"Shrink"-Ing the Mind: Does Psychotherapy Work? Yes. It Depends. What Do You Mean by "Work"?

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WHY BOTHER going to therapy? Can sittins around talking to someone really help anything'? Is it a scare? Are "shrinks" of every ilk--psychiatrists, psychologists, clinical social workers, counselors, addictions specialists, marriage and family therapists, life and wellness coaches, behavior specialists, and all the rest--nothing more than overeducated medicine show charlatans?

Clients often ask me these questions. To answer them, we must define "therapy." It may seem to be 'just like talking to any other person," but therapy is not the same as chatting with your best friend, venting to your spouse, confiding in clergy, or commiserating at happy hour. These conversations may make you feel better, or offer new perspectives, but they do not qualify as therapy. Therapy is different in critical ways. In therapy, the client is motivated to change something in his or her thoughts, emotions, or behaviors; in other conversations, the person may be complaining or wishing someone else would change. It is interesting to note that, in the case of so-called mandatory counseling, the actual client is whatever party has ordered the therapy.

A therapist discerns symptoms of serious emotional distress from situational unhappiness, understands human development across the life span, and has other professional skills. A great many clergy and bartenders have expertise in the human psyche and relationships, but they are not therapists. (However, there is a large number of ordained clergy who are, in fact, also trained psychotherapists.) Therapists should not be confidantes; they are hired to help the client reach his or her goals. A therapist (ideally) does not have ulterior motives, is disinterested, and is not self-serving in the relationship, whereas a spouse may be motivated to appease you, and family members may be invested in the status quo. In therapy, there is a guarantee of confidentiality with few legal exceptions; a friend may confide concerns about you to a third party. So, therapy, as a dialogue, varies in a few very important ways from other supportive, helpful conversations.

Does therapy, as described in its differences from other conversations, work? I propose there are three answers: yes; it depends; and what do you mean by "work"?

It works

The verdict long has been in, and repeated attempts to overturn it fail. Therapy does work. Therapy takes many different forms--from psychoanalysis to psychodrama, it can look (and sound) very different. Yet, there are certain elements--some researchers into the efficacy of therapy call them the four common factors--that occur in every effective form of therapy. These are the client, therapist, hope and optimism, and some sort of therapeutic intervention. Every breed of therapy uses them, whether people are reclining as they amble through a Woody Allen-type monologue or are arranging group members, statue-like, to represent their family structure.

The argument can be made that, to some extent, therapy works too well--so well that attempts by the various schools of therapy to show that their theory and approach are superior to others often are washouts. Writers on the efficacy of therapy have referred to this as the Dodo Bird effect, drawn from Lewis Carroll's Alice in Wonderland, wherein the Dodo Bird asserts that, "All have won, and all must have prizes."

There have been attempts to test various schools of therapy against one another in random controlled trials, much as one might compare painkillers or antibiotics. As numerous researchers have pointed out, differences in basic assumptions between some schools of therapy make direct comparisons of outcomes impractical. It is near impossible to control for differences. There is the conundrum that psychological and social situations are so unique from client to client that a strict comparison cannot be made. It would be impossible for a random controlled trial to take into account external situations such as a fracturing marriage, insomnia, a pending layoff, or a teenage child's perermial defiance's effect on a parent's nerves when the treatment is a strict behavior modification program for something like smoking cessation. …