Psychotherapy Isn't What You Think It is
Psychotherapy Isn't What You Think It is
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As is often the case, an online discussion on X (formerly and during better times referred to as Twitter) resulted in ridiculous statements. Often, this makes sense to me as the people involved are not interested in dialogue but only in the perceived zero-sum status game of social media. Further, those involved were mental health professionals, who, contrary to expectations, are just as prone to emotive declarations and scrambling for status as anyone else. In the end, it generated a great deal of reflection on my part, so all things considered, at least from my view, the experience was beneficial.
The conversation started over a ridiculous article about someone’s experience in mental health therapy that was less than a stellar example of professionalism. After a brief back and forth concerning what is or isn’t to be considered “legitimate” therapy, I received this response:
On the surface, I’m in complete agreement here. Mental health therapists are not paid friends. They should not agree with everything the patient says, nor should they engage in “diagnosing” the patient’s friends, nor, and this quite often rubs patients the wrong way, tell the patient what decisions to make in their lives.
Scratch that surface, and a great deal of it starts getting a lot more uncertain. So much of this opinion depends on the definition of things. People use “friend” to describe people they’ve never met online and rarely have any interaction with. The same word is used for people who engage in activities on everything from casual conversation to sex. To say that the mental health therapist cannot be considered a “friend” is an attempt at demarcating a professional relationship from a personal one in such a way that nobody actually thinks. Also, “agreement” is a slippery slope from mere non-disagreement, a common tactic in therapy where supposedly the professional should be a blank slate, to active declarations of support for the person’s propositions. Concerning “diagnosis,” it is quite easy to separate the practice of diagnosing as a formal process regarding consultation with the Diagnostic and Statistical Manual 5, resulting in digital paperwork placed in one’s electronic health records (EHR) and the casual conversation regarding diagnostic language that people, including professionals, throw around all the time.
This is not meant to be a pedantic exploration. Many of the considerations I mention above are often in mind when I hear from patients about their experience in therapy because I’m well aware that not only do people share stories from their own often myopic perspective, but verbiage is often interpreted through competing and dissonant lenses with a disregard for context. The anger/disgust in the tweet response had nothing to do with considering the patient's perspective and how their experience was being told, but with the perception that the practice of psychotherapy, having now reached the level of sacred in modern society, was being questioned.
So what, then, exactly, is mental health therapy?
A Definition in Search of an Answer
The American Psychological Association (APA) defines psychotherapy as:
Psychotherapy is a collaborative treatment based on the relationship between an individual and a psychologist.
Notice that nothing is said about what happens in the therapeutic space; the definition is entirely about the relationship. In other words, the definition doesn’t tell you what therapy is; it only tells you where it occurs, i.e., within the professional relationship defined through State statute and licensure.
In an attempt to clarify, the APA stipulates that psychotherapy “involves communication between patients and therapists that is intended to help people.” Again, there’s no clarity as to what is happening in the therapeutic space, at least none that would separate it from almost any other conversational space. For instance, you sit down and have a conversation with a lawyer. The person intends to help you. Is that then therapy?
Alright, so perhaps some more clarity is forthcoming? Kind of. Psychotherapy communication is helping the patient by doing three things:
find relief from emotional distress
seek solutions to problems in their lives
modify ways of thinking and acting that are preventing them from working productively
Let’s go back to the lawyer. In communication, your distress should likely be relieved; at least in part, solutions are being advised upon, though, of course, you don’t have to act upon them, and, as in any dialogue, there’s a modification of thinking and acting. Great, lawyers can charge you double because they’re also doing therapy.
Now, an argument can be made and should be made that the simple labeling of actions is often general, where specificity is to be found in the relationship, giving it a clearer definition. Fair. Take the word “advice.” Nobody who should be taken seriously will believe that legal advice, psychological advice, friendly advice, and so on will hold all the same content unless you have the misfortune of having a friend who is a lawyer and a therapist, though even there, they’ll likely stipulate as to what professional persona they’re operating from.
So now we’re back to therapy being determined not by what happens in the professional space but by the fact that it exists every time someone determined by licensure and State statute has entered into a legal relationship with someone then identified as a patient. Unfortunately, this doesn’t help us out either…
Now, the conversation, or whatever you want to call it, started with me pointing out that “legitimate” was doing a lot of work in the person’s disgust over what was being portrayed as therapy. As can be seen from the definitions offered already, anyone using “legit” beyond merely noting the existence of a professional relationship is really just saying they disagree with the content of what is being done in that space. There is no definition of therapy, at least by the organizations that oversee it, that determines what is and isn’t to be done in practice beyond vague generalities.
What makes the above statement so incredible, one echoed by many other therapists, is that the declaration undermines the structure of what determines mental health therapy to begin with. It’s safe to assume that all those apoplectic over critical reflection of their profession would be quite incensed if any random person starts declaring some service they offer as therapy. Instead, what they’re after, is a bit of having their cake and eating it too. They want the power bestowed on them by the State, but they also then want to set aside a narrower set of practices that, not at all coincidentally, aligns with their particular form of practice. This is pure status games, which in the normal course of events would just be humans being, well, human, but in this instance is concerned with effecting the lives of a great many people, fueled by self-serving moralizing.
If licensure “has nothing to do with” the practice of psychotherapy, what exactly does?
Here, we turn to the practice of therapy or what happens in session. For those hoping for any clarity, don’t hold your breath.
A Pox on All Your Houses
There are multiple schools of psychotherapy, from the psychodynamic to the cognitive-behavioral, the emotion-focused to relational-framing, and the behavioral. Without going into the details of each and every school of thought, suffice to say that there are varying differences in the philosophy of all these ideologies about the nature of humanity, how behavioral change occurs, the role and even definition of the mind (the latter being almost always tacit or assumed rather than fully defined), and the nature of reality concerning it being monistic or some form of dualism. When it comes to individual therapists, these questions are almost never fully formulated, not least because philosophy has almost no existence in graduate-level counseling programs but also because many don’t find it all that important. If you’re scratching your head at how a profession, ostensibly about making changes to the human person and, more specifically, the mind, has no consistent definition of said mind, you’re not alone, but that’s another article another time.
Rather than focusing on the, admittedly, more difficult and frustrating explorations of philosophical understanding, therapists often simply focus on particular intervention strategies and outcomes. Of course, the intervention behaviors are themselves based on a host of assumptions concerning the nature of mind, humanity, and change, but questions about that almost never come up. Instead, following the APA, what really matters is the relationship.
Because here’s the central point of psychotherapy: what happens in it, outside of wholesale ethical violations, is almost of no consequence. The efficacy of treatment is largely based on two factors: one, the projected buy-in or belief in the power of therapy by the therapist, and two, the projected buy-in or belief in the power of therapy by the patient. That’s it. When research is done on the efficacy of various intervention strategies, they’re all almost entirely identical in their percentage. Outcomes are about the relationship, hence the utter lack, within offered definitions, of any focus on the content of therapy.
How is that possible? How could wildly different psychotherapy schools, each promoting different ideas concerning the nature of reality, humanity, and relationships, lead to virtually equal outcomes?
Therapy Is Human Connection Given Purpose
There’s a lot to be said about the failures of research in psychotherapy, including the replication crisis, the glaring assumptions that are almost never questioned regarding the nature of the mind and humanity (spoiler: virtually all therapists and researchers claim naturalism but promote some form of dualism in practice), and the bait-and-switch of how the efficacy of therapeutic models is reported. That’s another article. Here, we’ll focus and close on what is actually happening in psychotherapy.
“The goals in therapy are a collaborative effort in which therapist and patient together identify what is distressing to the patient, what the patient would like to change, and what is realistically possible to change in the course of psychotherapy.” -Glen Gabbard
Notice that there’s nothing here unique to psychotherapy that isn’t found in any other professional relationship or, for that matter, many healthy personal relationships. Further, Gabbard allows for a lot of leeway when using the phrase “in the course of psychotherapy.” Now, he’s coming from a psychodynamic perspective, which commonly requires 1-2 sessions every week for upward of 1-2 hours each time, often going on for months or years, so “the course” here is not anything that most people associate with psychotherapy. Beyond it being a financial windfall for the therapist to find the small percentage of people able to afford such “treatment,” the vague definition offered here points to the same issue the APA and the lack of uniqueness concerning outcomes between therapeutic interventions indicates: that psychotherapy is simply the human capacity to find meaning and purpose and direction in relationships combined with the projected authority by those involved.
The uniqueness of psychotherapy isn’t because of anything the therapist, as a therapist, brings to the relationship; it’s instead simply an extension of the human condition: the need to determine meaning and purpose for one’s life within relationships and the human propensity to ascribe agentic power to things we make up. What is unique is what is unique in every relationship: the co-created space that each person involved contributes to from the wellspring of their individual histories, the personal, familial, and educational experiences, and the reflection done on them that each person has participated in within their life.
State statutes and licensure are important, not because they determine the quality of the professional services but because they contribute to the meaning-making and, therefore, the imagination-fueled projectively hoped for influence that the relationship will have. At the end of the day, your therapist isn’t a guru, nor are they offering up secrets of the human condition. Instead, they’re offering a perspective within the structure of a particular form of relationship, one that has been ascribed entirely too much power in the modern world.
Be reflective, critical, and focused on how you want to support your Values because we don’t get to choose whether we’re influenced in our decisions, only, in part, what/who does the influencing.
At the end of the day, you’re the one who has to live your own life.