Talk Therapy: Who’s on First?

What do people want from therapy? Any solution depends on how the problem is defined, of course. The question you ask determines the answer you get.  We therapists must all assess before we treat.

When they take a history, social workers factor in each person’s life stage and the fit between the person and the environment. The medical community makes symptom-based mental health diagnoses most of which lack scientific validity and reliability. Many of these diagnoses encourage even ordinary people to believe something is wrong with them.

Some mental health diagnoses don’t tell you anything you don’t already know. It’s as if someone were telling you that your child has sorethroatitis.

The pathological perspective has political consequences. Diagnoses imply that your problem lies within you. If so, it’s clearly up to you to fix it.  If the problem lies in your situation or in the environment, on the other hand, at least part of the responsibility for addressing it might fall on society.

We do not know enough yet about the human brain, medically speaking, to diagnose human unhappiness of more than a few sorts. We need to locate the causes and not just catalog the symptoms.  Much mental distress can be treated by improving habits of daily living. This undertaking is less problematic than medical diagnosis. We know how to help people lead healthier lives. We also know how to address their resistance to doing so.

In my experience, whether or not a person has a major mental illness, the chief problem people bring to therapy is that something is keeping them from reaching an important goal. Mental illness might be one of the obstacles that someone needs to surmount, but often it is not, and when it is, it is seldom the only one.

The tendency to see the management of mental illness as the primary goal of therapy usually reflects the concerns of outsiders—friends, family, schools, employers, insurance companies, and even the legal system—who consider the client out of line.

One of my professional mentors, not coincidentally my own therapist for many years, maintains that people need a listener more than anything else. You can’t be a good therapist if you can’t listen. Still, I think people knock on my door because they are stuck. They’ve tried unsuccessfully to solve a problem and don’t know what else to do.

From therapy, people want support, resources, and encouragement—and sometimes also guidance. For starters they want not just listening but also help framing a problem or defining goals. They need to be told not what to do but how to know what to do.

Many therapists believe that people change once they know what they are doing wrong and why. I disagree. Assuming that we can point to a reason, how does anyone know that it is correct? The voice of God does not come booming down from the heavens to say, “You’re right!” In His absence, it is possible to waste a lot of time on speculation.

What good would reasons do anyway? Understanding doesn’t necessarily bring about change. At best reasons reassure us by making things look orderly and understandable. Even if the correct reason were discovered, humans are not rational actors. Knowing something is unhealthy doesn’t guarantee that you will give it up. (Do you drink alcohol or smoke?)

Insight is purely intellectual. To operationalize it you must probe your feelings. It’s not enough to perform an analysis. If you want to replace a bad habit with a better one, you must make sure that the new one fills the same psychological need. People are most likely to look for ways of thinking and acting differently when they see change as a means to a compelling end. Our feelings and our intuition, not our brains, tell all of us what we want. People who heed their brains alone are living in black and white, missing much joy.

Therapists are by definition fixers, a.k.a. control freaks, but there’s a boundary issue lurking here. The life being altered belongs to the client, not the therapist. A well-trained therapist can hear where a person’s energy and passion lie. Only the client can decide what values and priorities to pursue. Books, tests, clinical supervision, and academic degrees don’t make the therapist’s judgment superior to the client’s. The therapist can propose. The client alone can dispose.

We therapists often blame the client for inaction when we see nothing happening. Sometimes we are blind. People often need time to prepare for drastic change. It can help to remember that none of us does anything until we are ready. That’s a good thing.

According to the research, the client’s relationship with the therapist determines success more than anything else. Methods and techniques don’t matter. Cognitive behavioral therapy is touted as a “best practice” for many complaints, but every practitioner does it differently, so how can we tell exactly what’s been effective?

Methods and schools of thought aside, I think everyone wants some of the same things from the therapeutic connection. We all want to believe that our feelings are understandable and reasonable, given the situation. We all want to feel that we are normal and okay. The back and forth of communication between people lets us all know that we are not alone. Much unhappiness stems from silence and isolation.

The client alone can pronounce treatment effective or successful. No one else can judge personal relief or success. Admittedly the measure is qualitative and subjective, but so is the experience of being alive. How long must an outcome last to be valid? Three weeks? Three months? Three years? There is an arbitrary quality to the question. Can we fix the client for life? What would that even mean? The very idea seems the antithesis of continuous personal growth. Isn’t therapy really a form of education, a drawing forth of someone’s potential?

Quantitative outcome measures seem designed to let outside observers substitute their judgment for that of the client. When the principal aim is to help some people control others, are we talking about therapy or merely behavior management?

In our society truth usually comes packaged in words and numbers. Numbers in particular convey a false impression of certainty. In the realm of therapy, though, where so much is ambiguous, numbers often seem irrelevant to the work at hand. Surely it makes sense to weigh qualitative evidence as well as quantitative.

Schools teach children from an early age to rely on logical reasoning, but there are many different ways of knowing. Our bodies have intelligence in places other than just the brain. Much has been written about encouraging people to notice their feelings and trust their intuition. Even if we agreed to rely on quantitative measures that purport to have been statistically validated, how would we know that the research design and the findings had not been distorted to oblige commercial interests with a stake in the published outcomes?

Wouldn’t it make sense to assume that the objective of therapy is not a cure or good behavior but the acquisition of attitudes and skills that will help people cope with adversity down the road? The measure of success would then be not merely subjective well-being but also the ability to apply new skills successfully, now and in the future.

To succeed in our work, we therapists must be consultants and coaches. We must also learn from those who come to see us. We learn to teach, and we teach to learn.