In Melissa Dahl’s “Maybe You Shouldn’t Talk to Someone,” she discusses her growing dissatisfaction with therapy, and the belief that others are growing similarly dissatisfied: “I’ve suspected there are an increasing number of therapy quitters like me — people who have been helped by talk therapy but are in the mood for a less examined life.” The piece is provocative and honest, but thin, and whatever force it has is owed to the author’s skill as a compelling writer. Stopping just short of saying “Stop going to therapy,” she provides a series of evocative arguments about why it is overhyped.
I’m a biased reporter – I am a therapist in New York City after all – but in some ways that makes me a good conversation partner for Dahl. So, I have tried to coordinate her arguments and respond to them one at a time in order to give therapy a defense.
What is Therapy?
This is an important question that too few psychotherapists answer directly. Briefly: “Therapy” refers to a medical treatment for a disorder; when it is combined with the prefix “psycho” it refers to the medical treatment for a specifically mental disorder. However, this is incomplete in a misleading way. Physicians, for example, treat physical disorders – that is their mandate - but also frequently treat patients with non-disordered conditions. If you’ve ever had a dental cleaning, a cosmetic surgery, or been pregnant, you’ve been one of these patients receiving a medical treatment – a therapeutic – for a non-disordered condition. Similarly, psychotherapists treat people with genuinely disordered conditions, but also people who are grieving, learning how to become an adult, working through divorce, feeling anxious, or struggling to find meaning in their lives.
There are dozens of modalities vying for prominence in the psychotherapeutic space, each of which emphasizes different aspects of the mind and are argued to have different pathways to symptom remediation (Wakefield, Baer, Conrad, 2020). Some focus on the here and now, some are emotion focused, some examine family systems, some plumb for unconscious meanings. The only point of commonality is that they occur through an essentially conversational process.
This is important because it seems that Dahl has a rather narrow view of what therapy is. She explains therapy is for problem solving but “Fifty minutes is a lot of time to fill when nothing much is bothering you” and so, when there were no problems to solve she and her therapist would invent some. She suggests: “Maybe a more useful way to think of therapy, for some, is to seek a discrete solution to a discrete problem.”
Treating discrete problems is an important part of psychotherapy, but orienting to therapy as a problem-solving exercise can keep you looking for problems and creating one’s that don’t exist. Worse yet, it invokes a kind of redditified treatment of simple answers to complex problems: Does your spouse have an anger problem? Leave him. Feeling alone now that your spouse is gone? Start dating. Dating makes you anxious? “Try dating multiple people” (actual reddit advice). This might be why Dahl’s takeaways from therapy are box-breathing, “locat[ing] an emotion within my body,” and distinguishing between physiological and psychological reasons for her feelings. An alternative way to approach psychotherapy is as a way to understand yourself so that you don’t get stuck repeating the same type of problem again and again. Rather than focusing on a discrete problem, this means focusing on the internal schemas that sustain their reemergence.
When you make this shift, you no longer need to find some problem to talk about; you can talk about anything as those "discrete problems" occur in the context of your whole life. The point is to uncover the various schemas you unconsciously employ in order to understand the world, how those schemas underly some of your evaluative judgements, and how the patterns you find yourself in – good and bad – are informed by those patterns of thought.
Suppress, Repress, Success
Dahl’s confusion around what therapy is is later reflected in a brief discussion of some recent empirical research on the benefits of suppressing negative thoughts. Summarizing an article by Zulkayda Mamat and Michael Anderson, Dahl explains that “suppressing negative thoughts can in fact improve your mental health”: When shown a reminder of the negative thought, the participants were to simply acknowledge it without dwelling on it. They weren’t supposed to distract themselves by substituting a happy thought in its place; they weren’t supposed to change the way they felt. They were just supposed to stop thinking about it.”
Try that next time you feel the pang of sadness remembering the partner who cheated on you, your dying brother, or your childhood of abuse. I bet it won’t work. And I bet neither do the researchers who Dahl cites who trained their participants in a specific method designed to obstruct memory retrieval.
Interestingly, however, this approach resembles several empirically tested psychotherapeutic modalities. Acceptance and Commitment Therapy (ACT), endorsed an empirically supported treatment for multiple common disorders by the American Psychological Association (APA), the World Health Organization (WHO), the UK’s National Institute for Health and Care Excellence (NICE), and many others, for instance, teaches patients to identify negative thoughts as they arise and feel their discomfort without responding to it.
Dose Response? Another question Dahl seems to have is whether people need to be in therapy forever: “It feels as though the longer you’re in therapy, the healthier you’re getting — or the more you’re healing, to borrow the language I’m often served on TikTok. But is that true?" This is an excellent and understandable question. A measure of something’s causal efficacy is dose response: if substance S is effective in producing effect E, more of substance S should produce more of effect E. For example, we know that gin is the causal factor in making people inebriated because the more of it one has , the more inebriated one gets, whereas an increase in tonic water doesn’t do anything. So, Dahl asks: if you have more therapy, you should get even better, right?
Dahl cites a meta-analysis of studies comparing short-term and long-term therapy that, as she puts it, “found no difference between shorter- and longer-term bouts of psychotherapy on a depressed or anxious person’s level of functioning. With therapy, it’s not clear that more is always more.” However, the cited research is not as demonstrative of Dahl's point as she would like. First, the researchers were only able to identify 19 randomized clinical trials, all of which, they explain, were highly biased. Second, they utilize the studies's own definitions of "short-" and "long-term" therapy:
"If we had used a specifc threshold distinguishing short-term from long-term
psychotherapy, e.g. by applying a definition of short-term psychotherapy as including up to
24 sessions and long-term psychotherapy as including at least 50 sessions or having a
duration of at least one year as suggested by others, we would have only been able to
include three trials in the review" (Juul et al., 2023)
As a result, the findings do not represent what is standardly considered "short-term" or "long-term" therapy and so doesn't demonstrate that the latter is no more effective than the former.
So much for the study. But the essence of Dahl’s question remains: do you have to be in therapy forever? The short answer is: No – of course not. The long answer is: it depends what you are trying to do. If your leg is broken, do you need to keep a cast on it forever? No. If you’ve learned a language and are trying to maintain your fluency do you have to keep speaking it? Yes. If what you’re after is help grieving or getting over a phobia – that is, working through a discrete problem – then you can get in and out of therapy relatively quickly. However, if you are trying to figure out why your anger response is so easily triggered or why you keep engaging in the same patterns that make you miserable, then it may take some time.
And that’s fine. The way you were bullied in elementary school might have a different meaning to you when you go to college and are trying to make friends, when your boss insults you in front of your colleagues, and when you’re in your 40s and see your own child get bullied in school. You might want to revisit that feeling over and over in your life as it affects you in new ways.
Nothing Changes
Dahl brings up her own therapy in the piece, explaining that, though her sessions were initially helpful, they became ineffective: “I would bring up the same issues; she would give the same advice. Nothing changed.” (This line reminded me of Catie Turner’s sardonic and gutwrenching song, Nothing: “I Hope my self-awareness is endearing/ And doesn't make me come across as shitty/ But I can promise you one thing/ I'm working on myself and doing nothing”.)
One wonders why things didn’t change. Was Dahl’s therapist simply not doing her job or was Dahl not incorporating into her life what was discussed in the session? I don’t know. What I can say, however, is that patients also contribute to the effectiveness of therapy – including physical medicine. If, in the course of therapy you come to understand you feel most valued when you can provide something for someone and so you pursue romantic partners who don’t have their lives together so you can “fix” them, then you need to consider that on your next date. When you feel that jolt of satisfaction at buying your date a drink, or loaning your partner that money, or having sex when you don’t really want to – you need to remember the work you’ve done, that hard-won knowledge of your unconscious life, and apply it. Similarly, when your physical therapist gives you stretches to do and an exercise regiment to strengthen muscle groups and prevent injury, you then have to do it.
Of course, if you’re struggling to identify when to apply the work, if you know when to apply it but struggle to actually do it, or if you apply it and feel empty without the feeling that comes from engaging in those familiar but painful behaviors, you should discuss that with your therapist. The two of you can come up with a plan to figure out your triggers, how to push through resistances, and recalibrate those empty feelings. The point is that if you make that discovery in therapy but continue to date as though you hadn’t, nothing will change. I’m just not sure that means you shouldn’t be in therapy.
In the End…
… not everyone needs to be in therapy forever, as Dahl rightly noted. Therapy can be something you engage to get through a difficult period or to sort out a “discrete problem” But life is not a series of discrete problems and you are not a patchwork of symptoms. Therapy can shed light on aspects of yourself that you keep hidden, even from yourself, and uncovering those can decalcify hurtful feelings, change deeply held beliefs, and disrupt patterns that keep you from living the life you want to live. But that takes time and effort.
References
Juul, S., Jakobsen, J.C., Jørgensen, C.K., Poulsen, S., Sørensen, P., & Simonsen, S. (2023). The difference between shorter- versus longer-term psychotherapy for adult mental health disorders: a systematic review with meta-analysis. BMC Psychiatry 23, 438.
Mamat, Z., & Anderson, M. C. (2023). Improving mental health by training the suppression of unwanted thoughts. Science Advance, 9(38), eadh5292
Wakefield, J. C., Baer, J. C., & Conrad, J. A. (2020). Levels of meaning, and the need for psychotherapy integration. Clinical Social Work Journal, 48, 236-256. doi: 10.1007/s10615-020-00769-6