When You Don't Know Where to Turn / A Self-Diagnosing Guide to Counseling and Therapy

by Steven J. Bartlett

We must grab the bull by the horns. Thousands upon thousands of people continue to enter psychotherapy. How long would any service last if it failed to serve the needs of its market? It is tempting to suppose that something constructive, at least sometimes, happens as a result of psychotherapy to justify the time, expense, and faith of clients. Or is their faith really misplaced?

One of the most outspoken critics of psychotherapy is psychiatrist Thomas Szasz. His views are an unlikely source for a defense of psychotherapy, but its defense, oddly enough, can be found there.

Szasz argues that psychology has been influenced by the disease model that dominates medicine. Medicine bases its conception of treatment on the fact that there are diseases (or injuries) that can be helped by means of drugs or surgery. Illnesses and injuries are treatable conditions. Treatment is applied from outside by the physician, and the condition, when the treatment is effective, improves.

But psychiatry goes a step too far when it claims that people who become emotionally helpless, hopeless, lonely, or agitated are actually sick. Szasz claims that they are not sick; they are helpless, hopeless, lonely, or agitated. These are not "illnesses" but, rather, some of the tragic conditions of life. They are problems of living. For Szasz—and for therapists like Viktor Frankl and Alfred Adler—psychological problems resemble "moral problems" much more than they do "physical diseases." They involve discouragement, loss of morale, loss of moral courage. They are states of demoralization.

Now, demoralization is not a treatable condition—not, certainly, in the medical sense. You cannot apply treatment from without and expect that the patient will get better. The situation is much more complex than this. The patient—let's shift at this point to calling him or her the client—is much more actively involved in the process of psychotherapy than is a patient in medicine. A woman who contracts pneumonia can be cured with antibiotics while she lies in bed watching television or sleeping. But an emotionally troubled woman—who has had a succession of unhappy marriages, who has lost job after job, whose personality is offensive to others, who has a low sense of self-worth, and who has lost a sense of meaning and direction in life—cannot be cured while she lies in bed and is treated with appropriate medication. "Effective treatment" just isn't possible; too much is up to the client herself.

Basically, this is why studies of the effectiveness of psychotherapy have generally led to discouraging results. Most psychological conditions (there are exceptions, as we will see) are not, at least at present, treatable in the medical sense. To combat them requires of the client a great deal of his or her own effort and even exertion. They require self-discipline, moral courage, faith in oneself—all the things emotional distress tends to undermine. No approach to psychotherapy can itself be medically effective in treating conditions like these. Somehow, the client must reach a point where he can lift himself by the bootstraps. He can be encouraged by the therapist, he can be reasoned with, he can be manipulated in strategic therapeutic ways, the therapist can exhort him to be rational, but the focus always comes back to the client. Is he or she motivated to learn how to change? Is he or she an "effective learner"—that is, a "good student"?

The hundreds of attempts to evaluate the effectiveness of approaches to psychotherapy have, incredibly, left out this essential reference to the clients themselves: What kind of people are they? What encourages them? What can act as a source for their motivation, for the strength they have lost?

Ironically, the answer to these questions also lies unwittingly in the hands of psychotherapy's harshest critics.

The worst blow to fall on the shoulders of psychotherapists was dealt by placebo studies. Experiments were designed that would convince a group of emotionally troubled clients that taking a pink pill (in reality, a sugar-filled placebo) would reduce their symptoms. In fact, their symptoms were, in general, reduced, and often by as much as treatment in formal psychotherapy. This fact has been interpreted by most therapists to mean that psychotherapy must therefore have been ineffective. If a pink and useless pill could equal the effects of therapy, then therapy was equally useless.

But this involved a huge oversight and a mistake in logic. The therapy did work, as did the placebo. But why?