Why psychotherapy is so weird; or, One problem with the crazy leading the crazy

Created 4 Jan 2012 • Last modified 30 Mar 2013

The reader is no doubt aware that therapists are divided into many cults—I mean, camps, each with its own One True Way to conceive of and treat mental illness. Many of these camps are attributed to single founding figures: Sigmund Freud was the father of psychoanalysis, Carl Rogers was the father of person-centered therapy, Albert Ellis was the father of rational-emotive therapy, Aaron Beck was the father of cognitive therapy, Steve Hayes was the father of acceptance-and-commitment therapy, and so on.

What is remarkable is how many of these paternal figures invented their therapies more or less in the process of treating their own mental illness. An article in Time magazine (Cloud, 2006) characterizes Hayes as crippled by anxiety until he (presumably) became more mindful and accepting, and Beck as overcoming his fear of tunnels by challenging his irrational thoughts. A New York Times article (Carey, 2011) quotes Marsha Linehan, the mother of dialectical behavior therapy and a sufferer of borderline personality disorder, as saying "But I suppose it’s true that I developed a therapy that provides the things I needed for so many years and never got." And the Wikipedia article "Wet nurse" says that Steven Pinker speculated in his book How the Mind Works that "Sigmund Freud's theories about the Oedipal complex were the result of Freud being raised by a wet-nurse, rather than his mother, because this dissociation from his mother would have prevented the Westermarck effect from taking hold." In the face of all these stories, it seems a reasonable hypothesis that the typical way in which therapies are invented is through the introspection and personal experience of the therapist.

To show how this phenomenon can be particularly problematic, let's think about something entirely different for a moment: computer programming. Haskell is an awesome, deep, powerful programming language, but the sophistication comes at the price of a steep learning curve. Particularly infamous are monads, a feature of Haskell that underlies operations as basic as I/O and can be very useful but are legendarily difficult to understand. You may be able to find on the Web as many tutorials about monads in particular as about Haskell in general, each with its own approach. The Haskell wiki has a whole catalog of the darn things. Extreme creativity is common: Eric Kow, for example, compares monads to space suits and containers of nuclear waste.

Seeing as demand for these monad tutorials continues unabated, one might imagine that the tutorial-writers are doing something fundamentally wrong. Yorgey (2009) puts it like this:

…imagine the following scenario: Joe Haskeller is trying to learn about monads. After struggling to understand them for a week, looking at examples, writing code, reading things other people have written, he finally has an "aha!" moment: everything is suddenly clear, and Joe Understands Monads! What has really happened, of course, is that Joe's brain has fit all the details together into a higher-level abstraction, a metaphor which Joe can use to get an intuitive grasp of monads; let us suppose that Joe's metaphor is that Monads are Like Burritos. Here is where Joe badly misinterprets his own thought process: "Of course!" Joe thinks. "It's all so simple now. The key to understanding monads is that they are Like Burritos. If only I had thought of this before!" The problem, of course, is that if Joe HAD thought of this before, it wouldn't have helped: the week of struggling through details was a necessary and integral part of forming Joe's Burrito intuition, not a sad consequence of his failure to hit upon the idea sooner.

But now Joe goes and writes a monad tutorial called "Monads are Burritos," under the well-intentioned but mistaken assumption that if other people read his magical insight, learning about monads will be a snap for them. "Monads are easy," Joe writes. "Think of them as burritos." Joe hides all the actual details about types and such because those are scary, and people will learn better if they can avoid all that difficult and confusing stuff. Of course, exactly the opposite is true, and all Joe has done is make it harder for people to learn about monads, because now they have to spend a week thinking that monads are burritos and getting utterly confused, and then a week trying to forget about the burrito analogy, before they can actually get down to the business of learning about monads.

Joe had a mental problem of sorts, and he managed to solve it, but he is mistaken about how he solved it. Worse, he's unlikely to ever be corrected. For, I imagine that the readers of Joe's tutorial will be left with a better impression of the tutorial, and will be better affected by it, than Yorgey predicts. Will the burrito analogy be all they need? By no means. But by reading that tutorial, they'll inevitably work with monads some more and think about monads some more, and over time, after reading a lot of other tutorials and writing code and scratching their heads, they'll come to understand monads, just as Joe did originally. All the silly quirks of the tutorials had nothing to do with it. The learner just stumbles to the understanding themself.

My idea is that this is what happens with psychotherapy. It has often been argued (e.g., Wampold, 2001) that most current psychotherapies are about equally effective, despite their exaggerated differences. And clearly, none are silver bullets. But people manage to get something out of them from what makes psychotherapy psychotherapy—confessing one's insecurities to a benevolent authority figure, thinking critically about one's problems, and so on. In order to create psychotherapies that treat mental illnesses more effectively and more reliably than a burrito analogy can explain monads, we'll need to stop relying so heavily on introspection and determine precisely how mental illness is brought under control.

Considering the huge range of possible causes of mental illness, I'm betting that powerful psychotherapies will be much more narrowly specialized on problems (but still much less subject to variation between patients in method and in results) than PCT, RET, CBT, ACT, DBT, and the rest of the alphabet soup we have today.