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Time, Knowledge, and Power in Psychotherapy: A Comparison of Psychodynamic and Cognitive Behavioral Practices

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Abstract

Time has long been recognized as a marker of professional control and a tool for the organization of work. Yet we know less about how temporality intersects with experts’ epistemic goals. This article illustrates how the patterning of time in psychotherapy shapes the construction of knowledge about mental illness and how this relationship is mediated by patients’ own interventions. I focus on psychodynamic and cognitive behavioral therapeutic practices and draw on data from ethnographic observations in an outpatient psychiatry clinic and in-depth interviews with psychotherapists. The article details the constitutive relationship between two dimensions of temporality: first, clock time, namely the length of treatment, the length and frequency of sessions, and the flow of the therapy hour, and second, the temporal epistemics of illness, its construction as a phenomenon with a past, present, and future. Clinicians in the two orientations attempt to construct particular temporal landscapes by integrating these two facets of their work. Yet they must always do so in response to patients’ own temporal interventions. By attending both to the organization of professional work and the temporality of illness, this article brings together two largely distinct literatures within medical sociology, namely scholarship on the profession of medicine and social scientific understandings of the temporal dimensions of illness. It shows that temporality is constitutive of how knowledge and power are negotiated in expert work.

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Notes

  1. An experienced therapist set aside an hour and ten minutes for our meeting, but told me that her “body works on a forty-five minute clock” so she might have to glance at her watch to grant me the full time she had allocated to our conversation.

  2. In the psychotherapeutic community, psychodynamic therapists practice under the aegis of psychoanalytic concepts and ideas, but are not technically psychoanalysts. The terms psychoanalytic therapist and psychodynamic therapist are used interchangeably to signal those who work with psychoanalytic ideas but are not formally trained to practice psychoanalysis. What “psychoanalysis” is has been up for debate for decades and falls outside the bounds of this article. For clarity’s sake, I will use the term “psychodynamic therapist” for those clinicians who adopt a psychoanalytic approach but do not practice psychoanalysis; when appropriate, I will specify whether someone is practicing the latter.

  3. The literature on time has a long history (Bergmann 1992). Durkheim (1912/1995) and Sorokin and Merton (1937) established early on that time is a “social fact” worthy of sociological attention. A rich body of scholarship has since illuminated the calendrical organization of everyday life and the meanings that social actors attribute to different temporal orders (see Auyero 2011; Douglas 1966; Goffman 1959; Hochschild 1997, Hochschild and Machung 2003; Roth 1963; Schwartz 1974; Sennett 1998; Thompson 1967; Zerubavel 1979, 1982). Sociologists have demonstrated that roles are associated with particular times, while distinct temporal flows recall specific ways of thinking, feeling, and doing (Bourdieu 1977; Durkheim 1912/1995; Fine 1990; Roth 1963; Zerubavel 1979, 1982). Tempo, rhythm, and directionality make up the “temporal structure” of practice, thus “constituting” its meaning (Bourdieu 1977). Recent research has shown that time is a productive site for analyzing the structural embeddedness of practice, for example how free markets shape contract workers’ schedules (Evans et al. 2004), how the state fosters an ethos of “waiting” in its neediest citizens (Auyero 2011), and how class and political mobilization are linked through temporal “trajectories” and “landscapes” (Tavory and Eliasoph 2013).

  4. In addition, Luhrmann (2007) has shown that schizophrenia can be rendered chronic by cultural conditions organized around experiences of “social defeat” that emphasize stigma and isolation.

  5. Significantly, the DSM 5 has eliminated the axial classification of mental disease; at the time of my fieldwork, the DSM-IV-TR was still in use.

  6. Such “causes” remain little understood (see Whooley and Horwitz 2013).

  7. Tavory and Eliasoph (2013, 909) argue that we must examine the “coordination of futures” that make possible social action and constitutes larger organizational factors such as social class or social movements. They contend that these function at three scales: “moment-to-moment anticipations” that they describe as “protentions,” actors’ culturally-shaped trajectories, and meso and macro “plans” and “temporal landscapes.”

  8. However, one of this article’s limitations is that it does not include patients’ perspectives. Two primary reasons account for this: First, the larger project focused on psychotherapeutic expertise in practice and training; second, obtaining approval from the Institutional Review Board would have been made much more difficult (logistically and temporally) by the addition of a patient population. This article focuses on how psychotherapists’ own time work intersects with their epistemic and professional goals and, as such, depends less on patients’ perspectives; however, I do suggest this as an important direction for future research in the final section.

  9. It is worth noting that the “evidence-based” label is contested in the field. Psychodynamic clinicians have made their own claims to “evidence;” such contestations are beyond the purview of this article. Nevertheless, practitioners of cognitive behavioral interventions use the label “evidence-based” to distinguish themselves from their psychoanalytic colleagues and establish their legitimacy in the field of mental health.

  10. Since 2012, clinicians must fulfill an additional field in their insurance claims that indicates the length of their sessions: 30 minutes 45 minutes or 60 minutes each of which is differently reimbursed. I conducted my fieldwork before this new rule, thus none of the therapists I spoke with mentioned it. With one significant exception, none of my interviewees mentioned working with patients for longer than approximately fifty minutes. The exception was a patient suffering from severe OCD (obsessive compulsive disorder) who was receiving multiple 60-minutes sessions per day in an intensive, inpatient-like treatment.

  11. For a comparison of primary care physicians working in private offices vs. HMOs, see Hoff and McCaffrey (1996). Mechanic (1975, 2006) also compared how fee-for-service and capitation payment arrangements affected physicians’ work.

  12. Lucas began seeing Elisa for psychiatric medication-management but, he explained to me, he quickly realized that her problems could not be simply defined biologically. When he asked her whether she would want to be in psychotherapy with him, she agreed. Throughout their psychodynamic treatment, Lucas continued to also treat her with psychiatric medications.

  13. Signaling how much things had changed since he completed his residency at the height of psychoanalytic dominance in psychiatry, Terry told residents that he “learned the fundamentals of psychodynamics…in a six month ER rotation.” He pointed out that, in a departure from the current model focused on symptoms, doing a consultation at that time was still focused on “understanding who your patient is, and why are they crazy at this moment.”

  14. It is understood that patients are not the only ones bringing their past to bear on the present but that therapists do so as well. This is termed “counter-transference” (Chodorow 1999). Monitoring their own “inner time,” to borrow a phrase from Garfinkel (1967), becomes for these therapists paramount to building a clinical relationship that can function, along with their emotions, as an epistemic tool.

  15. The therapy office, the frequency and length of meetings, the length of treatment, the exchange of money, and other professional norms restricting interactions between therapists and their patients form the therapeutic “frame” (Gutheil and Gabbard 1993). Through the frame, clinicians set parameters without which, they argue, psychotherapeutic work could not take place. Its manifest function is to protect patients, shielding them from the abuses of power possible within therapeutic relationships (American Psychological Association 2010; Gutheil and Gabbard 1993). Yet these temporal, spatial, and economic arrangements also protect therapists and their claims to professionalism. Just as the laboratory legitimates the work of scientists (Gieryn 2002, 2006), so the therapy office and the therapeutic hour distinguish clinicians’ work as expert and professional. They engender a “symbolic capital” (Bourdieu 1991) that grants therapists power in the clinical session and legitimate jurisdiction over their patients’ problems (Abbott 1988; Freidson 1970).

  16. This, as Lutfey (2004) has shown, is a common but contested explanatory mechanism is medical work.

  17. An experienced analyst I interviewed early on recalled a patient who, taking what she understood to be his advice, went on a weekend getaway with a new partner. This proved disastrous for their relationship and the outcome was blamed on the analyst. He questioned whether he had really taken such a directive stance, implicitly reaffirming the incompatibility between such direct intervention and the historical focus of psychodynamic work.

  18. Roth (1963) also demonstrated that physicians and patients in a tuberculosis hospital had conflicting “timetables” regarding the latter’s illness and length of stay in the hospital. Patients’ illness “careers” are thus objects of contestation. In contrast, Calkins (1970) observed little conflict in a rehabilitation center where staff and patients’ nearly opposite time perspectives seemed to operate in parallel. The psychotherapeutic process, as I have shown here, is more open to intervention and collaboration.

  19. It is not only therapists who must maintain their fronts. Patients are similarly concerned, and one therapist pointed out that they must be careful how they schedule their sessions: “it’s generally not a good idea for people to schedule themselves so tightly that they’re going to come from my office straight to something else without...at least a ten minute transitional, or fifteen transitional.” This, she noted, was due to the emotional upheaval that patients may experience in session and that they may want to separate from other aspects of their lives.

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Acknowledgements

I wish to thank the editor of Qualitative Sociology, David Smilde, and the anonymous reviewers for their helpful feedback. Camilo Leslie, Steve Epstein, Kim Greenwell, and Jason Owen-Smith offered valuable comments on earlier drafts. The psychotherapists who kindly and openly welcomed me into their often complicated professional lives deserve my appreciation. This work would not have been possible without them.

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  1. Department of Sociology, Tulane University, 220 Newcomb Hall, New Orleans, LA, 70118, USA

    Mariana Craciun

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In September 2017 Dr. Craciun’s university affiliation will change. After this date, please direct correspondence to: Department of Sociology, 220 Newcomb Hall, Tulane University, New Orleans, LA, 70118

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Craciun, M. Time, Knowledge, and Power in Psychotherapy: A Comparison of Psychodynamic and Cognitive Behavioral Practices. Qual Sociol 40, 165–190 (2017). https://doi.org/10.1007/s11133-017-9355-x

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