Despairing of Excuses

“There are three kinds of lies: lies, damned lies, and statistics.” -Mark Twain (though he attributes it to Disraeli)

In a candid moment of discouragement one of my best friends asked me, “what is the purpose of psychotherapy?”. Sensing her despondency and smelling a rhetorical trap, I banished as much sunny optimism as possible from my answer and replied, “to render life tolerable.” Not long after this conversation, another of my closest friends made reference to the studies that seem to show that grief counseling does no good and that patients leave therapy no better off than when they started. Sadly, though I had just narrowly escaped a similar trap, all I could muster in response was that advances have certainly been made, that group therapy seems to be the key, and so forth. However, it just struck me how ridiculous these findings are if interpreted as the abject failure of psychotherapies: if I am alive and physically healthy but seek treatment because life is intolerable, only to leave treatment alive and physically healthy, then has life not been rendered tolerable and psychotherapy proven successful by my pessimistic definition? So what I didn’t leave treatment exuberantly happy, tap dancing all the way home! At least I didn’t descend further along my downward spiral towards harming myself, harming others, or succumbing to nihilism. The glib conclusion that psychotherapy is worthless remains a lie, a damned lie, and a steaming pile of statistics!

If your old, beat-up commuter vehicle begins to develop a bad wobble in the alignment, you may begin to worry that this issue will worsen and wear out your tires, other parts, or potentially lead to a cataclysmic accident, but you would not get angry at the mechanic who fixes your alignment for failing to restore your car to its factory condition! The mechanic just wanted to stop your car from further degradation, returning it to a stable condition, while never promising to return it good as new. The magical thing about psychotherapy is that occasionally it can do more than just stop your vehicle from further degradation, but sometimes will remove decades of such damage and send you home good as new or even better!

People love to point out that therapy doesn’t work like polio inoculation, but this is just their despairing of any real excuses for not seeking treatment, as they most likely feel comfortable in depression and like the pleasurable solutions offered by hedonism, nihilism, and the comforts of receiving sympathy, love, and support from family and friends for their “condition.” Some of us even worry that without our despair we would not be “deep;” that we would run out of interesting things to talk about. These same folks usually deny any sort of free will and posit all manner of external coercion to explain their lives, even going to the extent of citing their own genes as such “external” forces. This attitude was even in vogue in many medical circles where it was concluded that “talking cures” are not serious treatments and that only drugs could solve problems with the brain and character, which were thought to be determined by genes. After Eric Kandel’s research on memory, which garnered him a Nobel prize in 2000, this strategy of denying freedom has become radically obsolete. “There is no longer any doubt,” Kandel writes, “that psychotherapy can result in detectable changes in the brain.”

Kandel has shown that as we learn our individual neurons alter their structure and strengthen the synaptic connections between them; that they actually change their anatomical shape and number of synaptic connections when we form long-term memories. Furthermore, he showed that short-term memories are turned into long-term memories when the protein ‘kinase A’ moves from the body of the neuron into the nucleus where the genes are stored, where it proceeds to turn on the gene responsible for making another protein that alters the structure of the nerve ending, allowing  new connections to be grown between neurons. Our genes have more than a “template function,” but also include a “transcription function,” which is influenced by what we think and do. So much for genetic determinism! Where does this leave my answer about the purpose of psychotherapy? Mark Solms and Oliver Turnbull make a great addition:

The aim of the talking cure…from the neurobiological point of view [is] to extend the functional sphere of influence of the prefrontal lobes.

Studies of depressed patients have shown that a short-term treatment that is partially based on the theoretical work of John Bowlby and Harry Stack Sullivan demonstrated that prefrontal brain activity normalized after treatment. Of particular importance is the right orbitofrontal cortex (just behind your right eye); a part of the prefrontal cortex important for recognizing and regulating emotions and relationships. A more recent fMRI study of patients with anxiety and panic disorders found that pscyhoanalytic psychotherapy strengthened the prefrontal cortex’s ability to regulate the limbic system, which became abnormally activated by potentially threatening stimuli for these patients.

So be careful when applying pessimism to growing fields like psychology and beware of applying statistical conclusions to your individual case. I don’t care if treatment shows statistically to help only one out of a hundred patients, for I might be that one. If psychotherapy doesn’t make many people happy “on average”, this doesn’t mean that an above-average patient or an above-average therapist can’t affect a sea-change or psychological breakthrough. Furthermore, as much as I love the Twain quote that starts this post, the simple fact is that most studies show that psychotherapy is incredibly beneficial on average. Still, don’t ever disregard the exceptions. Ramachandran once responded to the claim that the remarkable exceptions to the human norm that he explores don’t prove anything by joking that (and I paraphrase) “your telling me that if I can show you a talking elephant that this single aberration isn’t statistically significant?” Beware that cynicism can be its own form of naivete, for, as Schopenhauer reminds us, it is highly unlikely that the highly unlikely never happens!

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2 Responses to Despairing of Excuses

  1. Salila says:

    I don’t think psychotherapy per se can MAKE anyone happy on average or non.. I actually would feel rather intimidated (and I am because I see myself going it) if anything, including psychotherapy, had that magical power to MAKE me anything.. It even feels scary to consider that even the one in a hundred might be getting his cortex clay molded (dare I say programmed) by a psychotherapist.. I would rather like the therapist to make space for me to COME OUT be my sand box play partner.. where I could actually feel what I am about and then, through that, let me reshape my own neuronal clay, in which case I would feel fully responsible for it (..and empowered).. Otherwise, I feel like the patient is there for the therapist .. (you know, there are some mechanics who fix the car juuust the way and juuust enough for you to keep coming back to them) I think people actually don’t mind, as some prefer a polio inoculation kind of treatment.. or to believe in one, perhaps even at the expense of the result being just.. tolerable.. which is intolerable to me.. All due respect to the one in a one hundred who have a sand box partner and who actually leave without turning their therapist into a Prozac pill ..

    • Salila, I couldn’t agree more. The expectation that a pill-like cure is available or on offer by the field of psychology is deeply harmful to successful therapy, but a mature person shouldn’t even want something invasive like this! Roy Baumeister pointed out in his book “Will Power” that the great insights that a psychotherapist might give a patient (which is the only “pill-like” aspect to psychotherapy) are no longer very helpful to the modern patient because their primary problem is a lack of individual initiative, will-power, courage, confidence, and so forth to actually carry out what the insight would recommend. Freud’s solutions worked very well for the Victorian, repressed man, because his problem is too much will-power, too much control…give him an ounce of insight and he will run with it! Give a modern patient the same great insight and he will stare longingly at you and say “great, thanks…so why don’t I feel any better? How do I do anything about this?” What a strange paradox for the psychotherapist: he has to simultaneously tell the patient that he needs to take responsibility for his own well-being and psychological growth/health, while at the same time telling him that he is suffering and unhappy because of things largely out of his control (genetics, early childhood/family life, the facts of life/death, etc). The best therapist needs to be a philosopher of Free Will…or at least have read Rollo May’s “Freedom and Destiny.”

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