The Value of Therapy - Part 1 (of 2)
Is Therapy Working?
When debating some it’s useful to first establish terms, and make sure you’re both talking about the same thing and that you understand each other’s claims. After that it’s often helpful to state your areas of agreement with your opponent, and to be honest about your areas of uncertainty.
I will start by saying that therapy can serve many functions and is doubtlessly sometimes helpful. I feel sure that I benefitted from therapy years ago when I was in inpatient substance use treatment in Florida. That experience made me want to be a therapist, and a good number of people have since told me that they think I would be a good therapist (even unprompted) which is not something anyone would have said about me as a younger man. Talking things over with another, neutral party is obviously useful and it’s more so if the person has some training in human behavioral patterns and communication and defense strategies.
Therapy has gone from being a niche service available only to rich urbanites paying hundreds of dollars per hours for Freudian analysis to a broadly available and often-recommended process for a number of psychological conditions… or no condition at all. It is extremely common to find people (mostly young women) who proclaim that everyone should be in therapy. Of course, most of these young women are rich even for America and virtually all of them are wealthy in the global sense but they’re not thinking about resource distributions or costs or financial privilege when they say this: they’re making a claim about the value of therapy in modern life.
However, one quickly realizes a curious thing about these people (as a group, not as individuals): they do not seem obviously more healthy or well-balanced than others. This might seem like a difficult judgement to make but I’ll give you a counterexample: people in recovery who go to meetings frequently and take the suggestions of prayer, and meditation, service seriously seem more content and more serene and less reactive than other people. Not all of them, of course, but I would say most of them evidence the benefits of their practice in their daily lives. Ultimately this is the mark of any practice or religion or belief system: how well does it equip you to deal with life?
Back to our therapy clients: how do they appear? Keep in mind, this is purely my own series of impressions and is fully unscientific. Nevertheless, honestly take a look at your experience with such people and tell me if it diverges. People in therapy are often poor communicators. They are often petty, or sensitive. They rarely seem to be married and while they often have impressive careers those careers usually predated the initiation of therapy. They are often self-centered. They struggle with anxiety or negative self-talk. They often live alone without a large number of close friends. Are these things more well-represented in therapy clients than others? Honestly… I would say yes, but my point it they’re not less well-represented. That should be the mark of therapeutic efficacy: wisdom, equanimity, love, and a flowering of your life in unforeseen directions.
I’ve made these observations to a number of young women and often receive anger or offense in return (which is interesting because emotional reactivity is one of the things which should be reduced in a mental health practice… you might disagree with a person or even believe they’re trying to frustrate-and I’m not trying to frustaret anyone-you but an effective discipline of personal growth will reduce and eventually eliminate this kind of sensitivity and tendency to offense in most people). Let me state what I think might be happening before I introduce the (frankly appalling) statistics about therapeutic efficacy: clients (mostly young, mostly well-off, mostly women) are struggling with some issue or hurt or anxiety… or they’re not and they begin therapy because it’s close to a cultural expectation in certain privileged circles. Regardless of the reason, these people begin to work (remember that word-it will recur) with a therapist and build trust. After some time they genuinely feel better. They feel more confident and les anxious and they heal from their fears or emotional wounds (which are often romantic or linked to family issues). Therapy works and they know it! It worked for them, after all. They begin (mis-)using words like process and trauma and phobia and gaslight and anxious attachment. They actually come to enjoy therapy and it becomes a regular feature of their life. They often recommend that everyone avail themselves of this service.
A few caveats: therapy, to be effective according to the standards of evidence-based medicine cannot just be useful or enjoyable or even healing (it shouldn’t really be enjoyable at all, but I’ll come to that later). First, there is the placebo effect. This describes a still-unknown healing factor which seems to be tied to belief in the medicine or procedure. In other words, if people believe that something might help them it often does… even if the factor in question is just an inert sugar pill. Therapy must exceed the placebo effect. Therapy must exceed the benefit of speaking to friends or family. Talking to anyone about your problems regularly will have profound benefits, even if this person is a bus driver. Also, time heals many of the wounds which are addressed in therapy. If if you never talked about your break-up you would tend to feel differently about it as time went on and eventually you would probably gain some distance and equanimity and compassion which eluded you at first. Therapy must exceed the healing factors of human conversation and time. What does the social science data indicate? We will see in Part 2, where I will explain the ways that therapy has become deeply unhelpful and even floridly pathological.
I would propose that effective therapy should help you achieve an emotional state (which usually includes compassion for others and a broad perspective and emotional non-reactivity) or a perspective which deeply helps you and which you would not have found on your own (at least as quickly as you did). It will usually be difficult to identify these changes in yourself purely based upon subjectivity and I tend to ignore those reports. If you could never nurture a long-term relationship and therapy helped you do this-okay, now we’re talking. Feeling better is mostly irrelevant. To evaluate the effectiveness of therapy I ask (myself, for these are not questions it’s usually appropriate to pose to others) does this person now do things totally differently than they did before? Do they have a radically different set of emotional responses? Are they involved in activities or relationships or occupations which they would have been unable or disinclined to pursue otherwise? That is how I measure therapy’s impact on my life. I think that if you were a young women with a professional career living alone and structuring your life based on your own priorities who was dating men and taking care of your pets, etc… and then you had a terrible breakup and you dealt with it in therapy and now you are a young woman with a professional career living alone and structuring your life based on your own priorities who is dating men and taking care of your pets, then therapy has had not had a clear enough impact on your life to say if it worked for you or not.
(Note: I believe that pair bonds and having children are extremely important norms for society because without these things society collapses in a horrible fashion, and because every human society which has ever existed has placed these things at the central position of their social organizations. You can either believe that all of those societies were, in a sense, wrong-because they would consider our modes of living to be incorrect and frankly crazy or that we are wrong today. This is one of those questions-like the existence of God or not-where only one party can logically be correct, or none. There is no coherent sense in which both positions can be correct. If a person from our 500,000 year hunter gatherer past views our social arrangements and says: you people are missing the point and ignoring the most important things in life, which are mates and children and physical activity and the health of the community they are either wrong or they are not. No one can know if they are right or not and whether they are ‘right’ depends on your sense of the meaning of life and the nature of eudaimonia but that statement can either be correct or it’s not. If it’s incomplete or based on their prejudice or not weighing the happiness of the individual enough then that’s just another way of saying you disagree with it. I would agree with that statement and the fact that we have diverged from our ancestral priorities is a major driver of our current unhappiness and neurosis.
There are many people who proclaim themselves to be varieties of cultural relativist and who say that every culture is different and no practice is ‘right’ or ‘wrong’ but a cultural norm either works to promote stability and happiness or it does not. If you think that we can’t condemn the practice of American slavery and that the Aztec habit of sacrificing tens of thousands of prisoners before the plaza of Tenochtitlan by tearing out their hearts while they were alive was not a bad thing and the Nazis just had different ideas but not necessarily worse ones then you are actually a cultural relativist. If you don’t believe these things then we agree that cultural practices can be deemed healthy/useful or not in some objective sense. That is the kind of claim I’m making here about marriage and children: it’s important for most people and always will be and the less important it becomes the less happy our society grows.)
Keeping my note above in mind I would say that if therapy was leading people to marriage or parenthood or bold life choices or new careers which used to elude them I would tend to think it was generally useful. My interaction with dozens of single young people who structure their lives around their jobs and dates and restaurant- and gym-visits and buying things on Amazon and yet still believe that therapy has really helped them makes me doubtful of this claim.
I have made many bold assertions here. I might sound like someone who thinks that he knows it all or that he’s better than other people. This is not the case. Life and decades of failure have taught me humility and a hesitation to pass judgements on the decisions of others. I never interact with a therapy proponent and think ‘they’re wrong’ or ‘therapy didn’t help them‘. But we are the loneliest and unhappiest and most mentally ill society which has ever existed… and we are also by far the most therapized and prescribed. If these things are helpful in the aggregate then we need to account for factors which are SO robust that they are basically drowning out the benefits of therapy. I think it’s more likely that therapy is often only marginally useful and sometimes counterproductive and has been unable to deal with the social changes which are making us unhappier. I remind you: if therapy worked you might be able to tell the people who regularly engage in it. Other than knowing that therapy clients tend to be richer and better-educated young women I cannot tell the therapy users from the non. How much of a problem you think this might be probably depends.
One final comment: therapy is a collaborative process in which a person is challenged to confront aspects of themselves and their decisions which are often hidden. We refuse to confront all of the things which our unconscious knows because it is (probably) too painful. Therapy should not be enjoyable. It can be comfortable (at times) and it should operate within a framework of absolute trust but if you’re not being pushed to grow and change (which are always difficult and often distressing processes) you’re not actually ‘doing the work’. Therapy is kind of like a psychedelic journey done in slow motion: you’re growing and learning and confronting painful elements of your past or your identity which wouldn’t be apparent without the help of the therapist. Too often, I think, people find a therapist they like to speak with and get through some painful issues and then settle into a kind of pleasant routine: they visit once a week and review their behaviors and download their decisions and get a different and trusted perspective and leave feeling happy and unburdened. These are the kinds of conversations people used to have with close friends or certain family members. They are not therapy. However, they do result in happy customers and billions of dollars for the field so who cares? As long as people continued to use therapists our collective mental health could continue to decline and sicken and no one would say a word. In fact, that is precisely what is going to happen, according to my predictions. If therapists pushed their customers toward difficult personal changes: reduce smart phone use, get married, leave your shallow and lucrative job, etc. they would lose business. The client will pay for what they enjoy rather than what benefits them, because the benefits are not enjoyable. This is how we arrive at a country full of shallow and lonely and fragile people who use therapy more than any group of people in history and are yet happily static (stagnant), using the practice as just another way to feel temporarily happy or easy or relaxed.
Therapy, as it is practiced today, either works or it doesn’t. If the statistics about body image and loneliness and anxiety and depression and sleep issues are evidence of a civilization with millions of patients engaging in a therapy that works… then I would hate to see ourselves at the mercy of a therapy that didn’t work. It’s almost unimaginable. What does that tell you?
In Part 2 I will describe ONE therapeutic practice with demonstrated efficacy (Cognitive Behavioral Therapy) and I will describe the common cases when therapy would not tend to be helpful and, indeed, will often make the patient worse (narcissism, histrionic traits, etc.). I will review some of the data on therapy which indicates that it is not very effective at improving mental health.
Spot on. It’s been my observation that CBT and DBT are the things that help people, and then joint counseling with loved ones with whom they have a contentious relationship and need a referee to help them see how they don’t communicate productively. Sometimes the framework of attachment disorders can be helpful too, but that’s gotten really corrupted by social media lately and it seems people are more often urged to call everyone toxic instead. When it’s just some vague thing where they talk about their anxiety or depression, it’s like they don’t get any concrete help besides medications or validation (which is more often than not the LAST thing they need) which I feel usually chip away at the very skills they need to hone, not muffle.