"Does Psychotherapy Work?"

For this blog the opening lines of Scott Stossel's review of Jonathan Engel's "American Therapy" are a holiday gift. Link to review here.

Stossel opens his review with a question: "Does psychotherapy work?" He follows with this line: "Depends on what you mean by 'psychotherapy,' and what you mean by 'work.'"

Where Engel concludes that psychotherapy does work, Stossel spends the first part of his review showing that the evidence Engel offers leads to a different conclusion.

The first problem with the question is the infinite variety of therapies. Some forms take years and pretend that insight cures. Some take weeks and focus on counterproductive mental habits. And others involve strange practices that range from primal screams to est training to beating on pillows with sticks.

Since these different therapies have little of nothing in common, the question of whether therapy works must be qualified: which therapy are we talking about?

Next is the question of what it means to "work?" Most studies base their conclusions on interviews where patients can assert their opinion about whether their therapy has helped them.

Is this really a reliable indicator of clinical success? If you go out and interview Tom Cruise and ask him whether scientology works, you will receive a heartfelt, albeit deluded, exposition about how the teachings of L. Ron Hubbard have freed him from the malevolence of Xenu. Would you then conclude that scientology works?

Beyond that, someone who has invested considerable time and money in therapy has a vested interest in believing that it works. Would you take his or her word at face value?

Engel bases his claim that therapy works on the fact that 59% of those who consult a therapist report that they were helped.

To which Stossel replies that 78% of those who consult a clergyman feel that they were helped. Better yet, 77% of those who discussed their problems with a lawyer found something therapeutically beneficial in the experience.

The difference between 59% and 77% is not trivial. Talking it over with a trained therapist is significantly less likely to be helpful than talking it over with a professional who has no training in psychology.

Today most therapists agree that therapy works when the therapist makes a human connection with his or her patient. Since many patients are suffering from feelings of isolation, anomie, and disconnection... then connection would certainly count as therapeutic.

But the data also suggest that professional training tends to make it more difficult for therapists to connect with their patients. Other professionals, even non-professionals, have a much higher level of connection.

Surely, Freudian training, with which I have more than a passing familiarity, teaches people how not to connect with people. In fact, psychoanalysts are taught that it is bad to have anything resembling a human connection with a patient.

Perhaps this is why psychoanalysis has fallen out of favor. The group I used to belong to, the Lacanians, resembles what Engel called: "... a fanatical Essene sect, living apart in the wilderness where they could continue to seek truth in the master's writings."

That is the most extreme case. Yet, Freud continues to influence the profession, and some therapists still believe that connecting with a patient is a technical error. Perhaps this is why you will do better to talk it over with a friend and why people today are turning away from insight-oriented therapy and toward coaching.

As for the question of what works, I recall a comment by Dr. Gail Saltz in a televised interview a month or so ago. A reporter asked Dr. Saltz what people should do to deal with their anxiety over the current financial crisis.

I paraphrase Dr. Saltz's reply: "I shouldn't be telling you this because I am a psychiatrist, but the best and quickest treatment is aerobic exercise."

Since it is the holiday season, let's ignore the implicit notion that a group of professionals might even imagine not telling you what really works, and let us simply add exercise to human connection on the list of what works.