Does Therapy Work for Depression?

The psycho world is abuzz today about Benedict Carey’s New York Times report about the effectiveness of talk therapy.

A recent study—already disputed—suggests that talk therapy is less effective than previously noted in treating depression. In the past such treatment was touted as helping in 30% of cases, now it is seen as helping more like 20%.

By way of comparison, anti-depressant medication provides a benefit in around 25% of cases.

Clarifications are in order here. For the most part, when the researchers are describing talk therapy, they are referring to cognitive-behavioral therapy for depression. Some of them also use a variant on cognitive treatment, called interpersonal therapy. For the most part, they are studying a treatment that can be practiced pretty much the same way by any practitioner.

It makes sense in terms of science. And yet, calling cognitive therapy “talk therapy” is somewhat misleading. It is based more on doing homework assignments and performing mental exercises than it is on a conversation between therapist and patient.

The point needs some emphasis. I consider cognitive treatments a major improvement over psychoanalysis, and I have often reported success stories from such treatments.

And yet, doing therapy by the book does create certain disadvantages. If the therapist is fundamentally disinterested in forging a human connection with his patient, this is not beneficial to depressed patients, in particular.

Keep in mind, depressed patients often feel detached from other people. They feel that they are not worthy of any real relationship. If their therapist refuses to engage them in a conversation, if he does not even try to connect with them, his attitude will reinforce their negative self-judgment and will prove an obstacle to recovery, even with constructive homework exercises.

As it happens, classical psychoanalysis, the kind where the patient lies on the couch and free associates, has always refused to allow patient and analyst to form any real connection. For that reason psychoanalysis has produced far more depression than it has cured.

It is easy to get slightly confused by the new research.  Psychoanalysis has long been called the “talking cure,” and thus is easily confused with “talk therapy.”

The research does not test psychoanalysis, because there is no real reason to do so. Effectively, psychoanalysis has been practiced for over a century now. Everyone knows that it has failed clinically. Its failure laid the groundwork for cognitive therapy and for SSRIs.

To repeat a point I argued at length in my book, The Last Psychoanalyst, namely, when the most influential psychoanalyst since Freud—that being Jacques Lacan—said that the clinical practice of psychoanalysis is a “scam” you do well to pay heed.

Lacan’s minions believe that his perfectly intelligible statement could not have meant what it said or said what it meant. If it did you would not need them to tell you what he meant and what you should think. And yet, they are wrong. Anyone who understands Lacan’s theorizing knows that if his reading of Freud was correct then psychoanalysis as a practice is unsustainable.

In truth, psychoanalysis is moribund in America. It is doing well in France where people do not think of it as a clinical treatment. There they see it more as a pseudo-religion, one that affirms their identity as Frenchmen and Frenchwomen.

The few psychoanalysts who still practice in America tend to present themselves as eclectic. They do a little bit of this and a little bit of that. They do not feel bound by the rules and the Freudian creed. Each one has his own guru, whom no one has ever heard of, but whom they quote as a serious authority.

Scientifically speaking, you cannot run clinical trials using an ill-defined,  eclectic discipline, one that changes in the hands of different practitioners and with different patients. If you were doing science and you had a dozen or two dozen different compounds and decided to call them all the same thing—let’s say: psychoanalysis—and if you then claimed that the clinical results produced by the distribution of these compounds told you something about psychoanalysis, real scientists would laugh at you.

Obviously, it is much easier to do a clinical trial on a medication than it is to do on something as imprecise as therapy. Even where the treatment is performed in roughly the same way by different practitioners, still, it happens that the practitioners are not the same. They have different skill sets, different appearances, different ways of relating, different persuasive abilities, different ages, different genders and different qualifications. I could go on. 

If the effectiveness of therapy with depressed patients in any way involves having a human connection, something that is akin to friendship, then the person of the therapist is not incidental.

Worse yet, if it is true, as the Atlantic reports, that it is becoming more and more difficult to provide good mental health treatment for men, in particular, the reason might be that the profession of psychotherapy has become a woman’s profession. This has caused it to lose prestige, for feeling more like nursing than like doctoring. Worse yet, in many cases its practitioners do not even pretend that it is science. Their minds have been infested with leftist ideology, to the point where they do not even know that they are transmitting an ideology, not helping their patients.

Thus, many men feel that if they go to therapy they will be encouraged to get in touch with their feminine sides. If not that, they feel that they are being mothered. And for most men, one mother was enough.

If men fear what feminist therapists want to do with them, they have reason to be afraid.

The New York Times has offered a set of characteristics that supposedly define the modern man. One hopes that this is a lame attempt at humor. One suspects that it is not.

Among them are these:

When the modern man buys shoes for his spouse, he doesn’t have to ask her sister for the size. And he knows which brands run big or small.

The modern man makes sure the dishes on the rack have dried completely before putting them away.

The modern man still jots down his grocery list on a piece of scratch paper. The market is no place for his face to be buried in the phone.

Does the modern man have a melon baller? What do you think? How else would the cantaloupe, watermelon and honeydew he serves be so uniformly shaped?

On occasion, the modern man is the little spoon. Some nights, when he is feeling down or vulnerable, he needs an emotional and physical shield.

  

The modern man has no use for a gun. He doesn’t own one, and he never will.

The modern man cries. He cries often.

If this doesn’t make him depressed, nothing will. Someone who often cries is probably depressed, intractable so. This therapeutically correct version of the modern man represents the latest in metrosexuality. It shows us why men are averse to therapy and also why, when they do go, they are unlikely to sustain any lasting improvement.

The problem is, the modern man is not a man. He is a facsimile, a weak, ineffectual househusband who has good reason to cry, and to cry often. 

  

If we are talking about cognitive treatment, this also means that the effectiveness of the treatment must depend on how well the patient performs the prescribed exercises. The same applies to 12 step programs, where detractors have often noted that a significant number of participants in these programs tend to drop out and to start drinking again.

If we were evaluating a course of medical treatment-- say antibiotic medication-- and if the patient chose not to complete his treatment, we would not say that the treatment did not work. We would think that the outcome was not relevant.

Also, some versions of cognitive therapy suffer from one of the same problems that doomed psychoanalysis: a failure to consider the patient as a something more than a mind. Patients are social beings. They live in social worlds. If they do not know how to navigate those worlds, if they do not know how to conduct themselves with others, if they do not know how to manage themselves and their lives, if they do not have healthy relationship habits… they are likely to fall back into depression.