Less Therapy, Please

It’s nice to see the world catching up with you. It’s nicer to see that your blog’s basic theme has now been more-or-less validated by recent psychiatric research.

So, longtime readers of this blog will feel that this is an old story. And yet, Dr. Samantha Boardman’s essay in the Wall Street Journal dates to yesterday.

Boardman addresses the ubiquitous advice, thrown about with wild abandon, for people with emotional problems. They are told, whether by advice columnists or friendly neighbors, that they should repair to a licensed credentialed professional therapist, to talk about their problems.

To which, Boardman, a psychiatrist herself, responds: Hogwash. Not because therapy cannot sometimes help people, but because therapy often does not work at all. 

So, in a therapy-addled age, where therapy culture rules, people have been led to believe that more therapy will solve their problems. Boardman responds:

But what if I told you that talking to a professional about one’s psychological woes might not be the answer to every problem? Or that there might be times when therapy actually does more harm than good?

Why not? Well, first, not all distress signals pathology. Sometimes we are distressed because our situations are distressing. And, dare I mention, sometimes when our situations are distressing, we are being called upon to deal with the issues, not to numb ourselves to the pain:

First, underlying the blanket recommendations for therapy is the belief that stress of any kind is harmful. This line of thinking fails to recognize the growth that often accompanies challenging experiences. New research from the Youth Development Institute at the University of Georgia found that low to moderate levels of stress can help individuals develop resilience and reduce the risk of developing mental-health disorders such as depression and antisocial behaviors. According to the authors, stressful situations and environments prompt individuals to be resourceful and cognitively flexible, and as a result learn strategies and skills that help them overcome adversity and thrive.

Surely, Boardman is right. We do not want to pathologize normal experiences, experiences of failure, for example:

Reflexively referring to therapy anyone who is going through a rough patch presumes fragility and pathologizes perfectly normal experiences of being human. Sadness, worry, discomfort and anxiety are part of life and not necessarily signs of dysfunction. It’s entirely natural to feel overwhelmed—or even bad—at times. It’s evidence that we’re alive and engaged. The idea that we require psychological treatment to cope with every negative emotion or challenge we encounter represents a particularly noxious strain of toxic positivity. 

And then, another salient point, one that we have been making on this blog since its inception some fifteen years ago. A lot of what passes for therapy is largely ineffective. 

Talking it over, rehashing your problems does not solve your problems. It makes your problems more important and more intractable. It identifies you with your traumas.

Boardman explains:

Second, the therapy-is-the-answer model assumes that all therapy is beneficial. In fact, there is evidence that rehashing what is bothering you can actually worsen symptoms of anxiety and depression. Self-reflection, a cornerstone of many therapeutic interventions, is a slippery slope. If not careful, it can amplify self-focus and aggravate rumination—the clinical term for repetitive negative thoughts about what can, did or will go wrong. If therapy becomes an excuse to vent, and sessions are mostly used as an opportunity to air grievances, maladaptive rationalizations and unhealthy narratives may become even more entrenched.

While well intended, there is no evidence that debriefing interventions actually help. In fact, there is reason to believe that a debriefing session may do more harm than good. It’s possible that asking people to talk about their emotional experience too soon may make them feel even worse. It also can be further traumatizing.   

Who knew? Dare we mention that this effort to wallow in the muck and mire makes the muck and mire into the meaning of your life. And yet, therapy retains its Freudian provenance by holding that not talking about trauma is repressing it, and that we need to remember and recollect all the bad things that have happened to us. 

Boardman offers an example:

He said that when he awoke from a medically induced coma months later, in pain and disfigured, he recalled being angry, upset and deeply sad. A few days later a psychiatrist arrived at his bedside, suggesting they talk about his trauma and asking if he was depressed. What he said next made me cringe. He said psychiatrists need to stop asking people who have been through hell to talk about their trauma and if they are depressed. “Of course we’re f—ing traumatized and depressed,” I recall him saying. How often had I been that psychiatrist, convinced that my clinical interventions were necessary to help someone navigate the unthinkable? The man told us that what he really needed at that time was to be with his friends and family, not a therapist.

As for what really does work, you will not be surprised to learn what it is, because you have heard about most of it here over the years:

When the Harvard T.H. Chan School of Public Health report asked people about stress and what helped them feel strong, regularly spending time outdoors topped the list, followed by spending time on a hobby and exercising regularly. Also cited were getting a good night’s sleep, eating well and spending time with family and friends. Other mood-enhancing boosters were doing something for others, learning something new, doing something creative, meditating and using one’s strengths. Prescription medication and professional help made the list but hovered near the bottom.

The therapy-is-the-answer model also glosses over the social determinants of mental health such as education, the physical environment, safety, employment and social-support networks.

More therapy can’t address social issues that erode well-being.

Would the world really be a happier place if every single person had a therapist? I don’t think so. Therapy can be helpful but we’re leaving a lot on the table if that is the only solution we have. 

Well said, and on point.