Does Therapy Work?

The New York Times has nothing to say about Biden family grifting. It has downplayed the results of the Durham investigation, lest it find itself expelled from the Democratic Party, and lest it make Hillary Clinton look bad. We certainly cannot have that.

And yet, the Times has plenty of time and space to devote to the question of therapy. That is, to the question of whether therapy works. 

Given the number of therapists that colleges and postgraduate programs are producing, you would imagine that the mainstream media will defend all of that credentialing. And, mostly it does. 

In an extended report, Times journalist Susan Dominus suggests that research shows that therapy works, but maybe it does not. And she seems to conclude that therapy works when the therapist can connect with a patient, can produce a social connection. As it happens, this has nothing to do with advanced academic training or even self-knowledge. 

Being a child of our age, Dominus suggests that the best therapists are the most empathetic, but that is just a dodge. As the science tells us, the quality is mostly associated with young mothers. When a woman is pregnant the empathy circuits in her brain become more active. Thus, if you want to develop your capacity for empathy, get pregnant.

So, the connection that therapists tout is intrinsic to motherhood. This makes therapy a woman’s world, from which men are largely excluded or demeaned. For some patients this might be just what the doctor ordered. If a patient is having problems navigating the business world, a warm bath of empathy is unlikely to be of much value.

Of course, the research has very little to say about gender differences, but, you cannot have everything.

As for the general confusion about therapy, Dominus sums it up well in this paragraph, recounting her own experience of therapy.

I know therapy provided me comfort, and I believe I developed some self-awareness, which has served me well. But during that phase of my life, I also spent more time than I should have, I’m sure, in a patently unhealthful relationship that my therapist and I endlessly discussed, as if it were a specimen to be dissected rather than discarded.

If this sounds like effective treatment, I have a bridge to sell you. One ought to mention that given the extent of her investment in therapy, Dominus has a special interest in thinking that it was of some use.

She continues, pointing out that for the most part the stigma surrounding therapy has disappeared. People are more than happy to consider themselves to be therapy patients, and that fact, by itself, must count as a reason why some therapies might be more productive than talking to the walls, so to speak.

Over the decades, and especially since the pandemic, the stigma of therapy has faded. It has come to be perceived as a form of important self-care, almost like a gym membership — normalized as a routine, healthful commitment, and clearly worth the many hours and sizable amounts of money invested. In 2021, 42 million adults in the United States sought mental-health care of one form or another, up from 27 million in 2002. Increasingly, Americans have bought into the idea that therapy is one way they can reliably and significantly better their lives.

Dominus explains that many studies, of more or less import, suggest that therapy does help.

Hundreds of clinical trials have now been conducted on various forms of talk therapy, and on the whole, the vast body of research is quite clear: Talk therapy works, which is to say that people who undergo therapy have a higher chance of improving their mental health than those who do not.

And yet, most forms of therapy yield similar results. This suggests that different theories and practices do not in themselves produce better or worse results. I certainly have my doubts about this, but here is her evaluation:

Hash out your childhood with a psychodynamic therapist, write down probabilities of feared outcomes with a cognitive-behavioral therapist, work on your boundaries with an interpersonal therapist — they will all yield equally positive results, found Wampold and others who have replicated his work.

As it happens, much of the research has not affirmed these suspicions. And besides, don’t we all know that self-serving research should not be taken literally.

As is true of much research, studies with less positive or striking results often go unpublished, so the body of scholarly work on therapy may show inflated effects. And researchers who look at different studies or choose different methods of data analysis have generated more conservative findings. Pim Cuijpers, a professor of clinical psychology at Vrije University in Amsterdam, co-wrote a 2021 meta-analysis confirming that therapy was effective in treating depression compared with controls, but he also found that more than half of the patients receiving therapy had little or no benefit and that only a third entered “remission” (meaning their symptoms lessened enough that they no longer met the study’s criteria for depression). Given that the patients were assessed just one to three months after treatment started, Cuijpers said he considered those results “a good success rate,” but he also noted that “more effective treatments are clearly needed” because so many patients did not meaningfully benefit. A blunter assessment of short-term therapies appears in a 2022 paper published by Falk Leichsenring and Christiane Steinert, psychotherapists and researchers affiliated with universities in Germany, who surveyed studies comprising some 650,000 patients suffering from a broad range of mental illnesses. “After more than half a century of research” and “millions of invested funds,” they wrote, the impact that therapy (and medication, for that matter) had on patients’ symptoms was “limited.”

So, therapy has only a limited impact on symptoms. This follows fast on those studies that tout the benefits of therapy. Obviously, if you believe that therapy will heal what ails you, because you read it in the New York Times, there must be something of a placebo effect. You will feel better for having done the right thing, regardless. It gives you something to brag about at cocktail parties.

Dominus concludes that different outcomes seem to derive from the interpersonal skills of therapists themselves. 

The most significant difference in patient outcomes, Wampold says, almost always lies in the skills of the therapist, rather than the techniques they rely on. Hundreds of studies have shown that the strength of the patient-therapist bond — a patient’s sense of safety and alignment with the therapist on how to reach defined goals — is a powerful predictor of how likely that patient is to experience results from therapy. But what distinguishes the therapists most likely to forge those bonds is not intuitive. Wampold says that some of the attributes that would seem most salient — a therapist’s agreeability, years of training, years of experience — do not correlate at all with effectiveness of care.

But, this suggests that the programs producing licensed credentialed therapists are largely a waste of time. Unfortunately, we, as a nation, have invested so much in such programs that we cannot shut them down.

For the past four years, Anderson says, he has been running workshops that aim to train therapists in these various skills. “Can we do it in brief workshops?” he says. “I’m not sure that we can.” Empathy, a capacity for alliance building — these might be innate, elusive, alchemic gifts that are challenging to teach. Anderson believes that people who become therapists tend to have more of those qualities than the general population, but he also referred to a study from the 1970s suggesting that laypeople who naturally have those skills performed nearly as well in therapeutic simulations as trained therapists with Ph.D.s.

And, of course, Dominus does not mention the new studies in resilience, researched by one George Bonnano. Most trauma victims get better without undergoing any therapeutic intervention.

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