Does Talk Therapy Ever Really Work?

When commenting on the New York Times article about Dr. Don Levin yesterday, I didn’t have time to address the larger, and more salient issue: Does talk therapy ever really work?

If you believe Dr. Levin, you would think that he was once a great talk therapist, curing scores of people. You might even take it as a given that talk therapy is an effective treatment for what ails your mind.

The question is difficult because few of us are going to agree on what does and does not constitute talk therapy. And fewer still will agree on what it means for therapy to work?

Someone you know may have gotten better while in therapy, but that does not necessarily mean that therapy made him get better. Correlation is not causation.

If today's therapists agree that the relationship between patient and therapist is the most effective aspect of treatment, that means that the therapy itself, the insights that the therapist provides, does not work.

For all of Dr. Levin’s complaining about his current professional plight, the larger truth seems to be that most talk therapy is not especially effective, and that when it is, the reasons do not lie in the treatment but in something more nebulous: the quality of the relationship between patient and therapist.

If psychiatrists were as great as they now say they were at talk therapy, fewer of them would be spending their working hours writing prescriptions for psychotropic medication.

If the relationship counts, then we should dispense with all the talk about therapy working. Because it does not. Insight does not cure; self-awareness does not curing; making your unconscious conscious does not cure.

Getting along with your therapist does cure.

The old paradigm for talk therapy assumed that therapy cures people because it reveals scientifically-based insights into their motivation, shows them the hidden meaning behind their symptoms, or allows them to express the hidden feelings that they had ignored or repressed.

Why doesn’t any of this work?

First, we need to understand the treatment population. As psychologist Jerome Frank once famously noted, most therapy patients are there because they are demoralized.

Most therapy patients feel isolated and disconnected. They are suffering from anomie, not neurosis, psychosis, or a personality disorder. (Those who are suffering from physiological illnesses are rightly treated with medication.)

If demoralized patients connect with their therapists, their feelings of isolation and anomie will diminish. If they feel that they are respected by their therapists, they will feel that they are more deserving of respect.

As I see it, this is not what you learn when you study clinical psychology or psychiatry. Getting along with other people belongs to the field of ethics, not science.

Of course, old style Freudian psychoanalysis was quite concerned with the relationship between patient and therapist. Dubbed the transference, this relationship was defined as anything but a human connection. It was a dramatic reenactment of a repressed fantasy. The patient was transferring emotions on to the analyst that supposedly belonged to an unresolved past trauma or parental failing.

By definition, psychoanalysis precludes the kind of real human connection that would actually help the patient. The best psychoanalysts do not even pretend that their method works.

Moreover, Freud thought that all human relationships were lubricated by libido. Life was not about building character. It domain was theater, and it involved seduction, the art of getting someone to do what you want him to do when he does not want to do it, and when it is not the best for him.

The relationship between patient and psychoanalyst is laden with potential conflicts and unruly emotions and attractions. Thus, many psychoanalysts have actively tried to produce conflicting feelings in their patients, the better to foster the transference.

They did it by refusing to converse with their patients, refusing to look them in the eye, refusing to take what they said at face value, and ignoring their entreaties.

When today’s therapists say that the relationship is curing the patient, they are not talking about a semi-erotic transference relationship. They are really talking about a kind of friendship where there is a reasonably open and respectful exchange of ideas, feelings, and information.

Connecting with other people requires the ability to find common ground, not to aggravate conflict. Assuming that we understand the difference between a friendship and a love affair, we will also understand that, when you are down, it is better to make a friend than to fall in love.

Of course, the only way you can learn to make friends is by making friends. Unfortunately, this is not taught in psychiatric residencies or clinical psychology programs.

Worse yet, the pretense that science can teach you about the way people become dysfunctional tends to cloud the real issue: how to become more functional and more contented with your life.

This sounds nice enough, but it still leaves us with the impression that the most important part of therapy is the therapist’s congeniality. Even coaches like to think that they are offering more than congeniality.

What is the “more?” In my view, therapists and coaches ought to be helping their clients to learn how to manage their relationships, whether personal or familial or professional. Since their world is the playing field or the arena, and not the stage, they will be coaching people on how best to play the kinds of games that constitute human interactions.

Since therapy tends to focus on the past, not the present, it is ill equipped to help people manage their current relationships.

The focus on healing illness or finding the root cause for dysfunction is not very helpful either. This focus assumes that as soon as you remove a toxin, then the person will automatically become more happy and functional.

Some people are naturals at some games, but most people who have been living in a world of therapy-induced drama are not going to pick it all up over night.

Most of the people who come to therapy are not sick. If we take the example of marital counseling, most couples who are in counseling are having trouble getting along.

They are not sick. But if they are not sick why does our culture tell them that they ought to be consulting with a physician or a paramedical professional? They might not understand what is going on; they might want to know how better to play the mating game; they might want to learn how better to manage their relationships with spouse and children.

If therapy patients have questions about current relationships, these questions concern ethical issues: What should I do? How should I handle this? What is the right thing to do, for me or for the other person?

More often than not people consult with therapists or coaches because there is no good answer. There are two different alternatives, neither one of which is very good.

Again, the fact that you are caught on the horns of a moral dilemma does not make you sick. It means that you have encountered a situation that is beyond your personal capacity.

It may be beyond you because you are young or inexperienced. It may be beyond you because your cultural background is very different from the culture of the place where you are currently living. Or it may be beyond you because it would be beyond anyone.

You do not learn this kind of ethics in medical school or in psychology courses. So, where can you learn them?

How does anyone learn relationship management? One might look outside of the domain of therapy, toward the world of business, where people understand that they need to learn how to promote comity and amity in the office.

It would be a great thing if psychology grad students were obliged to take courses in management and negotiation, through a business school.

Beyond that, these skills are best learned by doing. Human life is far too complicated and far too intricate to take one or two formulae and apply them to all human conundrums.

It is not about advanced theoretical knowledge or scientific experiments, but the wisdom that comes from experience.  Sad to say, there aren’t any shortcuts.