When does psychotherapy work?

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Imagine you’d spent your whole life in therapy. Daphne Merkin, writing in yesterday’s New York Times Magazine, paints a fascinating view of exactly that life. Merkin saw her first shrink as a kid, and then spent the next 45-odd years visiting a series of psychoanalysts, building intense but one-sided relationships over and over again, and at one point even getting married on a shrink’s advice. (She and her husband separated five years later.) Along the way Merkin develops a sense of self-reflection that may seem dizzying to readers who’ve never dropped $100+ on a 45-minute session of therapist time. But while the best part of Merkin’s story is no doubt her reflection on the process, her writing — and her doubts — also beg the question: When does really psychotherapy work?

Merkin writes:

To this day, I’m not sure that I am in possession of substantially greater self-knowledge than someone who has never been inside a therapist’s office. What I do know, aside from the fact that the unconscious plays strange tricks and that the past stalks the present in ways we can’t begin to imagine, is a certain language, a certain style of thinking that, in its capacity for reframing your life story, becomes — how should I put this? — addictive. Projection. Repression. Acting out. Defenses. Secondary compensation. Transference.

The style of thinking may be no surprise. Just as doctors complain that they start to see clinical symptoms in everyday life, with 45 years of training, you’re going to start thinking like a psychoanalyst at least a little bit. The more concerning part is Merkin’s sense that therapy isn’t really curing anything.

Therapy, as Freud himself made clear, is never about finding a cure for what ails you. Its aim [...] was always more modest. Freud described it as an effort to convert “hysterical misery” into “common unhappiness,” which suggests a rather minimalist framework against which to judge progress. There is no absolute goal, no lifetime guarantee, no telling how much therapy is enough therapy, no foolproof way of knowing when you’ve gotten everything out of it that you can and would be better off spending your valuable time and hard-earned money on other pursuits.

All of which raises the question: What exactly is the point?

Merkin does not argue, for the record, that there’s no point — more that the point can be, perhaps, elusive, or that a patient can get lost, unsure what the end point should actually be. She doesn’t spend much time on the clinical evidence for or against psychoanalytic therapy, however. (Hers is a personal essay after all.) But as it turns out, psychotherapy has shown reasonable results in randomized trials to treat both panic disorders and depression (among other conditions).

A typical trial like this takes a group of people willing to undergo therapy, and assigns half of them to treatment and half to some other, non-therapeutic session, like a series of informational meetings. A few weeks or months later, the patients are then assessed for clinical improvement.

Trials are often small, and of course patients can usually figure out pretty quickly whether they’re receiving the real treatment or not. A study a few years back in the American Journal of Psychiatry also suggests that, in trials comparing efficacy of different therapeutic styles, results may be hard to interpret since the therapy styles all overlap so much. (Yes, despite what your therapist tells you). But the bottom line: If you’re considering therapy, or if you’re in therapy and you like it, it would seem there is at least moderate support from clinical evidence that therapy can work. At least, that seems to be the case for short-term treatment programs. The effects of decades-long programs have probably never been tested.

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