Bad Therapy

It’s very difficult to assess what goes on in a therapist’s office. Yet, Eleanor Cummins gives it a good go in Wired. And she concludes that therapy is broken.

For the most part, one concurs. The simple fact--  that Cummins inexplicably ignores-- that our nation is awash in psychiatric medication tells us that talk therapy is not doing a very good job of helping people.

And yet, the buzz is unavoidable. As Cummins remarks, we are all being told, day in and day out, to go to therapy, to find a licensed credentialed professional who can help us sort out our emotional issues. Advice columnists and members of the pseudo-intelligentsia keep saying that therapy will solve all of your problems. 

Hamlet told Ophelia, “Get thee to a nunnery.” We are being told, “Get thee to a therapist’s office.” As for which is more salutary, I leave that to your imagination.

This raises another issue, one that Cummins does not quite grasp. How much of the benefit that people report from doing therapy has been produced by cultural expectations. The culture tells you that if you see a therapist you will feel better. If you do not feel better you believe that there must be something really wrong with you, so you happily decide that you must feel better. The relentless push toward therapy does not make you any more effective in conducting your life-- goal that therapy does not acknowledge-- but it manipulates your mind and makes you feel that you must be getting better. If you're not, you still must say that you are, and you must believe it.

This being the case, Cummins is certainly right to point out that our nation is awash in bad therapy. She is certainly wrong to believe that the situation can be improved by government regulation, but she has at least identified a problem.

She opens with a constatation, namely that the ambient marketing campaign is pushing people toward therapy. Funnily enough-- I mention it because today is Sunday-- some research has shown that an hour a week attending religious services will do more for your mental health than will an hour exploring your feelings and fantasies:

An hour a week in a shrink’s office is increasingly treated as a prerequisite for a healthy, happy life. There, we imagine, friends learn new coping skills and enemies realize the errors of their ways. Everyone is “healed.” Therapy has been marketed as a panacea for all kinds of issues, from fixing a bad personality to ending racism. Refusing to seek treatment becomes a red flag, while fluency in “therapy-speak” is all but mandatory.

And yet, therapy, Cummins adds, often sucks:

Unfortunately, as anyone who’s actually tried it can tell you, therapy often sucks.

Anywhere from 50 to 75 percent of people who go to therapy report some benefit—but at least 5 percent of clients get worse as a result of treatment. (For people from marginalized groups, harmful outcomes may be even more common.) The remainder report no clear benefit at all. Plenty of would-be clients go once and, feeling alienated, never return. Others keep trying, even as it becomes clear they aren’t really getting what they need, whatever that is.

Of course, this is self-reported, and might well reflect the ambient discourse, for the reasons I noted above.

Again, Cummins is right to say that bad therapy exists and might even be pervasive.

But the American mental health care system has hardly acknowledged the existence of bad therapy, let alone taken steps to fix the problem. 

As for defining what therapy is and what it is supposed to do, when we try to do so we end up in a muddle:

All psychic healers strive to “clarify symptoms and problems, inspire hope, facilitate experiences of success or mastery, and stir the patient’s emotions,” as Jerome Frank wrote in his 1961 classic Persuasion and Healing. But the fault lines between professional and public conceptions of therapy are numerous.

For example, research suggests that about half of therapy-goers will experience improvement in 15 to 20 sessions. But one study found that the majority of people incorrectly assume they need just six sessions to resolve their issue. Similar gaps in understanding emerge in views on self-disclosure by therapists, the value of negative feedback to therapists, and the purpose of therapy itself.

Of course, this is self-reported. This does not account for the suggestion effect and does not tell us whether or not these patients were on medication.

Worse yet, Cummins notes, correctly, there is no one thing called therapy. She says that there are hundreds of models. If therapy worked well, there would not be hundreds of ways to do it:

And while therapy is commonly discussed as if it were a single entity, there are hundreds of distinct theoretical models currently used, from EMDR to Gestalt to CBT. Depending on whom you ask, at least 20 orientations fly under the banner of psychoanalysis alone. Each provides its own model of the brain or mind, the nature of distress, and the path to healing—in other words, its own value system.

Of course, this leads to the simple fact that assessments of the effectiveness of therapy are often muddled. There is very little credible evidence, Cummins says, demonstrating that therapy really works. That means, works consistently with enough people:

 In fact, very little about contemporary psychotherapy is actually backed by credible evidence. In a meta-review of 70 purported empirically supported treatments, Williams and his colleagues found only 20 percent of the interventions are based on reliable studies. An additional 30 percent were in the “murky middle,” and fully half of the treatments under review didn’t have the evidence their boosters thought they did. 

It seems to come down to the individual therapist. If patient and therapist can get along, if they can relate to each other, if they can form an alliance in order to work on their problems, therapy has a much better chance of success. Naturally, psycho analysts tout the virtue of such an alliance, but the classical orthodox analytic pose precludes connection. If we assume that many patients are suffering from a form of depression, and if we understand that depression involves social isolation, obviously enough, a therapist who can make patients feel less isolated will produce more positive benefits:

To save themselves from analysis paralysis, many therapists fall back on the “common factors,” which suggest that good therapy can be distilled down to empathy, a clear shared goal, positive regard and affirmation, and the like. To date, the so-called “therapeutic alliance” between patient and provider appears to be one of the most important components of successful therapy. Therapy is indeed a “relational art,” and the success (or failure) happens in the unreplicable dynamic between two people. Unfortunately, that insight hasn’t made these alliances any easier to foster.

But building an alliance with a therapist—or failing to do so—is often slow going. Some individuals seem supremely skilled at this work: In a 2003 study, psychologist John Okiishi found that, in a sample of 91 therapists, the top performers enabled their clients to improve 10 times faster than everyone else. But even a supershrink would, inevitably, struggle to help certain people.

Of course, this obscures one of the principal difficulties with therapy. It obsesses about feelings and about feeling feelings. It focuses on dreams and fantasies and tends to ignore real events in everyday life. It emphasizes empathy and compassion and other forms of pathos and ignores the possibility that the patient might undertake to try to solve problems in the real world, rather than to whine about them to a therapist.

Heck, many patients reject suggestions for solving problems, with scorn and derision. Patients demand that their therapists feel their pain and shower them with empathetic understanding. If that is the expectation, produced by the culture, then therapy is not going to work.