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Psychotherapy: Does Therapy Work?

Many people who are considering therapy for their psychological difficulties, may wonder how effective talking about their problems is really going to be… So let’s examine the question: Does therapy work?

What’s Wrong with Talk Therapy?

The concern about whether or not therapy works, might not be assuaged by reading a recent Time Magazine opinion piece, that questions the legitimacy of longer term talk therapy. In the piece, entitled “The Trouble with Talk Therapy”,  neuroscience journalist and author, Maia Szalvitz, argues that most therapists have no clue about the latest and most effective treatments for common psychological problems. Instead they want to “go deep” to uncover unconscious feelings and motivations, which she says, has not been found to be effective in treating problems like Obsessive Compulsive Disorder, Depression, Anxiety, and Post Traumatic Stress.

The problem, she says, is not that effective treatments don’t exist for these problems, but that therapists either don’t know of them, or choose not to make use of them.  She cites Alan Kazdin, who is the former president of the American Psychological Association, for saying that “Most of the treatments used in clinical practice have not been evaluated in research.  Also, many of the treatments that have been well established are not being used.”

As a result, Szalavitz claims, she has a hard time knowing where to refer herself or her friends for effective treatment, for as she concludes, talk therapy has an “evidence” problem…

What’s Wrong with Szalavitz’s and Kazdin’s Argument? 

Psychological distress cannot be separated from who you are as a person:

Szalavitz and Kazdin are asking the right questions, but on the basis of a wrong understanding. Their assumption is that psychological problems are “disorders”, and that “disorders” can be treated like one treats a medical illness. Hence there should be one best treatment for depression, one best treatment for OCD, one best treatment for anxiety, and so forth.

The problem with that understanding is that it is based on ignoring the subjective meaning and function of our psychological distress. What makes a problem psychological is precisely that it involves the life of the person. This means that I can be depressed for different reasons than you and that your obsessions and compulsions can serve a different function in your life than they do in mine. OCD and depression are therefore not phenomena that exist in some objective reality where they can be treated using some standard method that gets applied the same way to each person. Instead they are surface manifestations of underlying psychological conflicts and issues that are highly particular to each individual. If we want to get to the root of the problem, we must therefore make these particular conflicts and issues the real focus of the therapy.

Psychological issues are intertwined, not separate from each other:

Szalavitz and Kazdin also make another mistaken assumption. They believe that problems like anxiety, depression, obsessions, and compulsions exist independently from each other, making it the case that one can focus treatment on a single problem and select the best treatment technique for each problem.

In actuality, however, most people who come to therapy have a variety of psychological issues that cut across identifiable “disorders”. They bring their life to the therapy, not an illness. Any therapist is likely to agree that the longer one works with a client in therapy, the harder it becomes to provide a diagnosis. As the complexity of our understanding of our clients increase, so does the inadequacy of any particular label or diagnosis. People are first and foremost people and as they expand their own understanding of the interconnections between their symptoms and themselves, the need to localize and separate their problems from who they are as people tends to disappear. As the now deceased Dutch psychologist, J.H. Van den Berg, has pointed out, people come as wholes, not as fragments, and one cannot focus on a single area of a person’s life without implicating all the others. One cannot lift the corner of a carpet, without lifting the whole carpet…  

Psychotherapy focuses on subjective truth, not objective knowledge: 

A third mistake Szalavitz and Kazdin make is that they fail to appreciate that there are two different truths and realities in life. Science deals with objective truth and objective reality. It deals with “facts” based on unbiased observations and treats these facts as universal truths rather than contextual truths.

Psychotherapy, however, deals with subjective truth and subjective reality. Subjective truth and subjective reality are not a lesser truth or lesser reality. In fact, our subjective experience is often what is most instrumental in motivating our behaviors.

To illustrate the difference, let me provide an example: If a male client can’t grieve the death of a close friend, this is not because he is objectively incapable of grieving or crying, but may be because he subjectively believes that “real men don’t cry”. This subjective reality, which he may or may not be aware of at the start of the therapy, can explain his lack of ability to grieve. It also provides “evidence” for why he may objectively present as depressed. Natural grief that is being suppressed may turn into a heaviness that cannot be released and may lead to a lack of contact with vital emotions that manifests  as symptoms of depression.

In therapy, however, the client may not initially be aware of this subjective belief, nor would the therapist know of it simply by looking at the client’s objective symptoms. The secret to understanding the client’s depression thus lies in a subjective truth that must be discovered, not in an objective knowledge that can be said to be universally applicable each time somebody shows up as depressed.

Why Psychotherapy Cannot be Standardized… 

What Szalavitz and Kazdin don’t understand is that therapy is not factory work and is not about providing prefabricated treatments of objective problems. It is about understanding the unique subjective causes that motivate and explain surface level symptoms that may look the same, but have widely discrepant reasons for being. This means treating the “person”, not the “disorder”, for the person explains the disorder and not the other way around.

So Back to Our Original Question: Does Therapy Work?

I believe the answer is yes, but it works in a very different way than a coffee maker works to make coffee or an oven toaster works to make toast. It helps people discover their own subjective truths, and not simply to change a behavior. Following Szalavitz’s and Kazdin’s advise is to apply a logic that may very well work in the realm of machines and objective cause and effect, but is very ill suited for the likes of us

About me: I am Rune Moelbak, Ph.D.,  a psychodynamic therapist in Houston, Texas. If you are interested in learning more about how a psychodynamic approach can help you get to the root of your problems, click here.

9 thoughts on “Psychotherapy: Does Therapy Work?”

  1. There is nothing new under the sun! People have been questioning the value of talk therapy since I was in graduate school in the late 1960’s. There it was the behaviorists (CBT folks) versus the psychoanalytic/psychodynamic types. I learned in time that all approaches have value, depending on the kind of challenge being addressed..

    While I think there is some truth to the charge that many therapists are not knowledgeable about newer tools and techniques, it is also true that talk therapy works well when there is a good fit between a competent therapist and a patient with longstanding issues that began early in their family of origin.

    Insurance companies want us to believe in quick fixes for almost everyone, which is sad as it creates unrealistic expectations for people who quit therapy once the insurance stops paying when they would really need a longer duration of therapy to make real progress.

      1. Dr. Moelbak About OCD. I had it. A psychiatrist cured it, using the couch. I wish I had followed through, now I have schizophrenia. He later died. Follow this therapy, and don’t follow through you’ll end up in worse shape like me. I’m also a writer now. Please visit my blog schizophreniarepressioncured.blogspot.com If I were to say there isn’t real hope for us now I’d be dead wrong. Thanks for caring Dr. Moelbak.

  2. Dr. Moelbak makes some excellent points. I would encourage more widespread awareness of the huge 1995 Consumer Reports study on the effectiveness of psychotherapy: http://horan.asu.edu/cpy702readings/seligman/seligman.html
    Consumer Reports found that people benefit substantially from psychotherapy, that longer-term is better than shorter-term, and that no single modality was more effective than another. It appears that good therapists have more in common than not, regardless of their approach. Given that the study was published during the heyday of the HMO movement and was precisely what the insurance companies did NOT want to hear, I can only think it was suppressed. Please share, as it is an essential part of the narrative if we are to understand this issue.

    1. Thanks for the resource, Cheryl. The common factors hypothesis is often denied by researchers and insurance companies because it offers a much more complex picture of change than people would ideally like.

  3. A great analysis here between the objective and the subjective. It’s rather like theory vs practice or how to turn an objective model into a subjective practice. As each client presents in their own unique way, it is more like having a study with an n = 1 and with this any theory can only be seen as a generalisation.

    1. Great distinction, Geoff: The trick is rightly to stay faithful to the specifics of the “here and now” moment which is unique, contextual, interpersonal, and temporal, and to let it unfold without forcing it into a universal framework.

  4. For an opposite point of view and a refreshing anti-dote to our current preoccupation with measurement, take Martin Heidegger’s statement: “If we try to lay hold of the stone’s heaviness in another way, by placing the stone on a balance, we merely bring the heaviness into the form of a calculated weight. This perhaps very precise determination of the stone remains a number, but the weight’s burden has escaped us”.

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