you can have everything. You can't, because if nothing else the time you spend getting A, whether it's being a better golf player or making more money, cannot also be used in doing B, whatever B might be. If you're learning to play golf you can't be taking dancing lessons at the same time, or writing, or practicing making speeches. So you can't have everything. How much are you willing to put into it? I think that's an extremely important question. Let me back up a little bit, because there's a more important question, or one that precedes that -- what is it that you want? I mean, a lot of people come into psychotherapy, just, "I'm not happy." Well, that's nice. What would you like? What would make you happy? How would you know if you were happy? These are things people can do for the most part on their own. You know -- what would it take to make me happy? Well, if I had a relationship, if I made more money, if I were better organized, if I lost weight or gained weight, or whatever. Having a specific goal is very important, whether you're going to work on it yourself or consider working on it, or go to therapy. It's the only way you can figure out, one, if you're willing to put the energy and resources into it; and two, it's the only way you can figure out if you got there or not, or are moving along to it. It's amazing -- one thing I think is an incredible abuse of therapy, a lot of therapists do not help people define their goals, and they sit there for years or months just droning on and on about all sorts of things, and you can't even evaluate success, because it's not clear where you were going, so how can you tell if you're getting there? Defining your goals, deciding if you want to put some resources into it -- time, energy, money, whatever it might take -- these are things people basically can do on their own.

MISHLOVE: Well, let's suppose now that a viewer has defined their goals, and they've decided they are willing to make a real commitment, they really want to change their life. Now there's a whole supermarket of therapies out there, and they all make claims, by and large, that they can handle a huge variety of problems more effectively than any of the others.

ZILBERGELD: It is not easy. Interestingly enough -- and viewers may get some comfort out of this -- therapists themselves have trouble deciding and finding a therapist for themselves. But there's not only therapists -- formal therapists, psychologists, psychiatrists and those kinds of people. There's also mass therapies, like Est and Lifesprings and things like that. There's things like Weight Watchers, TOPS -- Take off Pounds Sensibly. There's the AA.

MISHLOVE: Transcendental Meditation.

ZILBERGELD: Well, that I think, Jeff, is a thing of the past, but certainly there are things like that, places that'll help you do everything. Then there's also the self-help materials. Go into any bookstore. My God, there's all sorts of books on losing weight, gaining weight, being calmer, having more energy, whatever. What do you do? I think one good principle is start with the least expensive. Even though I make part of my living doing therapy, I still recommend that.

MISHLOVE: Go to the library first.

ZILBERGELD: Well, that I don't recommend; I want people to buy my books. But there's a lot of good self-help books. Whether you're talking about assertiveness, sexuality, depression, whatever -- most therapists these days, probably because of the advent of computers on the one hand, and on the other hand the idea that they're going to get rich with books -- there's a lot of good books, and a lot of therapists will put their best stuff into a book. So self-help books are one thing. Self-help groups -- after all these years, there's no psychologist or therapist or psychology program that does better with alcoholics than AA. That is a fine organization; I don't belong to it; they don't pay me for this promo. But when I have somebody who's having trouble with drinking or narcotics -- Narcotics Anonymous, Gamblers Anonymous, these are fine groups. They're not for everybody; some people do not like the atmosphere and they can't get along there, but that is one of the first things to try. Groups like Weight Watchers and TOPS, Take off Pounds Sensibly -- they've been found in actual scientific studies to be as good as anything we have to offer.

MISHLOVE: So you're not one of these professionals who maintain that you've got to go to someone who has a big degree after their name?

ZILBERGELD: No, no, no, no. Actually there's research to prove that the process of getting the degrees makes you less good as a therapist. There's actually a number of studies that show that. They really take out of people what's best in them in helping people change. Now, a lot of people have said this about medical school too. I would say start with what's around you -- a book, a self-help group -- and see if that will do it for you. If it does, you've got it, it will cost you less money, and the results may even be better. Also, a lot of therapy, as I maintain in The Shrinking of America, really is just talking to people. There's a lot of natural therapists around. In almost every extended family or large organization or neighborhood, there's a person about which it is said, "You know, Aunt Martha is a good one to talk about it," or, "Sid really knows about these kinds of things." On every campus there are professors that are known to be good people to talk to. And you can spot them right away. Just walk down the hallway when they're having office hours, and there's a big line out there. They can give you the kind of advice and hand holding you get in therapy.

MISHLOVE: What you're suggesting here, though, is that it is good to talk. If you've got a problem, if you're feeling emotionally bottled up, it's not good to sit on it.

ZILBERGELD: I don't do that a hundred percent. If it's really bothering you, then you've got to do something about it, or you might want to do something about it. A lot of problems are just best denied. I happen to be one of the therapists who's a great believer in denial. It's a great coping mechanism. If your mother, or someone you love, has cancer, it's really great to go for days without thinking about it. I mean, to drive yourself into the ground, to think you've got to suffer with this every day, I think is ridiculous. Now, if talking to somebody will help you get it off your chest, and then you can have some moments or hours or days of peace, that's fine too, but there are a lot of good people to talk to. I mean, human beings have been helping each other ever since the beginning of human beings, and we haven't been doing that terrible a job. A lot of what therapists do is take what human beings have been doing, and then give it a fancy label, and then say that only I can do it, or only my school or my group can do it. Well, but Aunt Martha may know it too; your grandmother may know it. I thought it was very interesting in the last few years when they were researching colds -- you know, hard science -- they found out a lot of your grandmother's advice was right.

MISHLOVE: Chicken soup.

ZILBERGELD: Chicken soup is good for you. Drink a lot of liquids. Stay in bed a few days. I mean, it turns out Grandma wasn't crazy.

MISHLOVE: In The Shrinking of America you describe some of the negative consequences that can come from therapy, and one of the issues that you get at is this sort of pop psychology, or psychologized version of what it means to be responsible, and that many people are told by their therapists or by seminars that they go to that they must take responsibility for their life, for their behavior. And it causes people to blame themselves instead of really being responsible.

ZILBERGELD: Oh, this goes on a lot. By the way, this is not pop psychology; this goes back to Freud, in that horrible case, which I think is available in paperback, and I think everybody ought to read it to see the ill that therapists can do. In this case with Dora, this young woman came in to therapy and Freud just beat the hell out of her. I mean, he abused her psychologically, in my mind, and he ended up saying she had an intention to be ill. A lot of therapists will do this to their patients. I think it's basically the therapist gets frustrated. They think they want to help, they think they can help, and then this person, this client, this patient, will not accept their interpretation, will not do the homework, is not getting better, and then they just get upset and say, well, it's clear that you want to be overweight, it's clear you don't want to stop smoking, it's clear you want to kill yourself, or whatever. And they do push this responsibility thing. If you were raped, you were responsible -- I mean, Est got into that, and some other people. I think one of the great virtues in life is to accept what you're not responsible for: "Look, I lost that money, or I screwed up this or that, but I wasn't responsible for it. How was I to know?" There are certain things that are beyond your control. One of the worst things, and I give a case example in Shrinking, is the cancer business -- blaming people, or holding them responsible, for their own cancer. You know -- because you didn't assert yourself, and because you didn't express anger, that's why you got cancer. You're telling this to somebody who already has cancer. I mean, they're in bad enough shape to begin with. Interestingly enough, recently Simonton --

MISHLOVE: Carl Simonton.

ZILBERGELD: Carl Simonton, who's really responsible for this, he sort of fessed up, and he has backed off. He is treating AIDS patients and cancer patients with the same visualization techniques he was using ten, fifteen years ago, but my understanding is, he's backed off from holding them responsible and blaming them, because that really wan't necssary.

MISHLOVE: I think the point that he's trying to make is that you could be responsible for changing your condition.

ZILBERGELD: To me that's a lot different than saying, "You're responsible for getting it, and you can get better." Why not just say, "You have some powers within you" -- which I certainly believe -- "that may help with this cancer," or whatever it is, and just take it from that side, rather than holding the negative side?

MISHLOVE: I suppose it's a little insidious, because therapists earn their living at this, and if they can get a person kind of guilt-ridden -- "You're responsible for your problem, and if you work with me we can find out how you caused this" -- it's a way of kind of maintaining the cash flow.

ZILBERGELD: Well, that's certainly true, and I think it's an important point. What's going on in both medicine and psychotherapy now really has to be seen to a great extent as money and turf. I mean, there are too many therapists, and it turns out really there are too many doctors as well, for all these people to be able to earn the kind of living they'd like to earn doing it and have the time off they'd like to have. And so there are incredible battles going on, and a lot of what sounds like ideological warfare or technique warfare is really who's going to get the money, who's going to get the patients. You have to see it in that light. People don't like to think of their doctors and therapists as businessmen and businesswomen. We like to see them as sort of tweedy people, kindly helpers. They may well be that, and I certainly think most therapists do have a real firm commitment to helping people; they would like to be of help. But also there's incredible problems about the oversupply of therapists, which we keep manufacturing. We keep turning out incredible numbers of therapists; there are no jobs for most of them. So they will compete with each other. This reinforces everything we're talking about. I have to show that I have a better system than you. I can't prove it, of course, and I wouldn't even try, but I've got to publish books or whatever, make speeches, that will get people coming to me and my students rather than you and your students, and you feel the same way, and so do five thousand other people -- five thousand in Los Angeles alone, maybe. So we get into this problem. People have to see it this way. It's no different than dealing with Honda and Toyota and Colgate and Crest and all that. You're dealing with people who are trying to get a bigger share of the pie, namely your pie.

MISHLOVE: Well, you and I are both psychologists, so this is an issue that we face personally. How do you resolve this for yourself?

ZILBERGELD: I've resolved it in a number of ways. For one thing, I'm not in private practice full time; that is only a small part of my life. I spend a large part of my time teaching and talking and also writing. I'm a person who gets bored easily, so I've got a lot of different things. And I've never had to fight for my practice, because I've been public early on, and people have read my books or heard my talks and come to me or been referred to me. So in a way I'm sort of aside from the fray. I don't have to worry, as so many people do, "Gee, I had five people quit last week, and at this level I can't pay the mortgage," or something. That's really where it's at for a lot of people. I taught at -- well, maybe I shouldn't mention the college -- a college that mass produces master's degrees in psychology, and they become Marriage, Family, and Child Counselors. I've taught at several schools like that in the past, and I've actually talked to the heads of the department, and I've said, "Why are you turning out all these people? There are no jobs for most of them. A lot of them will not --" He said, "You know, we're not a vocational school. We offer training. If people want to take it, that's fine. If they can't find jobs, that's tough stuff for them." I thought that was a pretty interesting point of view. What he didn't recognize -- and of course I've had some contact with some of the former students, and they said indeed some people couldn't make it, and are now painting houses or driving cabs or whatever -- but what they don't recognize is that the oversupply will generate a kind of hyping and exaggeration of results, and a kind of real advertising ethic and business ethic --

MISHLOVE: It hasn't necessarily resulted in lower fees.

ZILBERGELD: No, no, no, it rarely results in lower fees -- that may not be good for the whole field of psychotherapy, and that may at least be worthy of some consideration and thought. Most of these people don't think about it.

MISHLOVE: It's odd, because on the other hand -- and I know this is a point you address in your book -- from a different perspective one could look at the population of the United States or any of the Western countries, and look at the number of people who are addicted, the number of people who have suffered child abuse -- these are major problems, to say nothing of the kind of minor problems, anxieties and so on, that stem from this in the culture -- and think that, gee, we could use ten times as many.

ZILBERGELD: Well, we could use; a lot of people feel that way. The question is, who's willing to come to these people? Who's willing to pay for it? One point, going back several points here -- therapy has shown that it's very good for some things. Phobias, for example; certain kinds of anxiety; certain kinds of sexual problems; certain therapies with certain depressions. The problem is, the public by and large doesn't know this.

MISHLOVE: It's a question of matching up the particular problem to a particular therapy which is really scientifically known to work at this point.

ZILBERGELD: To work for that. But the fact is, it is very hard to get this information. I can get it, because I can go to libraries at UC Berkeley and UC San Francisco.

MISHLOVE: Can we enumerate some of those briefly?

ZILBERGELD: Well, sex therapy, the thing that Masters and Johnson pioneered, has indeed been shown to be effective with sexual dysfunctions.

MISHLOVE: Premature ejaculation.

ZILBERGELD: Orgasm problems, erection problems. Now, does it have a higher percent success? Of course not; no therapy does. But it can be helpful, if the person is using the methods that are shown to be helpful. Phobias -- behavior therapy is very good with that, and a lot of anxieties. Depression -- there's some real good news for people who don't want to take antidepressant medication.

MISHLOVE: Cognitive therapy.

ZILBERGELD: Cognitive therapy, which is a form of behavior therapy, is very effective. It has been shown to be at least as effective as the best antidepressant medication. The good thing is, no side effects, unless your therapist beats up on you, makes you feel worse. But that's all. We don't have a lot more to show for ourselves. With psychosis, with addictions, therapy has not shown that it can do anything. With sexual abuse, which of course is a much bigger issue than a lot of people thought, I would like to think, because I end up working with a fair number of people who've been abused, I'd like to think we're doing some good -- you know, good that could be shown in a scientific study. We don't have those scientific studies. So while we're sending all these people, we really don't know that it's that helpful.

MISHLOVE: Of course now there are limits to what a scientific study can observe, because if it's looking at outcomes of therapy it needs measurable behavior. And yet many people come to therapy because they want to feel better, or because they want insight, and these things are quite hard to measure.

ZILBERGELD: I disagree totally with that. I think if it makes a difference, it has to be discernible. Our difference may have to do with how we're defining behavior. I mean, for me to say if somebody says, "I feel better," that's behavior, or that's worthwhile. It has to be discernible. If it's not discernible to the therapist or the patient, or the patient's wife or husband or somebody, then it didn't happen.

MISHLOVE: Oh, I understand that. It just may not be discernible to an outside scientist, because if somebody reports that they fell better, well, they may not really.

ZILBERGELD: Well, but that is one source of information. I think self reports are necessary. I think the therapist's opinion is necessary, although obviously they're biased, and I think anybody else's opinion. In questionnaires we can use anything. I rarely quibble about outcome measures, but we've got to have some kind of outcome. And the therapist's argument -- it was typically the analysts who used to engage in this; now more and more therapists of all persuasions are engaging in it -- "We just can't measure these things. Science hasn't caught up with it." I say that's a real cop-out. What that is, is a whole hypocrisy. It's a way of saying we can't show we do any good, but please, insurance companies, governments, whoever, give us more money so we can keep on doing what we can't prove is worthwhile. I think that's crazy.

MISHLOVE: So in other words, you're recommending that for somebody who's considering that they get into therapy, that they really think in their own mind about establishing what would for them be a satisfactory, measurable outcome.

ZILBERGELD: Yeah, and I think any therapist who's worth anything will help you do that, whether you've done it or not on yourself. For a therapist not to do that, in my mind -- a lot of therapists will disagree -- is unethical. I mean, if you're coming here, you're coming to my office, it is incumbent on me, I believe, to ask you, well, what would you like to achieve? Let's say we spend some time together, Jeff. What outcome would make you feel your time and money were well spent, or at least weren't wasted? All right, you'd like to be happier. What would it take to make you happier? How would you know you're happier? Oh, if you didn't feel so tense when you woke up in the morning and the rest of the day. That's fine. I can accept most things that you would come up with, but we have to have something, otherwise how am I going to know how to plan treatment, and how are either one of us going to know if we're getting anyplace?

MISHLOVE: It's tricky. My sense is, from my own practice and colleagues that I know, that some people come and basically their real goal, although it's not often stated, is just to keep from getting worse, because they're afraid that they're sliding, and if you can kind of maintain them at their present level, that's doing good work.

ZILBERGELD: But that's fine too. How would we know you're at the same level and not getting worse? Well, I wouldn't be having any more migraines; I wouldn't be having any more panic attacks. OK, that's kind of a minimalist goal, but that's acceptable too. I think the important thing is that it be spelled out in some way, because not to spell it out helps lead to interminable therapy. You have people in therapy for ten, twenty, even thirty years. I know a therapist in Berkeley who had a client who'd been in psychoanalysis in Boston for thirty-three years, four times a week.

MISHLOVE: And didn't feel any better, but he sure learned a lot about himself.

ZILBERGELD: Right. That's actually what the guy said, and I kind of question that. Actually, if people have the money and that's the way they want to spend their time, I have no problem with it. But if insurance companies, or the government, is paying for it, I really have questions about it. Because you know what insurance companies and the government are. They have no money; their money comes from folks like us. So I do have some questions about that. Do we, as a society, want to spend money that way?

MISHLOVE: Well, you point out that other societies really don't focus in on psychotherapy to the extent that ours does.

ZILBERGELD: No society focuses in. Do you realize that Sigmund Freud would have been a footnote in history books if it had not been for America? Freud was accepted nowhere the way he was in the United States. I mean, he was long forgotten in most other places -- just some active little clusters in New York, France, and wherever. In Austria they forgot about him a long time ago. But it was in the United States that he caught on. We are the therapeutic society par excellence, and we are influencing other cultures because they take on whatever is here. So in other countries, even in Japan I've heard, they're starting to come along: "Well, if they're doing it in America, it must be good."

MISHLOVE: Well, it seems to me that's healthy in a sense, because it also indicates that we're on the leading edge of dealing with social issues -- discrimination against women, for example, against races. We're beginning to deal as a culture with psychological issues that are still being ignored in other parts of the world.

ZILBERGELD: Well, I think that would be room for another whole show. I mean, we have exported many good things. We've also exported some things that are not so good. My feeling about psychotherapy, and I know that's strange coming from a therapist, is kind of mixed. I think it is a tool; it is useful for certain kinds of things. I think unfortunately, like everything else, like all other tools, it starts being used for everything. I wish we would stop using it for psychotics; I wish we would stop using it for addictions; I wish we would stop using it for criminals. I wish we would stop using it for all the things where there's no evidence, despite years of trying to get it, that it does any good, and to use it for what it's good for. I mean, how would you feel if they started performing appendectomies on everybody, whether they needed them or not, or tonsillectomies, which was actually the case? Actually, I would like to see with psychotherapy what happened to tonsillectomies. They used to do it on everybody.

MISHLOVE: Right.

ZILBERGELD: And now, when they saw the results, when they really started looking at the research and seeing what it was doing to these kids -- you know, scaring the hell out of them, a lot of negative consequences -- now they're doing it in a more discriminating way. I would like to see psychotherapy being used in a more discriminating way. If you have a certain problem that we know a certain therapy works with, let's do it.

MISHLOVE: Dr. Bernie Zilbergeld, it's been very refreshing to hear a psychologist speak so honestly about the profession of psychology and psychotherapy. Thank you very much for being with me.

ZILBERGELD: My pleasure.

END 


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