To Be, or to Be 'Well': How Psychotherapy Works

A guy walks into a therapist's office -- sadly, this is no joke -- and says, "I just read a piece in The New York Times, and I've got some questions: What do you know about my condition? What's your success rate with people like me? When will I get well?"

Increasingly, psychotherapists are fielding such questions thanks to the recent onslaught of pieces proclaiming that short-term "evidence-based" practices (e.g., cognitive behavioral therapy, or CBT) "work" better than long-term psychodynamic treatments. The bottom line is that there is "evidence" supporting the efficacy of both. But I don't intend to go there, or to define "cognitive behavioral therapy" and "psychodynamic therapy" for the many people have no idea what the terms even mean; to do so would only fan the flames of the Republicans-vs.-Democrats-style war between the two camps. Instead, I'd like to discuss how therapy (all therapy) works, as opposed to why it works, and how specific people, such as those in LGBT communities, are affected when we presume to know what makes someone mentally and emotionally "well."

First, what does "well" even mean? We can all agree that our bodies are unwell when attacked by the common cold, cancer or even ourselves (e.g., self-mutilation or starvation). But who determines the wellness of the boy who feels more like a girl, or the girl who wants to marry a girl, or the girl who feels ostracized for lacking "sex appeal"? One self-appointed arbiter is Harriet Brown, the latest non-mental-health-professional to publish a piece on mental health professions in The New York Times this month, who asserts that motivational therapy techniques based on "scientific research" are "working," while clinicians who are merely "good with people," as opposed to being "scientific" in their approach, are wasting your time.

The idea of wellness underlying Brown's op-ed is summed up in comparisons that she makes between psychotherapy and buying a car: Brown quotes a psychologist who cites studies indicating that less than half of psychotherapists use "motivational techniques," and who reasons, "You wouldn't buy a car under those conditions." This is a conveniently tidy analogy, but the wellness of a car is objectively determined, and the emotional wellness of a human being is, obviously, not. Cars have malfunctions, not subjective experience. They don't have to conceal their sexual desires, fearing discrimination or physical attacks. Cars do not privately suffer from identity conflicts or body dysmorphia. (I've yet to hear of an anxious SUV that feels like a Mini Cooper on the inside.) If "well" for us means our "parts" are in order, who gets to decide what our sexual, emotional and gender-expressive "parts" should look like? Who can say if we're running properly?

When a client enters my office, I don't know them until I know them, and knowing a person requires time, patience and the wisdom to dispense with assumptions. I may use "evidence-based" directives at the beginning of a treatment with someone who can't focus, washes her hands until they bleed or starves himself (and I may refer them for medical treatment if necessary). But even if such a client were to increase focus, reduce hand washing or begin to eat, is that where treatment ends? Is she well? Engine fixed, exterior painted, let's sell this car?

Let's say a lesbian-identified client with severe anxiety enters therapy. We could use scientific research to explain why there are more straight-identified women in the world than women like her. We could also find studies that explain why she might have anxiety as a result. We could even prescribe evidence-based techniques to help reduce her symptoms. But would any of this validate her unique experience or give her space to discuss how she lives, how she struggles, and how she survives -- not all lesbians with anxiety, but she, with her specific history and challenges?

The benefits of psychotherapy are in being seen and heard and having the space to, as psychoanalyst Donnell Stern says, "formulate experience" -- often experience that never before had the chance to breathe. A therapist-client relationship is ideally a safe relationship in which to discuss how our bodies, desires and sociopolitical contexts affect our lives. It is an opportunity to discuss the undiscussable and how this very lack of discussion has influenced our behaviors -- a point that I made on HuffPost earlier this year regarding the discourse on guns and mental health. No matter what therapeutic method, style, type or technique is being used, good therapy allows one to be; to awaken to one's adaptive, or perhaps maladaptive, patterns; and to consider the propensity of these patterns, once "healed," to strike again in another form (not unlike fat cells accumulating in one's arms after one has had liposuction everywhere else -- I've seen it happen). Therapy helps us to be us, to genuinely be, feel and think in relationship with another.

As I stated above, a variety of therapeutic approaches can be useful at different times, but to be inundated with New York Times pieces about types of therapy that "work," fix" or make us "well," to the exclusion of other types, is damaging. It is damaging not only for therapists who have dedicated their lives to the art of empathic recognition but for the multitude of people whose complex stories, needs and longings remain unsung -- including lesbian, gay, bisexual or transgender people who are regularly told that they are "not well" by much of society.

Renowned psychiatrist and psychoanalyst Jack Drescher once explained in a paper how "traditional scientific viewpoints discredit personal voices" and, consequently, how his approach to therapy had shifted from "a scientific view ... toward a hermeneutic one," particularly because of his identity as a gay man and his desire to help other queer people.

All of us deserve to have our unique stories heard in a therapeutic context, beyond our "symptom" pictures and beyond the "scientific" solution to our "problems." As a client recently said to me, "getting well implies returning to the way I once was, but therapy has helped me to adapt and to grow. Simply erasing my symptoms would be like retreating, and why would I want to do that?"

This piece first appeared in Mark O'Connell's column Quite Queerly on