To Be or To Be ‘Well’: How Therapy Works

A guy walks into a therapist’s office — sadly this is no joke — and says, “I just read an article 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?”

 More and more, psychotherapists are fielding such questions due to the recent onslaught of articles 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, there is “evidence” supporting the efficacy of both. But I don’t intend to go there, or to define “CBT” and “psychodynamic” for the many people who have no idea what the terms even mean; to do so would only fan the flames of the Republican vs. Democrat-style wars between the two. Instead, I’d like to discuss how therapy works (all therapy) as opposed to why it works, and how specific people, such as those in the 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 such arbiter is presumably Harriet Brown, the latest writer (and non-mental health professional) published in the Times this month, who asserts that motivational therapy techniques based on “scientific research” are “working,” while clinicians who are “good with people” — as opposed to being “scientific” in their approach — are wasting your time. The idea of wellness underlying Brown’s op-ed piece is summed up in comparisons 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 attack. 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?