Coming of Age on Zoloft (21 page)

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| Flight of the Dodo Bird: Evaluating Therapy

I
enjoyed therapy immensely. I came away from each session feeling better, or at the very least, interestingly different, from the way I had going in. Over time I could sense myself growing. I developed new ways of seeing the world, and the new faculties allowed me to respond to life in ways that I’d never known possible.

But is psychotherapy more than a pleasant pastime for people who like to talk about feelings? When it comes to treating depression and other specific mental problems, do the “talking therapies” work?

There is quite a bit of evidence suggesting that they do. Though mental well-being is, much like mental illness, difficult to quantify, decades of studies of various kinds of talk-based psychotherapies all point to the basic conclusion that psychotherapy helps people.
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Specifically, about three-quarters of patients who do talk therapy show improvement on some concrete measure:
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diminished symptoms, greater length of time between episodes, or a subjective feeling that the problem has decreased.
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Therapy has been shown to be particularly effective when the therapist is an expert practitioner with a sure grasp of his technique (a mental health specialist of any kind is better than a family doctor)
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and when the therapist and the patient have a trusting relationship.
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In fact, research shows that the two most critical factors determining the success of a psychotherapy in any given case are the quality of the patient’s rapport with the therapist, and the patient’s and therapist’s trust in the framework being used. These positive expectations matter much more than the particular approach you might select. Psychodynamic therapy, cognitive-behavioral therapy, interpersonal therapy, family therapy: all can be effective. If you like your therapist and believe that her brand of therapy can help you, it probably will.
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The fact that a caring practitioner and a motivated patient are more important predictors of success than the actual theoretical underpinnings of the work they do was first discovered in 1936 by a psychologist named Saul Rosenzweig. Attempting to answer the seemingly straightforward question of what type of psychotherapy works best, Rosenzweig collected all the research available to him and arrived at his surprising conclusion—they all worked equally well. He called the phenomenon “the dodo bird effect,” after a scene in
Alice in Wonderland
in which a dodo bird judges a foot race that has no start or finish line; contestants run around randomly, and the dodo bird ends the race by declaring, “Everyone has won, and all must have prizes!” Rosenzweig’s work has been updated many times throughout the years, always with the same basic results.
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In the mid-1990s, the dodo bird effect got some real-life backup from a survey of 2,900 mental health ser-vice users conducted by
Consumer Reports
, the largest of its kind ever undertaken. Respondents who received psychotherapy rated their experiences with it subjectively: almost all reported that therapy had been a help to them, and that they’d made progress toward resolving the problems that brought them to treatment in the first place.
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The type of therapy was not important, but the duration mattered; the longer the time people had stayed in therapy, the better their results.
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Consumer Reports
called the survey “convincing evidence that therapy can make an important difference,”
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though critics have blasted the study for its selection bias, alleging that of course people who had a good experience would be motivated to crow about it.
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The dodo bird theory makes some people crazy. They want the efficacy of therapy to come down to something more standardizable than an ineffable bond between the therapist and the patient. Depending on your point of view, the dodo bird finding can be either a beautiful statement on the many possible paths to recovery, or a frustrating indication that all psychological techniques are equal parts mumbo jumbo, and that we may never satisfyingly separate placebo effects from real ones in this realm. Personally, the theory doesn’t surprise or threaten me. Certainly, the desire to be able to quantify the effects of therapy makes sense. But after my work with John, the idea that the therapist-patient bond and a mutual allegiance to the project are of utmost importance seemed only natural—and to wish for a way to distinguish between the content of the work and its human qualities struck me as both understandable and almost obtusely beside the point.

The type of therapy John was practicing is what’s known as “psychodynamic psychotherapy.” It’s a form that evolved out of psychoanalysis as it was developed by Freud; in turn, psychodynamic therapy forms the basis for many other talk therapies that are practiced today. The basic belief informing psychoanalysis, which also finds expression in all the therapies descending from it, was that much of our mental lives are subconscious—that we’re all guided in our actions by motivations that remain partly secret to us.
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The psychoanalyst’s job was to use careful listening and interpretation to help bring the analysand’s hidden conflicts and disowned feelings to her awareness. Making them available for conscious examination would allow the patient to begin the sometimes arduous process of personal change.

Psychodynamic therapy is less intensive than psychoanalysis, and more casual: patients are usually seen once or twice a week, rather than four or five times, and they sit face-to-face with the therapist instead of reclining on a couch. But it shares several of the tenets of analysis, including the idea that transference—the feelings of the patient for the analyst, and vice versa—is key to the treatment. The psychodynamic approach is based on the idea that people are formed by their personal histories, that those histories create patterns of relating to the self and other people, and that the resulting patterns can become the cause of suffering or maladaptation. When these patterns arise in the transference between the therapist and the patient, they can be noticed, studied, and worked on. Even the name “psychodynamic therapy” is a nod to the importance of these patterns. A “dynamic” is a structured, repeating unit of interaction and feeling, one tiny article in what the anthropologist T. M. Luhrmann called “the grammar of a particular person’s emotions.”
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Psychodynamic therapy also shares with analysis a belief in the importance of emotion in the therapeutic encounter. It’s not enough that the therapist helps the patient
understand
her problems; for real change to take place, the patient must be made to
feel
them, right there in the consultation room.
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(As Freud once explained in a letter to Jung, part of the importance of transference is that it gives therapy the emotional charge that makes it function: “Where it is lacking, the patient does not make the effort or does not listen.”
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) Finally, like analysts, psychodynamic therapists are expected to observe certain restrictions on their behavior. Therapists are not to give direct advice, not to share many personal details about themselves, and not to introduce the mutual obligations that characterize friendship.
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Counterintuitively, the restrictions of this “asymmetrical” relationship allow for the development of the unique form of intimacy that is necessary for the work.

But psychodynamic therapy isn’t the only or even, right now, the most popular talking therapy going. These days, that distinction belongs to cognitive-behavioral therapy, or CBT, a modality invented in the 1960s by an American psychiatrist named Aaron Beck.
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CBT is a short-term therapy, often designed to be completed in just twelve sessions, and it is highly “manualized,”
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meaning that it follows procedures that are standardized and written out in detail; the idea is that one practitioner should be able to deliver CBT pretty much the same way as any other. In treatment, the therapist and the patient work together to identify the patient’s dysfunctional beliefs, or “cognitive distortions,” and then they work on concrete techniques to substitute more accurate thoughts and adaptive behaviors, which the patient practices outside of the office.

Because it is highly manualized, CBT is easier to study than many other forms of talk therapy. Indeed, when Aaron Beck designed CBT he was partly motivated by the goal of creating a psychotherapy whose effects could be empirically measured and validated.
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This has led to a bit of a catch-22 situation. CBT is widely hailed as the psychotherapy “most supported by research,” but it’s also far and away the therapy on which the most research is available: 90 percent of controlled clinical trials of talk therapies look at CBT.
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Those clinical studies do show CBT to be effective, often nearly as effective as medication, at treating a host of psychological ailments, including depression. The claim that CBT is scientifically validated, while other talk-therapy modalities aren’t, glosses over the fact that other kinds of therapy haven’t been subjected to the same kinds of rigorous scrutiny. But it’s a claim that holds great appeal for insurance companies, which appreciate the idea of a clinically supported therapy that can accomplish in a dozen sessions what other therapies claimed to be able to do in an open-ended year or two.

As it happens, I had some CBT back in college, during sophomore year, when I was living in a house with Jeff and three other roommates, taking Wellbutrin, and feeling in need of a psychic tune-up. The practitioner was a therapist at the college health center. He assigned me a book—
Feeling Good
, by David D. Burns, MD, one of the standard texts in the field—and we worked through it together. I completed the homework assignments that CBT is known for: I made lists of my negative thoughts, identified the cognitive distortions associated with them, and came up with new, nondistorted thoughts or actions to take their place. My roommates had a record player in the house that year, and a few crates of LPs that Jeff had imported from his parents’ garage. We often sat up until late in the night, listening to records, drinking cheap beer, and talking. Once or twice the guy who lived next door in the duplex, and who had a small daughter, would bang on the wall for us to turn it down. Gradually I became preoccupied with the idea that even when he wasn’t banging, the neighbor could hear our noise and that he was sitting over there, disgruntled, silently hating us. I dutifully recorded these thoughts in my homework, flagged them as a case of “jumping to conclusions” (one of the ten “cognitive distortions” discussed in the book; others include “all-or-nothing thinking,” “disqualifying the positive,” and “catastrophizing”
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), and wrote down what I’d try to do instead: remind myself that I didn’t
know
how he was feeling, and that if he cared to complain, he would.

For me, CBT was moderately helpful. I still remember some of those lessons, and I can still use them to push back against my own negative thoughts and deliver myself a quick jolt of perspective. But there was plenty I was searching for at the time that CBT didn’t provide. Most of all, it didn’t answer my craving for a sense of meaning. At the time I felt wrapped up in uncertainty about who I was and what I ought to do in life. The therapy I did later with John nudged me slowly toward the realization that while those are important questions, sometimes it’s most productive not to ask them directly, but to look for little clues to the answers in the process of living itself. But CBT, with its relentless focus on a set list of distorted thought patterns, didn’t even provide a way for me to get those larger questions onto the table. During my twelve sessions, I kept feeling an impulse to interrupt my therapist and say, “Okay, but could we talk for a minute about what’s
really
on my mind?”

As a counterpoint, I’ve since spoken to a number of people who found CBT extremely useful. David, thirty-one, completed a course of CBT after an intractable depression forced him to take a break for a semester from college. David had had a little bit of insight-based therapy in the past, and he’d resented all the attempts to make him dredge through his past, pick apart his family, or locate the source of his problems in his childhood—he just wasn’t interested. David liked CBT’s focus on the present, its circumscribed nature, and its emphasis on specific results. The approach sounded right to him, and true to the dodo bird theory; CBT worked better than other things he’d tried.

Grace, thirty-four, received CBT in college and also found that it corresponded nicely with her sense of what her problem was. “Cognitive-behavioral therapy was really good,” she said.

It felt much more effective than just taking medication every day. I liked having assignments. The way it was explained to me, it totally made sense. Like there can be a moment in a situation where an insecurity that you have can cause it to spiral totally out of control. And it felt like, “I definitely do that.” It’s like when you’re reading your horoscope and you say, “I’m such a Sagittarius.” That’s how I felt about CBT. It was just like, “How did you know?” So I liked having assignments and trying to catch myself in those moments. It felt like something I could use on a day-to-day basis.

My sense now is that CBT and psychodynamic therapy cover a lot of the same ground, but that psychodynamic therapy tills deeper. A psychodynamic approach would use your worries about your noise levels and your neighbor’s displeasure as a jumping-off place to explore your personality structure:
Why do you care so much what your neighbor thinks of you?
the therapist might ask.
Where does your mind go when you’re worrying about his disturbed peace and quiet? What else in your life does this situation remind you of?
In CBT, it doesn’t matter so much why you jump to a given conclusion, just that you notice yourself doing it; in psychodynamic therapy, understanding
why
would be seen as essential to creating change. Which approach will work best for any given person probably depends on what kind of investigation appeals most. Are they more comfortable isolating and zooming in on the problem, or would they rather start by taking a slow, meandering walk to get the whole lay of the land?