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Beware Psychotherapy That Works

Much has been written about the problems caused by therapy when it fails. Less discussed are the problems it can cause when it succeeds.

· 11 min read
Beware Psychotherapy That Works
Photo by Julia Taubitz on Unsplash

Historically, the knock on psychotherapy has been that it’s a pseudoscience perpetrated by overeducated life coaches. Their insights are so arbitrary and insubstantial that they can render diametric judgments under oath about the risks posed to society by the same accused serial killer.

Jaundiced perceptions aside, therapy’s role in modern life is no joke. America is a nation increasingly surrendering itself to the therapist’s couch. Forty-one million American adults sought therapy in 2020–21 alone, which was peak-COVID. Nevertheless, that figure reflects a therapy juggernaut not out of line with trends before or since. Nearly a quarter of America has been in therapy in the past 12 months, according to Gallup polling. It is nigh impossible to consume any form of media without being bombarded with PSAs that herd people into overcrowded therapy waiting rooms the way Japan’s oshiya herd people into jam-packed subway cars.

Obviously, then, psychology’s efficacy is a matter of some importance. Yet this is where we encounter an irony—it may be that psychotherapy is most dangerous when it works.

Before we address the problems with therapy-gone-right, let’s recap the increasingly well-documented problems with therapy-gone-wrong.

A piece on therapy’s iatrogenic harms puts it like this: “The common belief that ‘talking can’t hurt’ is not true.” (See the National Institute of Health’s summary here.) Although the American Psychiatric Association claims that roughly three-quarters of patients report “some benefit,” in one major study, one in 20 patients reported a significant long-term adverse effect. There is evidence that among people with only mild complaints, therapy can actually create new depressives. The title of a major feature on the subject in Wired promises to explain “Why Therapy Is Broken.”

Anecdotal horror stories abound on the likes of the Very Bad Therapy podcast. Not a shock, considering the iffy science behind many of the realm’s standard interventions. One meta-review of 70 purported best-practice treatments concluded that only one-fifth of the approaches were based on reliable studies. Therapies long in use are now being repudiated as harmful. Here’s a priceless passage from an article in Aeon titled “Bad Therapy”:

A clear example is “cathartic interventions” that promise relief by directing people to express difficult emotions in a purge-like manner, such as punching pillows when angry and yelling as loudly as possible when distressed. Such practices ... lend themselves to the rising popularity of “smash rooms” in which people pay to “therapeutically” destroy items such as televisions and toasters with a hammer. ... [C]opious research indicates that, as a means of dealing with difficult emotions, these approaches have the opposite of the intended therapeutic effect, actually increasing anger and distress. Simply put, teaching people to punch when angered leads to more anger and punching.

At the opposite end of the spectrum there are problems with one of the buzzword concepts of the new millennium, mindfulness: For all its supposedly calming effects, the tactic may end up making people mindful of all the wrong things.

In an interview with Psych Education, clinical psychologist Michael Linden also voiced reservations about the common technique known as “exposure treatment,” frequently employed in combating phobias and generalized anxiety. “We want to have the patient confront anxiety in order then to learn how to cope with anxiety,” said Linden. “To get to that end, you have to expose the patient to situations which are frightening. ... I’ve seen dozens of patients who after that have more anxiety than before.”

“Many people will get worse in therapy,” Los Angeles therapist Patrick Lockwood tells me. He cites three primary reasons: “First, the clinician is incompetent. Then there’s counter-transference,” which occurs when the therapist drags his own issues into the sessions and responds to his patient through that lens. Finally says Lockwood, “Therapy may trap people in a victim-state.”

As Linden also explains, a psychotherapist “starts asking you how you feel about your mother and your father and your spouse, and so on and so forth. And just by talking about all the negative events which you experienced in your life ... you get the feeling your life has been possibly a whole mess.” And while group therapy has been hailed for its ability to provide patients with the comfort of knowing they’re not alone in their struggles, patients who hear a room full of similar complaints may grow overwhelmed and demoralized. “There is a kind of infection risk,” according to Linden.

The rise of app-based (virtual) healthcare, such as BetterHelp and Talkspace, has only made the overall therapy theater less centralized and governable and harder for untutored patients to navigate, while further frustrating valid assessments of outcomes.

Even when intensive therapy is finished and people are deemed ready to return to their normal lives, there can be hiccups. Seems that merely giving institutionalized patients discharge information can backfire: In a 2001 Scottish study of 114 hospitalized schizophrenics about to be released, half were shown a video on coping with schizophrenia. They later proved to be four times more likely to have contemplated suicide than their 57 peers who weren’t shown the video.

And yet, as bad as therapy may be when it fails, there is no discounting its possible dangers when it succeeds.

In the 1990s, when assertiveness training was all the rage, a joke circulated about how you could tell if total strangers were alumni of such programs. They were the ones in restaurants who demanded a different table from the one the hostess selected and then sent back their food at least once. The training “worked” for them in tight focus—but how the people in their orbit felt about it was another matter. Graduates of such training were bracketed as rude, difficult, demanding, opinionated, and aggressive.

By definition, psychotherapy lacks a social conscience. It does not concern itself with building a better society. Rather, psychology’s province is to equip you with the emotional skills to get what you want out of life. It promotes a “healthy selfishness” rooted in identifying and meeting your needs. (In prelude, psychotherapy must first help you overcome the fear that it’s self-indulgent to assign primacy to your “internal world.”)

Facilitating such goals is a canny new vocabulary as well as a conception of “boundaries” that fuels self-interested behavior. At first blush, this delineation of boundaries may seem reasonable and innocuous. But the solipsistic timbre of the broader discussion of such points suggests that it’s natural and even healthy for your engagement with others to be about your expectations, your wants, your sense of agency, and the validation that you reap from such interactions.

There’s also the validation you receive during therapy itself. Two of the realm’s canonical watchwords are affirmation and empathy, neither of which evokes a climate of candid appraisal. From the popular site Open Counseling: “To be good at what they do, therapists must avoid sitting in judgment of any of their clients.” Psychology Today observes that “unconditional positive regard is considered to be a common factor in mental health treatment.” The only exception is the therapist’s duty to report a patient perceived as an imminent danger to a specific third party.

More cynically put, a patient’s value and right to fulfillment are taken as givens, regardless of whether the patient has such value and/or if his wishes are deserving of fulfillment. The fly in this ointment should be evident. Even within the industry, critics recognize the risk of affirming self-serving (if not delusional) narratives that patients spin in projecting responsibility for their problems. From the above-linked piece in PT:

Affirming the cause of the feelings (“I feel mad because people do not always do what I want”) may reinforce false beliefs in the client and therefore perpetuate a continuation of such unhealthy behaviors. It may reinforce the story the client is telling the self of how others are always wrong and how the self is always right.

The simplest tics on a therapist’s part play a role here. A mumbled “uh-huh” or “I see,” or the subtlest of nods, may lead a patient recounting dubious behavior to think he’s receiving affirmation. This is not mere theory. Studies have found that psychologists end up affirming behaviors and outlooks that would be judged unambiguously inappropriate by any normal standards.

In the above piece for PT, therapist Robert Enright writes of a client whose broadsides against his wife’s “intolerable” behavior had been reinforced by other therapists before Enright decided that the patient sought justification for his own boorish treatment of his wife and permission to continue same. Under such circumstances, individual therapy may weaken marriages. As Rebecca Fishbein observes in Bustle, “Critics have noted that personal relationships require a touch more compassion than some of these therapeutic blueprints offer.”

Therapy’s collaborative, nonjudgmental ethos is such that patients come to expect to be coddled. In this way, psychotherapy can become a kind of professionally sanctioned ego trip. Though Lockwood insists that good therapists take a more balanced, nuanced approach to their craft, he concedes, “I would say half the patients I see come in with the life coach expectations.”

The effect is magnified, of course, in patients who are narcissists to begin with. This is no trifling matter, either, because by every measure, America since the advent of the self-esteem movement has been mass-producing narcissists at an astonishing pace. Even if not all would meet the formal DSM criteria for the trait, we are at minimum awash today in the sorts of obsessively self-absorbed types who populated Seinfeld. (In 2019, the New York Times published an interesting piece exploring this phenomenon.)

Rather than going into therapy with the goal of improving themselves or their relationships, narcissists are among a cohort of people with “secret agendas,” writes Jeffrey Kottler in On Being a Therapist. They crave yet another audience for their grandiosity, or—being nonpareil manipulators—seek tools that enable them to better enforce their will on those around them. In an anecdotal but grueling account, one woman explains how therapy worsened sociopathic tendencies in her lover. “A lot of people believe everything can be cured,” says Lockwood, “but there’s no cure for narcissism.”

This brings us to a key mile marker in the therapy patient’s journey of self-love: getting you past what’s “blocking you.” This is where the rightful interests of your spouse, kids, parents, boss, or others to whom you’ve “surrendered authority” are reframed as stop-strips on the road to your personal paradise.

(Quick personal aside: When I decided to devote myself to writing, I asked a therapist about reconciling my newfound ambitions with the unvarnished disapproval of my wife and my father, both of whom insisted I’d be stupid to walk away from my lucrative sales career. She replied, “Consider all factors and feedback, but in the end, the decision about your path to fulfillment is yours to make, isn’t it? And then they’re responsible for processing what you decide.” After consulting their own therapists, no doubt.)

From the homepage of a New Age-inflected therapy practice called the Love Therapy Center:

When you love and accept yourself unconditionally, your life starts to blossom organically. That’s what we set out to do with Love Therapy. Our goal is to help you remove those recurring patterns that keep you tethered to behaviors that no longer serve you in the present moment.

If this sounds likes something you’d expect to hear on an Oprah rerun, it’s because the distinctions between pop-psychology and the more formal kind are blurring, with the latter today importing mantras that emerged in its misbegotten stepchild, the self-help movement.

So, suppose both your aging wife and rote engineering job are part and parcel of those “recurring patterns that keep you tethered to behaviors that no longer serve you in the present moment,” and you “remove” them in order to move to Sedona to paint still life with lizards. Your children thus become the collateral damage of your epiphanies. Linden’s book Risks and Side Effects of Psychotherapy describes patients who became so focused on unburdening themselves of blocks that they began to struggle with “coping at work and at home.” They did indeed separate from partners, resign from jobs and/or break off contact with family and friends.

Today’s “empowering” therapy celebrates a kind of a nouveau Sartre-meets-Tolle existentialism wherein the patient—a perpetual tabula rosa inhabiting an ever-unfolding Now—is entitled to redefine himself free of higher powers, existing obligations, and even the guilt/shame contemplated in existentialism’s own “Other look.”

All of which further decreases the supply of America’s rarest latter-day commodity: adults in the room. That is, people imbued with a grown-up’s long view and the understanding that not every hedonistic impulse was meant to be indulged in real time. In contrast, personal-growth therapy cultivates the puerile forever-children that Steven Mintz labels “kidults.” Adulthood, writes Mintz, is about “maturity, caring, responsibility, reliability, and experience. ... Adults live not for themselves alone, but for those who depend on them, whether these are their children, a partner, aging parents, friends, or co-workers. ... These responsibilities make the lives of adults more stressful and demanding than at any other stage of life.”

At the same time, the adult realizes that because these stressful, demanding duties lay the groundwork for steady-state fulfillment, he is ill-advised to skirt such duties in order to simply “choose happy!” Popular therapies can upend the social-emotional growth envisioned in the famous Piaget/Kohlberg model of human development, reframing a reversion to Stage 1—“avoid punishment; seek rewards”—as the full moral agency envisioned in Stage 3.

The most eyebrow-raising trend in modern counseling might be termed ideological therapy, wherein social justice bleeds into psychology (as it seems to bleed into everything these days). Members of this counseling camp vow to help members of this or that identity group cope with racism, sexism, or other grievance-based identitarian concerns. This, of course, presupposes that society is patriarchal, racist, and/or otherwise riven, and that the need for change resides structurally in society and not in the mind of the patient.

In this instance, therapy not only lacks a social conscience, but actively sells the message that society is the oppressive root of all evil. Aside from undermining cohesion by reinforcing subjective feelings that fall under the umbrella of “your truth,” this approach reduces patients to generic avatars. How can a psychotherapist function as a true diagnostician if the diagnosis is an all-purpose prior: society is unjust, men are pigs, whiteness is pathological?

This kind of counseling, says Lockwood, “can reinforce maladaptive beliefs or cognitive distortions, or both.” As he points out, the skilled therapist challenges unproductive beliefs that may be needlessly playing havoc with a patient’s life, but “a therapist who shares the patient’s basic complaints is not going to take that step.” (This is a textbook case of the counter-transference aforementioned.) Instead of guiding the patient toward more productive individualized behaviors, therapist and patient scapegoat forces beyond the patient’s control.

Academic psychologist and PT contributor Matt Grawitch is more direct. The minute therapists “put their own ideological biases ahead of the client, they become activists, not therapists,” he tells me. In the process, they do their patient a disservice. Are you better off acquiring the coping skills to deal with the giant rabbit that visits your room at night ... or being led on a process of discovery that reveals it to be an illusion?

For some therapists, the commitment to identity über alles is such that they will turn away patients who fail to subscribe to their grim intersectional worldview. A recent Wall Street Journal piece describes how an abiding commitment to “anti-racism” on the part of these therapists transmutes into a virulent discrimination expressed as the familiar Hitlerizing of patients perceived as unaligned with progressive beliefs.

It’s too early to gauge psychotherapy’s ultimate role in America’s future, for better or worse. We’ve done our best here to look at the implications of what research there is, but the compilation of Big Data on the field is ongoing. It would therefore be a leap at this juncture to insist that therapy has caused (or meaningfully exacerbated) America’s manifest woes. And clearly therapy has shown its usefulness in crisis interventions on behalf of those in emotional extremis.

Just as clearly, though, in a more prophylactic sense, the ubiquity of therapy hasn’t exactly made America an emotional Canaan. Suicides continue to spike. Illicit drug use is a national emergency. Self-reported anxiety and depression are at an all-time high. As is social polarization. Even the divorce rate, after decades of moderating, is ticking mildly back up again.

America is lonely and vexed; we feel disconnected from each other. To believe that psychotherapy is working as advertised would require us to believe that the nation’s unprecedented mental-health challenges would be much worse were it not for therapy. That seems a stretch.

And yet the sentiment is ubiquitous: We all need therapy. You’ll find article after article after article that says this explicitly. The media champion the notion daily. It’s considered poor form in serious journalism to leave readers with a question, but an exemption seems warranted here. Is it possible for a nation of 330 million fully optimized Is to also function as a fully optimized We?

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