It’s virtually a right of passage. At some point in every psychologist’s career, he or she must confront a psychotherapy skeptic. My first opportunity came many years ago when I was seated on an airplane next to a middle-aged gentleman decked out in standard business-traveler attire: a charcoal gray suit, white shirt, and maroon tie. I’m not one for idle mid-flight conversation, but the gentleman was feeling chatty. After clearing the standard where-are-you-traveling-to conversation, he asked what I did for a living.
I told him I was a psychologist.
To which he replied, “Oh! A rent-a-friend.”
His premise was a simple one: Psychotherapists are friends for hire. If you had real friends, you wouldn’t need to pay a therapist. In the intervening half-hour conversation, no matter how hard I tried, I couldn’t convince this otherwise intelligent man that there was more to therapy. He was dead set on the belief that therapy couldn’t possibly work, at least not any better than chatting with an acquaintance.
He’s not alone. Since its inception more than a century ago, slews of smart people have attacked talk therapy. Sometimes the detractors are former clients themselves, reflecting on their particular therapists’ blunders, unethical practices, or lack of skills. Having lived through real and unfortunate situations, these critics make an important point: There’s no excuse for bad therapy. But we don’t judge the field of medicine by the worst doctors or the field of engineering by the worst engineers. Other critics have made more sweeping arguments. An article at Huffington Post, for instance, argues that psychotherapy often only seems to work, not because it actually does, but because people want or expect it to. A Time magazine piece even asserts that, "Psychotherapy doesn’t have an 'image problem': it has an evidence problem.”
Indeed psychotherapy has an image problem. But the evidence of its effectiveness is ample and expanding. Hundreds of studies show that the vast majority of people benefit when they are treated with appropriate psychotherapy. Therapies are studied in much the same way as medications. Researchers recruit a large sample of people suffering from a particular mental disorder—say, Major Depression—and randomly assign some of them to receive a particular type of psychotherapy, while others are assigned to one of several control conditions, possibly including no treatment, a sugar pill, an actual medication, or another comparison therapy. Although the numbers vary from disorder to disorder, studies like these show that therapy helps between 60 and 80 percent of people, as long they’re treated by a competent practitioner with techniques appropriate to their disorders. The studies aren’t perfect, of course, and all research studies are subject to some form of bias, but the convergence of evidence certainly doesn’t support the notion that psychotherapy is ineffective.
So, why do people continue to believe that therapy doesn’t work?
First, some people have a hard time believing that talking can make a difference. We talk all the time and it doesn't necessarily fix our problems. But psychotherapy is very different from the kind of conversations we have with our family members, friends, or colleagues. In fact, conversation might not be the best metaphor for psychotherapy at all. In many ways, therapy is more like teaching and learning. Instead of learning about mathematics or chemistry, however, clients learn about themselves and the tools that can be used to solve their particular problems. An experienced clinical psychologist friend of mine once said that his goal is to teach his clients all of his tricks, giving them the skills to be their own therapist. Anyone who's ever gone to school knows that, when students and teachers put in the necessary effort, education can change people’s lives. So why wouldn't psychotherapy?
A second reason why people doubt that psychotherapy works is that, at one point in time, it probably didn't. In 1952, a skeptical research psychologist by the name of Hans Eysenck wrote a scathing critique of therapy in the Journal of Consulting Psychology. In it, he reviewed the research available in that era, concluding that psychotherapy worked no better than the mere passage of time. The truth is, he was right. Given the state of psychotherapeutic technique at the time, you probably weren't any better off seeing a therapist. But most of the therapies in use today didn't exist six decades ago. After all, Eysenck was writing when physical diseases like polio and tuberculosis were still ravaging the American populace. Healthcare, in general, has come a long way.
The last and perhaps most significant reason that people doubt psychotherapy works is that our society has a cynical streak when it comes to believing in people’s abilities to change. We seem to doubt the ability of human beings to be resilient. People often think that mental illness, trauma, and addictions are destiny—that once you have them, you’re forever doomed to a life of pain and suffering. I noted this in a piece I wrote for Psychology Today a few years ago in response to the crash of a Germanwings Flight 9525, killing 150 people aboard. In this particularly sad case, the crash seemed to be deliberately caused by the co-pilot, Andreas Lubitz, who was determined to commit suicide. In response to this tragedy, voices in the media implied that, because Lubitz had been treated for depression several years earlier, he shouldn't be allowed to pilot a commercial aircraft.
Without a doubt, Lubitz should have been prevented from doing what he did that day, but nearly one in five people suffer from Major Depressive Disorder during their lives. In fact, almost half of Americans will have a mental illness at some point in their lifetimes. Stopping all these people from working in industries like aviation only makes sense if you assume that they simply cannot or will not ever recover. Given what we know about the effectiveness of psychotherapy (not to mention psychiatric medications), this simply isn’t a reasonable assumption.
The biggest difficulty with all of these anti-therapy beliefs is that they can prevent people from getting the care they need. The idea that mental illness is somehow untreatable can understandably make people reluctant to admit their conditions. According to research, people with depression often cite fear about what others will think of them as a barrier to treatment. Moreover, even when people are willing to admit their problems, they’ll be unlikely to seek psychotherapy if they believe it’s ineffective. This is exactly the opposite of what we want as a society.
So, therapists definitely are not rent-a-friends. The man seated next to me on the airplane that day may never change his mind about this. The doubts of a few, however, should not stop the rest of us from getting the care we need and advocating that others do the same. As a psychologist, I’m actually not allowed to provide therapy to my friends. But, if a real friend of mine were suffering from mental illness, I wouldn’t hesitate to advise them to seek therapy—not because they don’t have friends, but because therapy is so much more.
David B. Feldman is a Professor of Counseling Psychology at Santa Clara University and co-author of Supersurvivors: The Surprising Link Between Suffering & Success (HarperCollins). Follow his work at www.facebook.com/davidfeldmanphd.