I'm sure supportive therapy is useful to more and more people these days. But I have to wonder - if it's basically just talking things through with someone, how sad is it that people aren't already getting that from their lives? Insofar as I have an issue with the rise of "therapy culture", that's why. It seems like a pale, shallow, and *expensive* substitute for something that people should be able to access for free through normal human relationships.
Near the end of 8th grade, I wrote a suicide note to a teacher. I had no intention of killing myself, but this brought the full force of the District Psychologist to bear on me. While the school called my mother (a worst-case scenario for me), this man walked around the outside of the schoolyard with me. He told me that we can choose our feelings and responses to things, and can choose to feel better.
I know from having lived in the world for a few decades that this is terrible advice. No depressed person needs to hear this. Universally unhelpful.
That advice CHANGED MY LIFE. I gave it a try...and it totally worked. Between 8th and 9th grade I went from a kid who cried almost every single day to being pretty happy and cheerful. It was a total revolution in my feelings. I mean, what?
I’m sure that talking cures can help people. However how much, if any of this, is down to the supposed founder of psychoanalysis Herr Freud? Has he been overthrown.
I occasionally watch Fraiser on syndication and he’s supposedly a Freudian - but when answering people’s calls it’s generic helpful advice, I’ve never seen him suggest that the caller’s problem is his love for his mother, his death wish, or her penis envy.
Is any of this science? Is CBT science. Or is all that is happening is that there’s a helpful person there when you need one. How would be know anyway? It could be all placebo effect, which means it works, because that’s also a change of mind.
> But also: people vary really widely in their ability to do something sort of like hold a conversation with themselves - for example, some people totally lack an inner monologue. Nobody has ever checked if those people benefit from therapy more, and I don’t want to actively predict that they would. But I know that I talk things over with myself a lot. Does this help me stay emotionally stable? Not sure; seems plausible. If I didn’t have an inner monologue, maybe the only way I could get that same effect would be by talking them over with another person.
I would say that I don't have an inner monologue (I also have aphantasia), but am generally able to process my thoughts and stay emotionally healthy. I primarily rely on one-on-one conversations, mostly with my spouse, in order to hash out ideas. I also probably have some genetic predisposition to stay emotionally healthy -- at least that's what others have told me, and that seems like a good thing to believe so that I don't go around telling others, "why don't you just try to be more positive?"
Therapy is like having a friend that you can tell anything to and they can't get mad, leave you hanging, or tell anybody else. For people without close friends (which is a lot of people) they can work wonders.
I went to a counselor once for a problem I was somewhat embarrassed about. I talked to them for a while and they had some suggestions, which I filed away. But the problem never recurred, and I think part of the reason was that I really didn't want to sit in front of this high status person and explain how I'd failed to apply the really basic method they'd taught me.
I wonder how many people get a similar benefit from therapy - better not relapse, lest I have to explain it to this expensive professional?
“ some people totally lack an inner monologue”
I was totally shocked when I first learned about that. How can it possibly work? If they are waiting in line at the grocery store what do they think about?
I go back and forth between having an inner monologue and not. I do most of my important thinking nonverbally. I don't have any inner monologue when I'm taking a test of math or geometry or chemistry. I only need the inner monologue for doing verbal things.
As a former mental health counselor and someone who has been in therapy myself, I see the value of a therapist. I also see value in friendships and meetup groups. The cost makes you sure you will get value from therapy. IE: "Why would you pay for something useless?" "Cognitive Dissonance" is when you do something, you want to believe it makes sense, so you change your thoughts to explain your actions. Some people know themselves better than others. Some realize the value in knowing themselves and want help doing it better. When the outside world tells you to be one way but internally you feel the opposite, I think therapy works. After all, the therapist is paid to be honest with you and so many other people selfishly tell you what you want to hear or what is best for them.
I think what it comes down to for many people is personality style and where on the scale of functional to dysfunctional they fall on for each style. If your traits in these areas (i.e. obsessive-compulsive, paranoid, hysterical, depressive, impulsive, etc.) do not reach the level of neurosis, basic self-help and behavioral activation will suffice. Once you reach the neurotic level where your cognitions or actions are negatively affecting your life in some way, it is probably more efficient for you to talk it out with a therapist, pastor, priest, rabbi, etc. Once psychosis comes into play, you will most likely need some kind of psychopharmacological intervention.
I imagine most people in the EA community would fall into the obsessive-compulsive style, which is selected for in high-pressure environments.
It feels like there is an additional major ingredient that wasn't mentioned here - the healthy relationship. It never ceases to shock me how many people lack basically consistent, supportive, and loving relationships, and how beneficial it can be to simply sit with a caring individual on a regular basis, remunerative or not. It's soothing to the nervous system; it's reassuring; it's (for many) a necessity that's otherwise unmet.
I had two sessions with a therapist about a year ago when I was terribly, terribly depressed and under-confident.
In the first, I explained to him that I wanted to quit my miserable law job that I was terrible at and do software design, which I obviously have a talent for. I explained that I had a lot of confidence in my ability to career switch, that I thought the transition would be successful, that I'd given it a lot of thought, but that I felt stuck in the law job. He responded (with the tact and grace that therapists have to use) "Uh, okay, so...do that?" And then I did, and it worked.
I had a second session a couple months later, having improved significantly and successfully made my career switch and he said (again, with much more tact than given here) "So...what else do you need then? Why are we still having sessions?"
On reflection, the first session was him giving me permission to get to a place where I didn't need permission to do things that were good ideas, and the second session was him saying "uh, dude, now that you know your own judgment is fine you don't need my permission to do things that are good ideas."
That seems very very silly in retrospect. I don't think he was particularly skilled at drawing out emotions or deep healing or whatever. He literally responded the way any sane person would to a person saying "Hi I'm unhappy and this would make me happy. Should I do this?"
But from inside a mind that was completely enveloped in self-doubt and depression, it would have been absolutely impossible for me to figure out that the best way to stop doing stuff that made me miserable was to just not do stuff that made me miserable anymore. So good job random dude. And kudos for not milking me for weekly therapy sessions for a year and a half. That was the secret sauce.
I've had anxiety/depression for as long as I can remember, and therapy didn't do anything for me. The therapists were very nice and I went to plenty of sessions, but I don't remember any effects at all. Maybe because they didn't have anything new to tell me that I hadn't already thought of?
Meanwhile, meditation has been working extremely well for me. I feel like the anxiety dials itself down from 5/10 to 2/10, and my psychosomatic pain goes from 3/10 to 1/10. But then it comes right back the moment life interrupts my ability to meditate daily without being sleepy (another victim of Daylight Savings time).
And some people are *too* good at having conversations with themselves, they ruminate and reinforce unhelpful and inaccurate views about the world and other people. Bouncing the thoughts off someone else gives a chance to interrupt the death spiral.
It seems true to me that therapists are making up for something lacking in people's conversations with themselves, but you'd have to be a rationalist saint to not be lacking in any of these ways. People aren't instinctively introspective, and lots of obvious things aren't obvious until someone points them out to you explicitly. Remember your story about the person who had no sense of smell, and explained the whole thing to themselves as a metaphor, instead of realising everyone was experiencing something they weren't? That's the human brain doing what it does best: explaining instead of noticing.
I'm surprised that this discussion doesn't include interpersonal dynamics as a success dimension.
I have been to a few phycologists in my day, and honestly none of them were all that helpful to me in the aggregate.
However, there were a couple (literally two) times where a therapist would toss out a key phrase or an observation that seemed to instantly unlock a door in my mind and give me a new way to think about things.
The chances of me striking gold again would appear to be rare, but I'd be willing to go digging for gold if I knew how to identify the right person to invest my time with.
Ultimately, it seems to me that finding just the right person to discuss your distinctive set of circumstances with is perhaps the most important variable in ascertaining therapy efficacy.
It might also just be helpful to hear perhaps obvious truths said by someone you've imbued (rightly or wrongly) with authority to say something. The power of "have you tried this" isn't just high if the "this" is some deep insight.
I also think for many folks I know they a) either find this uncomfortable to do by themselves, b) don't have peer groups they'd trust to say it to incl spouses, and c) this becomes a ritual and rituals are comforting and helpful even if it's a placebo.
I'd wonder which of this,if any, Scott finds in his practice too.
Anecdotally, one of my best friends finds therapy completely ineffective, but she is also constantly thinking about her own problems. Versus me who has found therapy immensely helpful, as someone who finds self-analysis difficult to deal with
Predictive processing seems to suggest that most of us are living inside of something like 'cartoons.' _Especially_ in the area of "what happens inside other people's heads", because there's so little feedback from reality there. So maybe this is why some people's internal experiences seem so weird and out there to others?
I've been seeing the job of a therapist (or the coach I see), as something like 'increase the resolution of my cartoon so that it matches reality a little better. I suspect that trapped priors play a big role here. For example, I see an attitude coach, and our conversations are probably _extremely compressible_. "You don't need to expect yourself to be perfect" is the kind of thing that i've repeated to myself over and over and over and over and over, and i'm sure glad there's somebody i can pay who consistently notices when i'm acting in a way that suggests i expect perfection from myself.
A bit off topic, but this morning I read for the second time "Good Old Neon" by David Foster Wallace. One of the themes is the relationship between the narrator and his therapist. You feel sorry for the therapist in a "Good Will Hunting" therapy scenes way( before Will gets to Robin Williams). It's a brilliant and powerful piece of writing that should not be read if one is in a depressive state.
I am pretty sure most people would benefit from therapy in a wider sense, i.e. structured self reflection with the help of a trained person. Unfortunately I learned that only after my divorce and after I hit many walls with my rationality.
However, I am also convinced that talk-focused therapy is not the best way for many rational people. Body oriented therapy forms, including and especially intense breathworks seem to work better with mind-focused people. And - yes - psychedelics in the right setting
I would argue that therapy is optimized to provide the perception of value. In much the same way that being aware of a systematic bias doesn't make you immune to it, people come out of therapy with some profound realization about themselves and then don't do anything differently.
I'm not necessarily saying therapy isn't effective, but self report is basically useless here. There are no counterfactuals, and outcomes are poorly measured.
I was introduced to the idea of therapy more as a check on one's inner monologue, rather than as a substitute for its absence. In my experience, therapy was a helpful way to escape the destructive framing sometimes provided through introspection alone. In that respect, it doesn't feel too different from exercising principles of rationality, like rooting out cognitive biases, clearly stating assumptions, reflecting charitably, and showing your work.
The first time that a differentiation of different types of therapy made sense to me was in the book summary by Kaj Sotala of "Unlocking the Emotional Brain". There was a graphic included (at least in the print version) that described behavior therapy and emotion focused therapy as targeting emotional responses, psychotherapy targeting episodic memory, and Cognitive behavior therapy as targeting semantic structures.
I don't know how well this description meshes with either practitioners or patients. I also don't know anything about "supportive therapy". Is that the same as what I've heard referred to as "talk therapy" or is there a nuance I'm missing?
I'm wading into this discussion as a pretty blank slate without many preconceptions or background knowledge, so please forgive me if I'm framing this poorly.
(Edited to make it less ambiguous that the book summary was by Kaj Sotala instead of the book itself).
Are there really people who have no inner monologue?
To me the distinctive thing about therapists is that they are:
1) Pretty intelligent people
2) Who are paid to help you
3) But who are willing to offend you in ways friends/family might not be.
As a consequence, you can talk to them about stuff that would otherwise be taboo for you. If you're full of shit, they'll tell you. If not, that gives you permission to explore new sets of ideas. I think people generally underestimate how much of what's in their heads are the same thoughts that have been swirling around, unexpressed, for years.
People can be resistant to expressing those thoughts, which is why it can take a few sessions to make a "breakthrough".
Those breakthroughs are what's behind those people (including me) who have gotten extremely high ROI out of just a few sessions.
The rest I think is just life coaching by another name.
It sounds reasonable that many people will benefit from having someone to just sit quietly and listen to them talk about their problems. The act of explaining your problems helps you think about them.
But if the main skill is sitting quietly, why do therapists make a couple of hundred bucks an hour? Where are the minimum-wage therapists? An Uber driver can sit quietly and listen to people talk about rubbish for hours, if you take away the fuel costs he'd be a lot cheaper.
Heck, even if you insist on credentialism there's a helluva lot of psychology graduates who can't get a job in their field; give them a two-hour crash course in "sit quietly and listen" and let them charge thirty bucks an hour, they'll be happy.
My experience with psychologists is that the majority are there to listen to and soothe the anxieties of well off people without deep problems. Or to be used as internal weapons in behind doors struggles.
Of course, there are many that are not. Some deal with people with deep trauma or real mental issues. But your average therapist in an office in suburbia is mostly there to get paid by a husband to make his vaguely disatisfied wife feel less vaguely disatisfied. (I've also seen therapists who are effectively used like weapons. One therapist in Mass. had a good reputation as always siding with the woman and so was popular with a certain type of wife or daughter.)
The issue is these two get mixed up. Someone spends their entire career convincing wives that yes, gosh darn it, it IS meaningful that your husband didn't put the toilet seat down. Or husbands that yes, they're not Fabio but their wife still loves them. And then someone walks in with PTSD or deep complex trauma and they think they can handle it. But they can't and they just run out the clock on sessions accomplishing nothing.
There are no doubt therapists who could help these hard cases. But there's no meaningful way (from my point of view) of determining which is which.
If I had to guess, I think it's simply due to the fact that "guys want to be cool by not wearing jackets when it's cold."
I think the rationality community is very apprehensive about attributing common problems (for people like ourselves) to our relationships that we've had with broader hierarchical structures in society.
For example, a guy would (if he had been raised on that island that that king thought about once) if he felt cold, put on a jacket (or at least, fashion himself a jacket out of palm fronds or something I've never been on that island).
But seeing as how we don't live on that archipelago Scott's been looking for his entire life (and I'm also here to tell you that that archipelago is The Philippines) guys will have the following thought process:
-I am cold. I must put on a jack--
-Wait no then I wouldn't look cool I mean I don't need a jacket, jackets are for people who are weak (or at least, don't like the cold I mean can't handle the cold...)
Notice how disjunctured that is? Yet I bet that it's real fuckin' familiar to a lot of you reading this.
If I had to make a guess, it would have to do with the difference between how girls and guys perceive the cold, and where in the societal hierarchy they see themselves.
A guy with a fear of not finding a mate would do all he can to prove that he's the toughest (i.e. not wearing a jacket). Obviously this is a problem, but why? What is the source of it?
Because we all know that a "sensible person" wouldn't care about "trying to look cool", and so they would instantly put on a jacket (or fashion one out of beautiful banana leaves, right here in the Philippines!)
But the only people who would do that are people who don't understand just how high in the social hierarchy they already are, and so feel no need to prove to the cold that he's better than it.
On the other hand, the guys not wearing their jackets their mothers made and/or were handed down from their older brothers, who might have internalized a feeling of being "low on the totem pole" (which by the way, don't exist in the Philippines), or guys who were generally unattractive or ugly (or any sort of reason such kinds of people would like to insert for yourself here), would try their hardest not to think that the reason they were trying to not put on their jacket was because "I'm a real man!".
If you don't believe me, go ask a girl what she does when she feels cold.
And also, read Sadly, Porn again, but this time, don't skip over those blocks of text you think you're better than. That's where the secret to this lies, you skimmers.
I have never tried therapy, but there have definitely been instances where I had a personal problem and after much consternation either said to myself or had someone say to me "dude, why don't you just [really obvious solution that simply never occurred to me]?"
In our society, there seems to be very little formal development on how to understand oneself, others, and the world. Meanwhile, informal development is provided by family (with a huge variance in amount and quality) and society (which today means navigating hundreds/thousands of competing narratives). As such, there may be quite a few people still at very early stages of development when it comes to things like emotional intelligence. Therapy is a form of such development (at varying levels of quality).
To give an example that can maybe spur discussion: what makes the golden rule so golden in our society? I view it as a developmentally infantile and self-centered approach to understanding interpersonal relationships. "Do unto others as you would others do unto you." This requires giving absolutely no thought, modeling, or sensitivity to the mental states of others and yet it's often used as a paragon for interpersonal behavior.
On the one hand, something like "try to understand Jimmy's mind-set" seems like low-hanging fruit. On the other hand, I'm not sure that 95%+ of the population has ever been given any tools "to understand Jimmy's mindset".
My wife and I were wondering if it was always like this, or if we are living in an especially inept era. Perhaps in simpler societies, where there is high default sharing of values and behaviors, default emotional IQ is higher. I wonder if therapy is more or less necessary in such places.
Of course I can't help myself because I'm a therapist... a few random thoughts.
One is, I too have my own questions and doubts about aspects of my profession. I won't go on about those here, I'd have to start my own substack for that. All to say I'm not a cheerleader for my profession, but there are some aspects of its use that are not too hard to understand or communicate, I think.
You're not wrong in saying that many people go to therapy to get help with defective, deluded, distorted aspects of their thinking that are hanging them up in their lives. We do all have these aspects to us. That can work fine for long periods of time or in many circumstances, until we get thrown some curve balls of particular kinds and then our normal, human distorted thinking habits can cause us a lot of trouble. So...
The kind of people i see getting help with certain kinds of therapy:
* survivor of trauma, whether sexual assault or violent crime or natural disaster, etc. Your average friend or family member is not well disposed to handle traumatic material relayed to them, so friends and family can be of limited use sometimes initially, depending on the disposition of said friends and family. Debriefing traumatic experiences in a structured way can help a person recover and/or head off more lasting problems. Friends and family are essential though in addition, and I would say that for all these situations here...
* person going through a stressful thing and needing a safe place away from stressful thing to consider how to respond to stressful thing: divorce, terrible medical diagnosis, considering the end of a long relationship, considering a career change, bullying at work or school, heading towards retirement, recently relocated and without local social supports, adjusting to having kids or becoming a blended family, losing a child, and so on. There are so many circumstances like this where a basically healthy and mentally sound person just needs a grownup to talk to so they can sort through all the various feelings and thoughts, and often conflicting priorities. To basically listen for their signal in all the noise of the event. This is more like coaching, but is not reducible to supportive therapy, and often people's default modes hang them up in these moments so that something well beyond supportive listening and coaching is needed for them to navigate the change life is demanding of them.
* person in young adulthood -- say until age 45 (only sort of kidding) -- who experienced various kinds of emotional neglect (from quite benign to really malignant) and therefore failed to develop a sturdy inner guidance system. Mildly shitty or narcissistic parenting can leave a person constantly looking over their shoulder, paralyzed by all kinds of self-sabotaging habits, or just unable to identify and name their own internal experience or what they might want to guide them through life. Your writing above seems to suggest you underestimate how common this is and how impairing it can be. This person often has trouble attracting and forming close friendships with people who are wise and stable, and so they do not have in either friends or family the kind of steady other person to help them solidify a sense of self as distinct from all the bullshit they internalized growing up. Short or long-term psychodynamic, among other approaches.
* person who is trapped in long-standing cognitive patterns that feed their natural inclinations towards anxiety or depression. CBT, exposure therapy, mindfulness, etc.
* person who has developed behavioral habits to try to self-treat their underlying anxiety, depression, trauma, etc -- addictions, compulsions -- that have grown into their own additional sources of impairment. They may need a mix of all the things above depending on what's driving the behavioral compulsions.
* some people are external processors, as you suggest, and regardless of how nice their family and friends are, they need more time and audience during stressful life periods in order to hear themselves think. Sometimes these people want to talk about things that they don't feel they can share with their friends or family. Coaching, CBT, ACT, etc.
* some people face existential fear or existential predicaments that they likewise need a trusted other to talk through in the way one might have used a priest in a prior era. This work can be quite deep and rewarding and definitely isn't just supportive.
There must be therapists out there who only do "supportive therapy" but my understanding is that that's an expression more used to describe specific sessions here or there. "Client was highly distressed at news of mother's cancer diagnosis; intervention this session was mainly supportive." In other words, there are times in the course of therapy that the most appropriate response by the therapist is simply support, but that doesn't constitute the whole of a treatment plan. A person comes to you thinking they may want a divorce... after some sessions, they show up saying they told their spouse and now the separation is in process, and it's clear the job of that session is just to catch the grief or fear the person is experiencing at having made this choice and acted on it.
Otherwise, I think even the most in-the-moment therapists are operating at multiple levels of planfulness in terms of what they think they're doing with a client at any given time. I mean, of course YMMV. But the idea that it's a sea of "supportive therapy" out there seems inaccurate to me. The training, of whatever school, is definitely not mainly "oh, that must be hard" and nodding sympathetically. The entire arena of case conceptualization is aimed at helping therapists and clients come up with a reasonable story about what they are doing together and towards what ends, and to check in on that along the way. I have that case conceptualization in my head every time I meet with all of my clients -- and I don't work from any single modality so I'm not implementing any kind of manualized procedure on people.
Having said that, there are for sure clients who just want someone to talk to every week or every other week about whatever the hell happened for them that week. In my whole practice, I have a couple of people like that. It's pretty clear to me that my work with them is to address very entrenched personality adaptations to really significant trauma, and the stuff of their daily life is the arena of practice -- literally, how to have healthy friendships, how to set normal boundaries, how to self-soothe, how to name one's emotions and not have to act on them, how to allow oneself any amount of pleasure, how to make decisions towards one's own benefit, how to advocate for one's needs in multiple situations. That work can go on for years, and it is slow, but it absolutely yields improvement in that person's functioning every single year. I wouldn't be able to do it any amount otherwise, because I'm an impatient person.
Quite apart from the kinds of "clinical skills" that these above situations may entail, my experience generally is that most people are not great listeners. Our own narcissistic stuff enters so quickly into conversations with loved ones. Also, so many people are made very uncomfortable by other people's difficult feelings, so that support from one's friends and family runs into pretty hard limitations (minimizing, deflecting, fixing, etc) when one is faced with genuinely tough situations.
So, for what that's worth.
How is it that in a rational community dichotomies are entertained? Is it this way or that way for all? Or this way or that way for an individual? Given I've found these two approaches completely unreliable and crazy-making, I'm going with "What types of therapies are useful for any one personal are individual and extremely custom, and therefore rolling that up to the masses, as public health has to in this case, any public heath recommendation should not be followed blindly by an individual. Same caution for root-cause analysis - there are usually more than one cause for complex issues. Sure one may seem like the root, but resolving it may not in fact resolve the problematic outcome. Oh, how I wish the many doctors I've had over the years were more systemic thinkers.
The way that I would put it is that people think the purpose of therapy is INVESTIGATION when in fact the purpose is CONFIRMATION - and confirmation is hugely valuable, at times.
I have written this before. I tried classical Freudian therapy for my depression. Years later I tried Zoloft. The Zoloft worked. The downside of the Zoloft was weight gain. Freudian therapy didn't cause weight gain, and it didn't alleviate my depression.
Best benefit of therapy is having an adult to talk with.
Lots of therapists fail at that, though.
Possibly a stupid question: Has anyone made a serious attempt to construct a _list_ of all of these fundamental skills that most people have but a few people are randomly missing?
If that's knowable, but not currently known, it sounds to me like figuring that out would be worthy of being some brilliant scientist's life's work.
I know that professionals who work with developmentally-challenged people have some sort of list of milestones they use to approximate a patient's developmental progress/"age", which seems like it might overlap or be a starting point? But I don't know much more than that it exists.
Is there any evidence about people who's internal monologues ebb and flow? I have had a rich inner monologue at various times of my life, with droughts and many things in between. I find that I process many things verbally, often not realizing some emotion or preference exists until I voice-dictate it in to Daylio. I also love supportive therapy!
Re therapy and money, my favorite thing is how therapists justify the cost as "it has to cost a lot so you're invested in the outcomes". Which does make sense, to a degree: skin in the game. And yet, it's also what a psychoanalyst / TLP would call "a defense".
As far as "supportive therapy" goes, I totally agree. It makes me think of something Eric Berne wrote, about how there's 4 "levels" of therapy:
1. symptomatic control
2. symptomatic relief
3. transference cure (substitution of therapist for parent)
4. psychoanalytic cure (reveal the patient's fundamental conflicts)
My guess is that most supportive therapy takes place at the first two levels ("tell me about your anxiety" ... "are you feeling less anxious?") and MAYBE the third level. But it will never approach fundamental conflicts, although this isn't necessarily a bad thing, because, like with meditation, that's a door that you can't really close once you open it. Most people are happy to "return to society" after getting whatever support they need. Only in some cases does one need to go further.
My mom, a professional psychotherapist practicing "supportive therapy" (well, she'll call it "cognitive-behavioral with a psychodynamic bent"), has an anecdote from her years in therapy. She apparently reached a point where her therapist told you "this is as far as we can go together. If you want to dig deeper into your conflicts, I can refer you to an analyst." I don't think she took up her therapist on that offer, but to me it makes sense: there's different levels of interventions, that tackle different things and require different modalities.
Just chiming in regarding the internal monologue bit- I don't have one, and I am thankful for that. Having to think using words all the time sounds exhausting! I have no trouble using them as needed, such as posting this statement, or talking to someone. But I would say 90%+ of my thinking hours are spent considering concepts in a non-verbal manner. That doesn't mean that I don't have access to introspection. It just means that converting thoughts to words comes after the fact, not during.
I think I don't want a therapist, really. I want an expert. I guess it's why I follow Scott here. I feel like I've got a solid grasp on my problems, and even a decent idea of what I ought to do to solve these problems. But I wouldn't mind talking with someone who is an expert in how the brain works and has experience in how to attack depression and anhedonia.
Would be cool if this expert could prescribe ketamine as well; I think that might help.
Boring take: people used to go to their local religious leader for the kind of service they now get from a therapist. But now they don't believe that person knows anything, or don't want to be alone with them, so they need to look elsewhere. But advice has always been what some people needed but not others.
Having a wise and confidential person in your life seems like a good thing, and giving advice involves triage. That makes it hard to make any general statements beyond "we expect people to know a lot of things" and "when you learn you don't know one after you were supposed to, asking for help can work" but also "getting bad advice is bad" and "authority doesn't guarantee correctness".
Now, from the therapist's perspective, it's helpful for triage if you know what's generally going on in someone's life without asking. If they're depressed this week but last week you spoke at their grandfather's funeral, that's what you might call a clue. And you'll share a cultural context in which to broach some difficult topics. If we've successfully split that role off, great! If you get a bad therapist it's easier to keep shopping than for a new priest or rabbi. But we shouldn't expect that specialist advice givers and generalist advice givers have a totally obvious and easy tradeoff.
Personally, I've tried therapists twice. The less bad one was merely useless and expensive. The worse one taught me genuinely harmful ideas that I spent my teenage years methodically forgetting. And then I got stomach surgery and it cured my depression immediately, so figure that shit out. I've given and gotten life-changing advice, so I'm convinced it exists. I've never gotten it from someone who promised that on their business card, but I have to imagine it's possible.
For what it's worth, the most consistently useful advice for people in my experience has been to not imagine your mind like a pilot flying a plane, where it's just you and everything is on you, but more like a captain on the bridge of a ship, in which you have a lot of voices and specialists and your job is to synthesize them all and make command decisions. Yeah, lots of people have a weird voice in their heads that they don't like. But if so, that isn't all of you and you can isolate each component voice. A good captain knows where their subordinates are coming from. Not a panacea but it's helped a number of people.
I am a SMART Recovery facilitator, and it has become incredibly obvious that sometimes people just need to think things out loud in order to get to the next thought. In fact, there's a famous computer program debugging technique called rubber-ducking because of the story some guy told of his boss keeping a rubber duck in his office and inviting his programmers to come in the office and discuss their programming problems with the duck. It works. I can't tell you how many times I've been stuck in a bug and just explaining it to someone *who doesn't even understand what I'm talking about* is enough to make the answer blindingly obvious. This really is a way of hacking the brain. Sure, in SMART Recovery we say we don't give advice because of the motivational interviewing principle of people will follow advice if they come up with it themselves; but I fully believe talking to someone or something else is just a simple hack of the way our brains work. I've watched too many people decide to get their lives in order and live a life they don't want to relapse from to come to any other conclusion.
Anecdotally: I don't have an inner monologue, and yet I definitely think my problems through. My experience of not having an inner monologue is that you're directly thinking through the concepts without bothering with "shrouding" them in language; trying to debate matters "verbally" (albeit in my head) seems to me to *obscure* the issue more often than not. As a result, my prediction would be on people like me finding therapy/conversation *less* effective than those for whom the discussion with the therapist will be a much rawer translation of what's ordinarily going through their heads.
I have been very interested in thoughts related to how to reliably increase the agency of talented individuals, especially at scale. One of the many challenges here is definitely that everyone's' conscious experiences, world models, and self-models, are incredibly diverse, and it's very hard to learn a comprehensive representation of someone's internal structure in order to know what should be optimized (let alone how one would go about optimizing it, even if you instantly knew what should be changed).
I'd love to see any resources on how to increase the agency of individuals (bonus points if talented individuals + at scale) if anyone has any favorites to share
Much of this post reminds me of an XKCD comic: https://xkcd.com/1053/
I've been noodling on the idea that one pathway for therapy to be effective is to develop a secure attachment to at least one other person on the planet. This came about after reading the transcript for this podcast: https://www.janetlansbury.com/2021/03/the-truth-about-secure-attachment-with-bethany-saltman/ which is more about parenting, but it makes sense to me that everyone could do with having the experience of being fully themselves in front of another person and not being rejected but just quietly accepted instead.
> "Then they are delighted and go home! I sometimes think about this by analogy to “you can’t tickle yourself” - some people can’t reassure themselves either, and are very happy to hear thoughts they could have easily generated themselves coming from other people’s mouths. Are these some of the people who benefit from therapy? Seems plausible."
As someone who had/has an anxiety disorder that occasionally resulted in semi-obsessive episodes over some real-or-imagined danger, I can confirm that "people who can't reassure themselves" is indeed a real thing, and also that many of these episodes were resolved precisely by having a doctor (or other relevant knowledgeable person) tell me something along the lines of "this isn't even plausibly worth worrying about, go away."
This isn't so much about the reassurance factor of a trustworthy labcoat-wearing authority figure (although that may help), more it's about simply having an external reference point to calibrate against. An ordinary person sees a garden snake, isn't scared, and goes about their business; someone with anxiety sees a garden snake, feels scared, and suddenly has to decide whether this is just their anxiety disorder acting up or if it's their pre-reflective common sense telling them they're in real danger of being bitten by a poisonous snake that looks like a garden snake. This is a surprisingly difficult thing to solve through introspection and self-talk, since these processes rely on precisely the kind of fuzzy intuitive faculties which are malfunctioning in this case. But if someone just tells you that, no, their fuzzy intuitive faculties say everything's fine, you have some solid evidence to decide in favor of the "I'm just having an anxiety attack" hypothesis, and can move on.
(At least, you can move on to the stage of simply gritting your teeth and trying to tune out the parts of your brain that keep yelling that you're in mortal peril, but progress is progress.)
That's all an example in the case of anxiety, but I'd imagine "therapist as a reference point for internal calibration" is a broader phenomenon. Humans have *lots* of fuzzy intuitive faculties, and many of them concern judgements of very private things you don't usually talk about to someone aside from close family and friends (who are liable to have similar problems to yours!) and therapists. It's probably very easy to go through life with badly-calibrated intuitions for how people feel about you, or for your general prospects in life, or for how to navigate intimate relationships -- even in cases where a simple explicit check-in would correct the problem. Therapy is, among other things, how our culture administers these check-ins.
I think a lot depends on the context too. I'm generally psychologically healthy, but I benefited tremendously from a grief counseling session after the death of a parent.
We as a society have always needed calm, wise, objective people to help us talk things through. Back in the days when most people were religious, priests, ministers, & various clergy members often performed this calm listening function. In Asian/African cultures, it was often village or community elders. Therapists have taken their place. But the need has always been there, and societies have found ways to meet it.
I was surprised when I heard that some people don't have an internal monologue; it made me wonder how their decision-making actually works. Apparently there are also people who have no mental visual imagery either. Now I wonder what people with these deficits think about the rest of us; do they suspect we are hallucinating? Hearing "voices" and seeing "visions" would only be a more extreme form of these mental processes.
Supportive therapy was most useful for me when I was a confused ball of emotions about some ongoing or recent trauma.
A kind, steady, professional listener was helpful in those cases to help me figure out… where I was overthinking and where I was under thinking.
As I get older that seems less useful because both me and my friends have grown wiser and emotionally more capable, so we figure out 90% of that between ourselves easily. That seems like a common pattern.
I’ve never found supportive therapists to be useful in developing myself, though plenty of other things have been, including fairly mundane things like corporate management training.
Question for author - what are the areas of “basic human functioning” in which you suspect you may be deficient? I guess the term “deficient” also needs a definition, but it’s the same framing in your final paragraph, and I’d be curious to hear your answer... It struck me as a sentiment that is admirable for its vulnerability, probably universally true, and potentially interesting area to explore further. What thought patterns, aspects of self-awareness, intellectual qualities, interpersonal behaviors, etc. qualify as essential to “basic human functioning”?
Maybe this is merely tangential, but most of the value I perceived in seeking a professional for improving mental health is through the use of tools, exercises for psycho-social intervention. Therapy is one way to acquire them, another is just picking up a workbook for popular forms like CBT or 3rd wave CBT. My impression is that therapy is not usually about this, unless you explicitly seek it out. Maybe that's a problem, since in popular discourse everything is conflated.
When it comes to questions like "my job sucks, what do I do now?", you confide in people you know or look online. If the problem is depression or ennui, I think talking is insufficient.
Some things are easier to see from a distance and to be seen clearly by someone for whom doing so isn't emotionally expensive. I know I lived with faulty assumptions about myself that would have been difficult to have intuited or reflected my way out of. Maybe what I got wasn't "supportive therapy" but it was incredibly helpful.
As someone who was handed a bundle of really unhelpful ideas as a kid (see: Evangelical Christianity), and whose university experience only reinforced and expanded those bad ideas, therapy was extremely helpful to me.
I was depressed, isolated, full of self-loathing and inner conflict, and literally had no one to turn to who could actually help me, because I had spent the last many months pushing them all away. My quality of life was complete shit, and it was well worth $100 a week to improve it.
I’m not saying therapy is always worth it for all people. Some therapists are terrible. Some people are relatively psychologically healthy. But that’s certainly not a given. For many, therapy is a lifeline.
I can't imagine ever paying for therapy now--I'm somewhat too private. I feel a need to write journal entries thinking things through when I'm upset or having difficulties, but I'd rather think everything through on my own. There's lots of things I wouldn't share with my spouse, let alone anyone else. I guess I also doubt that another person would be able to do anything for me that I can't do for myself.
However, my 2nd-grade teacher referred me to the guidance counselor because I seemed sad a lot or something, and that lady has a very warm place in my heart. I told her all about my mildly abusive family life, and she told me that it was wrong for my parents to treat me that way, that there was nothing wrong with *me* that was causing this but that unfortunately some parents just don't treat their children the way they should, and that I should remember not to treat *my* kids this way when I grow up. Then she sent me on my way after a few meetings.
I think those were exactly the right things that I needed to hear; they really stuck with me. I'm not sure, for lack of a control, but it's possible that those meetings helped to inoculate me against some of the normal negative psychological consequences of a mildly abusive childhood: I never had any self-esteem problems, and was never tempted to think that any of it was my fault. She also shared things about how *her* family worked, which helped give me a healthier picture of what "normal" looks like which was different from what I was seeing at home.
With adults, alas, it's too late to inoculate, but some of that sort of thing could help an adult too.
So, the linked article about internal monologue is actually discussing inner speech. This might seem like a meaningless distinction, but if you asked me if I have an internal monologue, I would say yes, but if you asked me if I have inner speech, I would say no, or at least, no given my best understanding of what that's intended to mean.
As people go, I'd say I'm a pretty highly introspective person. I spend a lot of time thinking about the information I have to construct my understanding of the world, my own feelings and motivations, the feelings and motivations of people around me, etc. I think from my experiences I can say that I'm better than most people at predicting how I will feel or act in various circumstances, and how various life changes will affect my mental state.
But, I don't conduct this internal monologue in words. I *can* process thoughts in words; I write fiction, and when I write dialogue, I play it out in my head to check how natural it feels. But the idea of conducting all my introspection in words honestly feels really weird, slow and inefficient. Words are for communicating with other people. The idea that I'd need them to express thoughts within my own head feels bizarre, like if moving a file from one location in a computer to another required turning it into a huge verbal description in an MS Word file so the computer could understand it properly.
I don't think people without internal speech are necessarily more introspective than people with it, but I think it's worth being clear that a lack of internal speech doesn't necessarily inhibit introspection either. Some people may almost entirely lack introspection, but this would be a different, and probably harder to examine, matter than lack of internal speech. If someone is sufficiently non-introspective, are they capable of being aware of their own lack of introspection? I've definitely known people who give me the impression that they're not.
I still remember the first time I realized that other people I knew in grade school actually, you know, did stuff after school, and in a sense "had lives".
I'd say my inner monologue is the source of 80% of my problems. Therapy is often useful to me specifically because it's NOT that.
I once went to therapy because I was feeling paranoid about an issue. After a few sessions, the therapist assessed that these worries were normal to have and my reaction was proportionate. In other words I wasn't overreacting, I was having a big reaction to a big problem.
Once I heard that, I did not stop worrying a lot until that issue went away, but I did stop feeling overwhelmed by it. The therapist's opinion allowed me to accept that I was feeling big feelings and removed a huge part of why these feelings were problematic in the first place.
I'm confused by the basic assertions - isn't Scott Alexander a professional therapist?
I totally get what Qiaochu is saying - it's the kind of insight that sounds either like a platitude or tautological once expressed in words.
I noticed people struggling in life don't have that attitude - that problems are solvable, that whatever causes you pain in life is subject to the same approach as a dripping sink or a flat tire in your bike. It seems like you can actually lose this insight by cultural osmosis, if you spend a lot of time with people who have this kind of learned helplessness, you start to reify your problems as something that just happens.
I think the lesswrong alief vs. belief distinction is very relevant here, you can believe "problems are solvable" just fine but it does nothing for you, while acquiring the alief is life changing.
I'm sympathetic to Scott's speculations here about why different people would be helped more or less by therapy. I would add an evolutionary psychology dimension to the story (yes, it's a bit of a just-so story, but that's fine for a hypothesis).
Humans evolved to live in small clan groups, mostly under Dunbar's number. Under such circumstances, one is constantly receiving social feedback from people with whom one has some degree of intimacy, to include authority figures such as clan elders. We may have evolved to rely on such feedback for our problem-solving and basic sense of stability and wellness.
Under modern conditions, we often lack such social feedback, in both quantity and especially quality. Therapy often serves to fill that niche. Some people refer to therapists as "rental friends," but they actually may be more like "rental aunts & uncles."
Oh, I have no problem at all with an inner monologue, or even an inner dialogue. My problem is that I can talk myself right back into where I started from and nothing changes. Having someone exterior that doesn't follow the little script I write for them in the internal dialogue would be so much more helpful.
I would agree with you and many of the others in therapy discourse that therapy-as-a-means-of-just-talking-to-someone represents a large percentage, if not he majority, of therapy patients. Smaller, more atomized families coupled with technology limiting the availability of intimate in-person settings to have these deeper conversations mean that people have to spend more time inside their head. This allows their own cognitive deficiencies and biases to play an outsized role in their psyche, rather than having someone to sense-check or empathize with their feelings.
I think therapy can be very helpful in sorting out the various versions of oneself.
I think Freud‘s Oedipus complex is a very good summation of the whole whore – Madonna dichotomy which as we all know is a strong cultural trope and has been for a long time.
"Other people obsessively seek external reassurance. I talked here about the phenomenon of hypochondriacs who go to their doctor to be told that their latest concern (maybe the 25th time they had a certain symptom) isn’t worth worrying about, same as the last 24 times. They’re not even asking for an x-ray or something! They’re just happy to hear the doctor say the words “given that your last 24 symptoms were nothing, I’m assuming this one isn’t anything either”. Then they are delighted and go home! I sometimes think about this by analogy to “you can’t tickle yourself”"
huh... i suppose that describes me pretty accuretally. i have that sort of need for external reassurance for a lot of different things, with the added effect that i tend to loss the order i mentally need to continue doing it because i get uncertain, so just having someone to validate it can make me not panic when trying to do it... interesting
I was really hoping for someone to address the "benefit" part. What is the expected/supposed benefit? Obviously some people like to discuss their problems with someone paid to be non-judgemental. Is it done just for this contemporaneous enjoyment? Is there a temporary benefit that wears off over time and it is expected to continue this type of therapy for ever? Is the benefit is to address your problems make some realizations/improvements fix your issues and be healed, then the therapist just lost a customer. My assumption has always been it's the later, but based on the habits of people I know that go to therapy that doesn't seem to be the case. Or as a group they have terrible or fraudulent therapists?
I don't understand the title.
I'm not sure if you're being facetious, but I really think there are many people who have "no ability to systematically think about and solve" problems. I know several personally. Perhaps, then. we are too harsh when we criticize people for making bad choices in life. Maybe, as you suggest, they actually lack the ability to make proper choices at all?
The idea that "everyone is defective in some sort of basic human functioning" also struck me. I wonder if this is a trend over time? For instance, were our grandparents and great-grandparents much less lacking as a whole? Is the increase in people in therapy over time because of greater self awareness, improvements in the field and less stigma attached to seeking help -- or because people today are more "defective" than before? And if the latter, could this be reversed and/or trend the other way at some point?
I wish there were more alternatives to therapy, because it does seem like a gamble that I would be able to correctly identify the source of my problems, and then communicate it, to someone who will then give me useful suggestions I can implement.
I wish instead of therapy, I could pay to just be in the company of folks who know how to relate to others in ways I didn't have modeled for me. People who were raised in difficult environments can probably relearn a lot just from observing other people, but if they picked up difficult behaviors or self-loathing attitudes, it can be hard to get invited to parties.
Interesting speculation, Scott. I think there's something to it.
No one has ever suggested it, but perhaps I should go to therapy to find out if I need therapy?
There’s definitely been a recent emergence of a sort of “mental health industrial complex” that has become bloated and as a result needs as many people as possible going to therapy to justify its own existence. I say this because social work and mental health counseling have over time become some of the most popular and least rigorous programs at universities in the US. As a result these programs are churning out licensed therapists who partied their way through undergrad + masters programs (the few I know personally literally faked their thesis and graduated with honors) and thus are unequipped with the either wisdom or expertise necessary to help people navigate the nuances of their psyche. I went through multiple young therapists offered through my insurance and was sorely disappointed that they really brought nothing to the table outside of repeating cliches that could be found on a “mental health” tik tok page run by a 16 year old. I was a “functioning” addict and even had one therapist suggest I should keep using my drug of choice if it helped with my “anxiety.”
Unfortunately, it wasn’t until I left the insurance system and paid top dollar for a therapist with 20+ years of experience that I was finally able to see the benefits. She had seen it all and knew a ton about the nuances of addiction, ADHD, and the ways it manifests in different people. She was brutally honest with me at all times and I credit her with helping me get sober.
So yeah, I think the point here is that being a good therapist is difficult and takes a lot of experience and knowledge. Humans are complicated. Unfortunately there’s at least as many bad therapists as there are good ones, if my experience is any indication.
It seems hard to believe that no one has correlated the results of the various personality tests with clinical outcomes vs therapeutic approach...
What does the title have to do with the body of this post?
I've talked intermittently with therapists (broadly defined) over the last 20 years. It was only rarely helpful, but the few times it was helpful it was life-changing. I'd put the usefulness of therapy in three categories:
1) The large majority is rubber-duck debugging. It's amazing how many problems can be solved by just explaining them--somehow, for very many people, just explaining them with no worry about "what will this person think of me?" is enough to shake the solution into useful focus.
2) The more-helpful minority is asking good questions. "I'm having a problem with X." OK, tell me about it. OK, how about Z--is that going well or is there also a problem there? Have you considered Y? Sometimes, answering the right question clears things up a lot--but realizing that's the right question to ask and answer isn't easy to do for yourself.
3) The life-changing one for me was a missing tool. I was a 23-year-old freshman in college, trying to adapt to a different culture and with a history that posed some mental challenges. I talked to the school nurse, and she gave me this advice: "When something is going on and you feel stressed, try to decide if you are stressed about this thing on its own, or if it reminds you of something else and your stress is driven by the thing it reminds you of." That's been an amazingly helpful framing.
I don’t think “therapy helped me realize x” means what it sounds like it means, especially in the context of very obvious things like “I can solve problems with my brain”. It’s not “I would have disagreed that x is true before therapy” or “I’d never heard x before”, but more “I intellectually knew x was true but hadn’t ever really thought about it or internalized it to the point of usefulness”.
An example could be x = “I don’t have to keep relationships that make me unhappy.”
If you’d asked me directly, do you have to keep relationships that make you unhappy? I’d have said no, but when evaluating a given relationship in my life, I might not have been even asking the question “does this make me happy?”, instead evaluating it on things like “what do I owe them?” and “how painful would it be to try to end this?” and would have ended up keeping friendships or family ties that made me miserable. Therapy might help me think about that question more explicitly and help me consciously agree that it’s important and something I should value highly - it’s an explicit value realignment that you can clearly remember doing and reference in the future.
(For more example taken at a cultural rather than individual level, a thing the west coast has internalized that the east coast has not is “my happiness is important”, while the west coast could use a healthy dose of “some things are more important than convenience”)
Talk therapists have the invaluable tool of perceived authority. Like a hypnotist, this gives them the power to mold the thought process of their suggestable patients.
For example, IMHO, there seems to be two major (and opposite) tactics to make neurotic people feel better about themselves. Either, tell them: (A) "You don't need to feel bad, because you are a person with agency who has the power to control your feelings and actions. So be optimistic and empowered and change the things you need to change." Or tell them: (B) "You don't need to feel bad, because you are a person who has no agency due to a psychological condition that prevents you from controlling your feelings and actions. So just resign yourself to accept who you are and don't beat yourself up about not being a better or different person."
A good, intuitive therapist can figure out which approach will work with which patient and use their authority to get the patient to buy it. There are no doubt lots of other ways to "trick" people into thinking differently for their own mental health. Your friend or neighbor won't have the authority to get you to do so, however. Investing a lot of time and money to talk with a scientifically certified "expert" is probably the entry price of establishing the patient's "buy in" to the advice.
Re: inner monologue.
OTOH, talking to yourself should be fundamentally different from talking to anyone else and thus not quite comparable. If all you do for problem solving is talking to yourself, you can never get a fresh perspective on your problems, and at worst you get into an emotional feedback loop that has no outside corrective - youre going in circles.
OTOH, there is such a thing as rubber ducky debugging. You have a seemingly unsolvable problem, and you explain the problem in detail to a rubber ducky - either a literal rubber ducky or other inanimate object, or a figurative one such as a passively listening coworker/therapist. As you explain the problem, more often than not the solution will just pop up in your head despite you having received no pertinent input from outside. The solution was the problem analysis we made along the way.
Personally, I could vouch for either being true as Ive experienced both. So are they independent of each other, not mutually incompatible as they might seem? Are they true to begin with?
Years of therapy and also married to one. Here’s my take: rich people can afford better therapists. Psychologists who take insurance are either new to the profession, or not terribly effective and need the network to get new clients. Which is to say, if you have the money and the time, you might benefit from individual therapy. (Basically the worried well, sancerre crowd.) Cheaper and far more effective are therapy groups which help create accountability and community.
Boy was this a timely post for me. Just today I got off the phone with a social worker where I'd discussed my new job and my concerns about how long I'll be able to keep it. I've been struggling with issues of productivity in my personal and professional life and I'm considering therapy as a result. I've always thought of therapy like medicine, you take it when there is something wrong, but unless you have a "chronic" condition that will never go away, a healthy person should be able to function without it.
Therapists have nothing on receptionists. I have over 15 years of front desk staff experience, mostly acquired while getting a PhD in something else. It's crazy what people will tell you about themselves when they realize you're a captive audience. Not only that - they come back regularly. Twice a week sometimes. And often they repeat the same stories about their lives, over and over. For years I felt bad for these people and thought they just needed a listening ear, so my personal policy was to give it to them. But then weird things started happening.
A word to the wise, if you're thinking of getting free therapy from a receptionist: Don't pick a receptionist at a place where you work/study/live or otherwise hang out regularly. Receptionists know, see, and hear EVERYTHING, including things about other people that you may be talking about in your free therapy sessions. In two different cases, I had "regulars" who were around the place so often that I could watch how they interacted with others in real settings. Each of them was consistently misinterpreting reality in different ways. Person X was absolutely convinced that Person A was madly in love with them, when they clearly weren't, and Person Y was absolutely convinced that Person B was out to get them, when they clearly weren't. Again, two different people, each of them giving me weekly reports on situations that - as I could see for myself - were just persistent misinterpretations. No doubt a real therapist would say something interesting here about how misinterpretations arise from projections of desires or fears or the id or what you had for lunch; I don't know anything about that. I just know that these two people were clearly wrong about the things they were agonizing about.
(This shook my faith in the therapy profession as a whole. Assume most therapists don't have the advantage of being receptionists and thus actually knowing about the real settings their clients are in. They depend totally on the client to describe reality. And if the client is way off base, the therapist won't know. How is a therapist supposed to help someone if they're not even in a position to say "You're completely wrong"?)
Actually, I may have an answer to that last question. Eventually I decided to gently push back on Person X and Person Y. REALLY gently, I thought. When Person B asked if cheese were around, was it unquestionably a reference to a conversation three days before when Person Y complained about the shared fridge? I asked a couple questions like that. Then I got the reactions: defensiveness, vehement repetition of the original story, signs of distress. In both cases I was so surprised I backed off, immediately. Things toned down and we wrapped up our usual session pleasantly. But then Person X completely stopped coming to see me, and Person Y took a break for several months.
Was it a good idea to try to help these people by disillusioning them? I don't know. But maybe it's a good strategy for (not-too-awkwardly) decreasing the number of people who come to you for free therapy!
It took me going to therapy at the age of 24 (and the mindfulness practice the stemmed from it) to realize that I'd spent the last decade of my life completely dissociated from my body. I'd lost almost all sense of interoception and emotional awareness beyond the most gross of emotions and sensations.
Yes, traditional therapy is often just "talking with someone", but it is *not* just "talking with anyone" (although this in itself is something that would be healing for a surprising number of cripplingly lonely people). It's talking with a "someone" that is trained in helping you process and integrate all your shit, and the difference between that and just talking with your average untrained person is very often life-altering.
And this is just the traditional psychoanalytic model, not to mention the huge variety of embodied and trauma therapies that do far more than just "talking"
I had a similar take to Qiaochu after reading the Sequences. I'd emphasize "solving MY problems," because school/college just teaches you how to solve "the problems" that are handed to you. And when you're surrounded by people in an identical situation to you, you don't even need to solve “it’s cold outside,” because that's already covered by "dress like everyone dresses," a subset of "blend in with your perfectly homogenous peer group."
Rationality woke me up to the fact that actually there are problems that only I have, or problems that only I can identify, and I have the ability to both name them and apply myself to solving them, and if I don't then maybe no one else will, and there are $100 bills lying around everywhere, etc.
So that's why his take makes sense to me, even though we both probably appeared to have plenty of agency before we experienced those psychological changes.
I don’t know that this post delivered on it title (though I enjoyed reading it): Men Will Literally Have Completely Different Mental Processes Instead Of Going To Therapy
Was thinking maybe this was going to be more about why you therapy has evolved to favor techniques that work better for women than for men?
Note that therapists are quite likely to have their own therapists. In support of the "you can't tickle yourself" argument.
To me the reason to go to therapy semi regularly (in addition to reasons posted here) is simply that I've had a history of sudden depressive episodes, and maintaining the relationship means that if that occurs I will not need to start "from scratch" as I have in the past. Of course, this mindset and discipline means I'm unlikely to have an episode like that but sometimes tautologies emerge from this kind of process.
It seems extremely likely that most if not almost all people can, in principle, benefit from talking things over with someone else. Why not? We're a very social species -- it's no accident we have this incredibly sophisticated apparatus for communication -- and we would probably all agree *harm* can be done by having the wrong kind of conversations with the wrong person, so why not good done by having the right kind of conversation with the right person?
But what I would say is the $25,000 Crocodile Dundee question for a lot of people is: would the chances of a positive outcome be substantially improved if I talked to a professional, instead of to my friends, a 1-800 phone pr0n number, Eliza, random trolls on the Internet? Is it possible in principle to train someone to do significantly more good than average when talking things over with troubled people, and does it actually happen in practice?
 Because in the eponymous movie the Croc when told about a NYC woman who was going to therapy to talk about her problems responded in surprise 'Hasn't she got any friends?'
Is there a type of therapy that just consists of working through a remedial education on every micro-soft-skill you could potentially be missing? I wonder how effective it would be if given to the people looking for the more regular types of therapy.
An obvious comment: Remember Scott's take on Jordan Peterson? https://slatestarcodex.com/2018/03/26/book-review-twelve-rules-for-life/
I quote as appetizer: " IV. Peterson works as a clinical psychologist. (...) Much of what I think I got from this book was psychotherapy advice; I would have killed to have Peterson as a teacher during residency. (...) Jordan Peterson’s superpower is saying cliches and having them sound meaningful. There are times – like when I have a desperate and grieving patient in front of me – that I would give almost anything for this talent. (...)
So how does Jordan Peterson, the only person in the world who can say our social truisms and get a genuine reaction with them, do psychotherapy?
He mostly just listens: (...) -end of quote - now you get to that link and read up! :) btw: was the first text I ever read of SSC/Scott, following a quote I found somewhere - a lucky day, if ever there was one
There is a huge skill gap between the median software developer and someone in the top 1 percent. I expect the gap among therapists to be even larger because brains are more complex than computers and don't give as much clear and immediate feedback. So I don't think it's just the patient but also the therapist who determines how effective therapy is.
As a retired CB therapist my experience was like yours that about 50% of my clients would achieve a satisfactory outcome. There is a movement within my former profession that the relationship is everything, but I note that the average rate of success still remains around 40% for therapy outcomes.
My client's feedback was pretty consistent. They thought I gave hard love. Tough, but practical. Those that said that did well. My other clients often complained and wanted a different therapist. They didn't do well with me.
Unlike my more touchy-feely colleagues, I was happy enough with this, because as my Isaac Marks said, the therapeutic relationship is not sufficient unto itself to effect change. Have being first taught under Prof Marks I tend to concur.
That's not the current flavour of the month for evidence based medicine in Britain, or anywhere else AFAIK, especially with programs to teach people scripts tailored to specific client problems by using actors for example. I understand that good results were achieved, and using unemployed actors is cost effective, but my intuition tells me that if this is so, then what is it that makes cognitive behavioural functional analysis useful if it can be delivered by rote?
It nags me that that therapy can be reduced to scripts, because while I have script routines/approaches to client problems, I also make use of my ability to think outside the box too. Maybe I'm just deluded about that.
With regards to what is often called the worried well; those people with the need to seek reassurance from health professionals, my answer would be blunt. Reassurance doesn't work, because if it did then the clients wouldn't keep returning for reassurance.
Sorry, not sorry, but as you may have guessed my training emphasized behavioural modification, though I also took a lot of course with Padesky, so not a purist about this.
Also sometimes you have one little problem that you assume means you are irremediably broken, until someone comes along IRL or in a random internet forum and you realize everyone else got it. I have a friend who thought she was a horrible person for having intrusive thoughts until I reassured her that it was normal and something everyone had. I also heard a first hand story about a girl who thought she was dying until someone told her that periods were a thing. And there are phenomenons of rural families where no one ever goes to college, until one person does and suddenly half their cousins start to want a higher education too. Maybe sometimes you just need reassurance that everything will be okay.
This seems like a clear case of one man's medicine being another man's poison.
Can it be that people with a reduced capacity or habit of introspection can benefit immensely from outsourcing the job via therapy, while people already living too much in their heads, already too stuck in their own mental loops or even already too self-absorbed can actually be hurt by therapy (or become *pathologically* self-centered and narcissistic and unable to see anything beyond themselves, as I have seen firsthand), and in these cases of the already excessively self-reflected, "men will literally go outside and fix motorcycles instead of going to therapy" is 100% the right thing to do.
I think an important factor in the variance of therapy outcomes is that many (most?) therapists are bad.
I got, I think, what many people describe getting from therapy, from joining a discord server full of like-minded people that happened to contain a decent number who were older than me, and had been trial-and-erroring psych solutions longer than me, and could offer guidance about what to maybe trial first to get good results faster.
I had seen four therapists and two psychiatrists before joining that server, and all of them rank in benefit to my life below that discord server, my countertop dishwasher, and my toothbrush. Some of them were outright negative in benefit by themselves, most of them were absolutely negative when the costs in time and money are factored in.
I personally attribute most of this to the ableism inherent to the therapist selection process. The skills needed to become a credentialed psych professional are exactly the kinds of things I was up against a wall about, and every single one of them reacted to my problems as if it was impossible for anyone to have the struggles I was having, they did not appear to have any of the problem-solving thought-skills you describe, and could at best offer the empty encouragement that it was obvious I was easily capable of the things I had just described struggling with. One of them said, verbatim “will it really sounds like all of your problems are psychological” and that was, the END, of their insight. All they had to offer. Nice people, empty heads.
Every human and human situation is different. It's a dangerous thing to profer advice to someone. And to pay for it! Poo hoo!
I dont doubt that there are some areas in my life that could benefit from me hearing something pretty basic. But what I do doubt is whether I would be willing to listen to someone telling me one of these basic pieces of advice. I think often once I'm ready to hear it I will also come up with it pretty soon myself anyway.
Personal experience: I lack internal monologue and I achieved huge progress in functioning with therapy (ACT) in very short time.
Yeah, I never even understood the basic idea behind therapy — if thinking about my problems could help, it'd have done so long before I went to therapy.
I went a few times just to see — well, more because everyone kept telling me to try it — and yep, it was exactly as useless as I expected. The problems and solutions were obvious: it was my willpower and emotional state that stood in the way, and no words or thoughts could change them.
I remember seeing a therapist and always feeling bad when I left. Then getting through my week to go back. It seemed like a goal I was not moving forward with except I was running out of weeks until the end of therapy. With feeling so bad, I decided NOT talking to a therapist felt better. I found an online group beneficial. That way I could write at any time of day or night. I found the typing itself got out the energy and bad feelings. And reading about many others with similar, or worse, situations helped too. All on my own schedule and when I needed it.
Also, even if you know how to do the required introspection yourself, paying for a therapist is committing future-you to actually putting in the time to do the work.
It’s like going to the gym (or maybe paying for a personal trainer) vs. just working out at home; many find it’s much easier to blow off the latter, even with the best of pre-registered intentions.
I hesitate to mention this, because in the video the analogy is from, the idea that's being compared is specifically political, and I think it under-credits more thoughtful people from the side of the political spectrum who are being criticized. But, well, there's this video, "I Hate Mondays", which is basically explaining that a move that gets used in politics, to avoid engaging with uncomfortable thoughts about a problem, is to treat the problem as if it were something inevitable -- as long as you have a day or two of rest, the day when you go back to work will always be a bit of a drag. You could change exactly which day that is, but work has to get done _some_ time, and so well, Mondays, whatchagonnado? We can gripe about them, but that doesn't mean we should try to change anything.
The criticism is that people often sweep problems into this category -- things that you can gripe about, or in some cases even sincerely feel sad about, while still considering it a waste of time to try to _do_ anything about them -- even when there are actually things that _could_ be done, because those things discomfit them. The video poses this as being a common pathology of conservatives, but one might just as well look at liberals whose mental processes go skating away from policies that might address homelessness when those involve deregulation, or reforming California's notoriously terrible CEQA. One of our local Sierra Club chapters has recently taken up a position _against_ streamlining CEQA review for bike lanes and sidewalks. Clearly the best way to protect the environment is to make it prohibitively expensive to facilitate non-car modes of transit. We must protect The Process. I'm sure that endangered wildlife will find a welcoming home in the thickets of paperwork. /headdesk
In any case, to circle back to the point: I think what your friend was saying, when he said it hadn't occurred to him that he could reason about his problems and then solve them, is that he had been trained to make this move almost reflexively, about anything bad. Thinking about bad stuff is uncomfortable. So just tolerate it, be stoic about it. You can't _do_ anything about bad stuff anyways, trying to just means spending more time with your mind in a state of discomfort.
As someone who went to graduate school to be trained as a therapist, I was planning to jump in to offer some alternative takes on therapy as a profession - both how it is more than supportive therapy/talk therapy as well as the trends/flaws/susceptibilities within the industry that have contributed to many individuals' negative outcomes - but Radar has already covered the subject eloquently and likely far better than I would, especially since they've got real-world experience backing it and I segued into higher education afterwards. Instead, then, I'll offer a metaphor for how I always viewed supportive therapy specifically.
I would equate supportive therapy to getting dressed in front of a mirror with someone else giving their opinion on your outfit. Some people have an innate (or have developed over time) a sense of fashion and are aware of their own personal tastes and can get dressed just fine without a mirror or any outside assistance. Some people have a good sense of what they like but also want to double-check themselves, and so can get by on their own as long as they have a mirror to take a look at themselves and double-check their outfit before going out. Others (whether because they haven't developed a personal sense of fashion or style or are just seeking some outside validation to make sure they're in step with their local groups/social circles) like to have a third party offer their advice on what is working with the outfit, what isn't, and offer suggestions or changes as necessary.
I think that goes a long way towards explaining the variance in the efficacy of supportive therapy! How much bang you'll get for your buck depends on how much you have access to an empathetic ear outside of therapy, your ability to self-reflect, your own strategies and methods for processing your feelings and the various day-to-day events of your life, and how capable your third party is in helping your evaluate (or re-evaluate) the approach you're currently taking. It's definitely not necessary for everyone, and the industry is definitely saddled with its share of individuals who are doing more harm than good (whether properly credentialed or not), but I don't think the variance is all that mysterious.
A difference I found in therapy is: when talking with friends and loved ones about sources of conflict, hardship, whatever, I frame it in a way that is attempting to garner sympathy. When talking to a therapist, I frame it in a way that is attempting to be constructive and resolve the issue. Sometimes just framing things in that new way caused me to realize I had methods to deal with these issues already, but wasn't consistently applying them.
Doctor: Do you hear voices?
Patient: No never. Not the way you mean anyway.
Doctor: Hmmm.... that's concerning. You should talk to a therapist.
Patient: What! Why?
Doctor: Well hearing voices is healthy. So...
Doctor: Yep, just as long as the voices aren't, you know, utterly insane themselves.
Am I the only one who read the headline and thought that it was going to be something about gender differences in therapy participation?
In my own experience therapy is really helpful to time-bound lines of thought that otherwise become dysfunctional.
For instance if late at night i start falling into a depressive thoughts rabbit hole in which I question all of my life choices I can defer thinking those thoughts to the next session.
I also have a relative has a really bad addiction and has consistently harmful interactions with me, and i can cope as long as I can vent my frustration with someone, but I don't want to berate my friends thrice a week telling them how a person they don't even know has found a new way to get at me.
I don't go to therapy to be given advice (clearly), nor do I go for reassurance. I simply enjoy and benefit from setting aside an hour and having someone help me organize my thoughts; I'm paying for time outside my own head. I can't do this with a friend because they're too quick to try to advise, or to be indifferent. The therapist remains objective yet engaged at the same time. It's moderately helpful.
you wrote "all debates are bravery debates" where there are obviously very different types of people and general rules that apply to one but not the other.
what if this is not a useful treatment for people who read things like SSC/lesswrong/overcomingbias etc?
I would definitely benefit from talking to someone about my issues in order to think through them more clearly. I have inner monologue but there's some ugh field around some of my issues; and also having to explain stuff to another person can help when I'm stuck even when there's no ugh-field (https://en.wikipedia.org/wiki/Rubber_duck_debugging).
But this requires me feeling that the person I'm talking to cares, is interested, actually follows, and is open and not trying to fit into a model of a healthy mind. The couple of times I tried therapy, this didn't happen. I find the relationship with the therapist unnatural, unclear, uncomfortable. I don't know to what extent I am supposed to give in to their expertise and "treatment" and evaluate the results months later, or treat them like paid professionals that I can use to help myself by taking the lead.
Just came here comment on the insanity of the lack of studies
My therapist (rogerian) is basically someone who I pay to listen to me. All they really do (except on one quite funny occasion) is basically paraphrase what I've said back to me. Over time this basically helps me narrow down themes, things I'm actually unclear on, things that I'm hiding from myself and others etc.
You can basically do this with journaling etc. But I don't trust myself to accurately reflect myself.
You can do this with anyone really, but friends and family are often the people I'm talking about so that's not really possible. Friends and family also have years of ideas about who I am that could get in the way.
My therapist is just a relatively neutral sounding board that helps me to uncover the layers of things obscuring the path forward. The quote unquote breakthrough I had was basically me slumping into therapy, flopping to the chair and being like "This is all the stuff I need to change, I've been hiding it by xyz, you have known this since our first session because its painfully obvious from the outside isn't it?" and them basically smiling and nodding.
For me, it's a combination of "you can't tickle yourself" and the old adage about how with prostitution, you're not paying for the sex as much as you're paying for the prostitute to leave afterwards.
You just can't call yourself out on your own bullshit as effectively as someone else can. Or, even if it is something you're already telling yourself, it can be helpful for someone external — who isn't meaningfully in your life — to back you up and help your homunculus lean on the right levers.
And there are certain things you can't or shouldn't put upon the important people in your life, at least not unfiltered. With therapy, you can just say the most unfiltered version of things without worrying about judgment or eroded relationships.
Lastly, I find couple's therapy really helpful in that difficult conversations can be moderated and steered back towards productivity, and it provides a sort of "disinterested third" who can provide accountability for partnership goals.
Someone else brought up priests, here, and I find that really interesting because I do think that therapists can be like secular priests, and this could be a good or bad comparison, but I take it as a negative...
you could say that a priest's job is to selflessly help his parishoners, but more often than not you can find examples of priests abusing the power imbalance in some way, or using their position as a way just to rag against all the things they hate... rather than be a holy, good, nice 'man of ogd', like you might say the job description entails... because descriptions rarely capture how something plays out in the real world.
The same thing with therapists, but a different set of people might be fooled by the same behaviour that corrupt priests exhibit, but because it is not about 'religion', but instead framed as 'laws of psychology'...then different people might take it seriously.
A lot of people are more interested in dogma, than actually discovering more about the universe... and you might say 'honoring God', if they're priests...
The best the therapist I ever had was a psychiatrist who kept telling me how f**ked up my life was. Every session with him made me more depressed. Moreover it made me angry, because there were a lot of wonderful things that I had experienced, and he didn't seem to be acknowledging them (I just wanted advice about how to get through a particularly stressful time in my life). I finally lost my temper with him. I shouted at him, "My life isn't f**ked up!" He smiled at me indulgently and told me the session was over. I walked out angry, but in defense of my statement I kept thinking about all the cool and fun things that happened over my life (up to that point). Then I realized that my life was actually pretty good, and whatever problems I was having weren't that big. And I realized I didn't need his help. I never went back. To this day, I'm NOT SURE if he provoked me on purpose to get me out of my rut, or whether he really thought that I had messed up my life. Either way, once I started looking at my situation in positive light I never needed counseling again.
What does the title of this post have to do with the content of this post?
I’m honestly shocked to be reading this from a rationalist and psychiatrist. Therapy provides patients the framework to think about mental health and the vocabulary to talk about it. It is the only chance many patients will ever have at reconciling the “why” behind their illness. I am curious why the rationalists on this substack would cite inconvenience or "just use a friend" as reasons to shy from the chance to test their mental constructs of the world by an objective party who will challenge their consistency/accuracy. Am I missing something? Why all the hate?
I might suggest that -a- reason (not THE reason) for the popularity of "talk it out" therapy is the decrease in personal relationships.
I was in an isolated place and time in my life going through a divorce, and going to a therapist was helpful, just to unload a little. After about a year, the initial trauma was, well, scabbed over if not healed, and at some point I realised that continued progress would really depend on me making significant changes in myself and my life, and quit going.
I buy the idea of the therapy I had 2 years ago, during a severe bout of anxiety & depression, as unlearning a set of rules I had about myself & replacing them with more useful ones. There was nothing mysterious about it per se, although the therapist was remarkably good at treading the line between being a faux parent and a kind of dispassionate mental mechanic. My default state remains 70% actively happy, 20% neutral & 10% confused & anxious. Prior to this I was 70% confused, anxious & angry & 10% happy but waiting for happiness to dissipate. I doubt I could have got here without 2020’s 6 months of weekly Zooms with her.
Is it possible that therapy has very little effect and people are just believing that it does? For example, could it be possible that without therapy, QiaochuYuan would have been the same successful person, but would have nothing to attribute his success? A bit like billionaires who credit hard work for their money, while it's usually just luck?
Are there some studies that prove that therapy is *actually* effective?
I went to group therapy and we had a new person introduced, who among other things had anger issues.
they would start arguing with their partner about something and in the end they'd black out and become violent, and wanted to do therapy to well, stop doing it.
I asked if they ever tried to just stop arguing and go for a walk until they calmed down when they felt they were becoming agitated, and they just looked at me like I said water was dry and the ground is lava.
they said that "not having arguments that lead to violence" had never, ever crossed their mind, and were flabbergasted at the mere thought of "just stop doing that bad thing that leads to even badder things".
I want to throw a big old culture clash into this discussion.
I've lived big, big chunks of my life alongside two groups: jewish academics, and old fashioned Chinese farmers who happened to become engineers during the cultural revolution.
The jewish academics can't get over the idea that the old fashioned Chinese farmers who happened to become engineers during the cultural revolution have precious little to no self analytical habits.
The old fashioned Chinese farmers who happened to become engineers during the cultural revolution can't *see* therapy, or self analysis, or a robust inner monologue. It all might as well be the seventh ultraviolet shade of purple, or the color greb.
I'm sorry if this ruffles anyone's feathers, and I welcome if someone wants to offer a different experience.
This really speaks to me. I've struggled with fairly severe depression my whole life, as well as anxiety and addiction. Due to the nature of my work I couldn't get therapy for a long time, but that recently changed and I started going. I've probably been in it about five years. I've tried about five therapists in that time, almost always giving them month's worth of time to give it a valid try.
Honestly, it didn't help. Pretty much at all. I blame myself. There's something about me, even when I have a realization it doesn't do anything to persistently change my mood.
It's so frustrating because I know *so many* people who talk about how much therapy helped them. Which really makes me wonder what's wrong with me.
The things that have helped in that time:
1. Cymbalta was amazing at first, then over the course of a year or two the efficacy went away.
2. TMS was amazing for a while as well, although its effects are waning recently as well.
Has anyone read "Psychology Gone Wrong?" I hear it's a great book but a poor translation. An article based on it in Psychology Today basically said a good friend can fill the role of therapy just as well, that it's merely being able to talk through issues with someone empathetic.
I spent my time in the trenches doing therapy, including everything from manualized treatment protocols to "supportive" therapy. I don't think it works much for a lot of reasons, but I love being basically a forensic psychologist only now.