Who shouldn't be in therapy?
I'm reading Jung and learning about feedback-informed therapy at the same time and it's confusing.
I disagree with the idea that “everyone should be in therapy”. I think my side is gaining steam, because I’ve seen justttt a couple other clinical contrarians start to put that out there. Whether it’s to get more engagement on a post or a genuine belief, I don’t know. On the occasion that someone expands on their statement, I’ve seen 2 reasons:
YES narcissists go to therapy and learn therapy language to better manipulate people!
This mostly happens in the comments when the mental health professional or advocate or influencer whatever does not explain why they think not everyone should be in therapy. I have indeed seen people get secondary gains out of therapy. Sure, depending on your therapist you might learn to talk like Jonah Hill to better manipulate your girlfriend. But in instances I’ve seen it, it’s more like a status symbol, assigning a middle class distinction and an I-have-a-college-education vibe to yourself akin to a New Yorker tote bag. Some people are able to feel self-assured in their behaviors, even when those behaviors are bad, because their therapist agreed with them (did not verbally fight with them) about the version of the story they told about the situation. I’m convinced they didn’t know they were doing that and would never be able to admit that to themselves.
YES people need community care and therapy is a fundamentally individualist, isolating, pathologizing practice!
There are decent arguments for this on a macro scale that work depending on your ideology. Surely many people would have better mental health outcomes if they were more connected to people and nature, less alienated from their labor, blah blah. Surely networks of wellness exist through the world and across history. It is great if people can provide care for one another, and get good at it, without having to be paid for it, which in my opinion is when it starts to become therapy in some form. Something easy I think about: it would be great if we all had a few months of basic mental health skills and crisis management our last year of high school and then we had to dedicate at least a 5 hours a month to our choice of a variety of tasks supporting the mental health of people in our neighborhoods or whatever. We don’t live in that world and even if people know how to help, they rarely have time, unpaid, they can dedicate to even caring for themselves, to say nothing of others. Most of us have no community to speak of. But this “they just need community care" argument kind of falls apart at the individual level. Sure, many people’s mental health can be helped greatly by those around them, or winning a union, or by getting a dog they have to walk every day. But I have yet to see a solid account of a culture or time period in which there were no people who had significant struggles with what we call mental health here and now. The smartest and most caring community members may reach a point where they need to call in mental health professionals because they are not equipped to deal with a loved one’s or community member’s needs. I resent the way the argument above makes the people who believe it feel- like they’re just doing something wrong, and if they were smarter or better somehow, they could help they friends or family without professional help. I personally think it makes sense that some people would study and practice for a long time to become experts on complex issues and take the load off of the people most affected by a crisis. It is really cool that we have a way to help most people that experience that should they choose to and be able to access care.
That disclaimer was long. Sorry.
When I say not everyone should be in therapy, I’m not invoking either of these arguments. I’m saying that I believe there are people in therapy who do not need to be there, and they should at least be informed of that.
One topic the (amazing) podcast Conspirituality plays with is the self-optimization gurus of the past decade. I cannot find the percentages, and if you can please tell me, but I know they have said something along these lines: Wellness is historically about people attempting to get from 0-90%. Modern medicine and its associates are pretty good at getting us just about there. The self-optimizers are obsessed with summiting the last 10% of wellness, reaching human perfection, and will likely spend the rest of their lives chasing it.
This is the attitude some people arrive at an intake session with. And they usually don’t know they’re doing it- no one is saying “my life is almost perfect, but I could be getting a *bit* more sleep”. They have been indoctrinated by the ideology of self-optimization to the point where they see their imperfections as failures. I think we all have to some degree. By agreeing wholeheartedly to the premise that they need me and my idealized expertise, or could even meaningfully benefit it, I fear that I’m cosigning a mission of obsession marked by feelings of inadequacy.
self-optimization ideology + “therapy as medicine” + the over diagnosis of normal human experiences = I am imperfect and thus I am ill.
The medicalization of mental health has helped reduce stigma with a lot of people who wouldn’t otherwise have a functioning metaphor. It’s also helped us all use our insurance to get things we know make us healthier, like therapy. But it also scares the shit out of some people to imagine that their anxiety disorder or run-of-the-mill human malaise is a serious chronic illness. If the metaphor you use to understand mental suffering is medical, it necessitates the urgency and precision of medical treatment. I don’t think that’s always a good thing.
By the way, it’s not just the “worried well” minor problems you’re thinking of. There are people who have experienced so much pain and lived through so many horrible things, but adapt and adjust fine themselves. Does this mean someone grieving the death of their father should wait and see if they need need therapy in a year? No. But if 5 years later they come in with lingering human despair that does not cause them distress or prevent them from getting what they want out of life, I might tell that person they may not need to further process it (after obviously assessing for other stuff). Up to 26% of people who meet criteria for substance use disorder enter spontaneous remission- they just stop on their own, without formal intervention. Should that person losing their life to alcohol wait and see? No. But 1. we need to be careful about the amount of credit we take as clinicians and 2. No one would say that they need to go to therapy for alcoholism if they’re doing fine in recovery years down the road.
I’m always looking out to see if people are setting goals from a “striver” part of them. It’s an easy task for me. I don’t have to pick apart their words. I just need to listen to this part of myself whispering “yes, yes, an agenda! we will crush it! we will be victorious!” I think earlier in my career, the part of me striving to accomplish, to make sure I’m useful, would be happy to ally with someone else’s. I loved written treatment plans with numbered lists. To keep it short, I no longer take breathless demands for self-control at face value.
Feedback-informed therapy is an evidence-based practice developed to improve clinical outcomes in the course of therapy by formalizing the approach to collecting feedback and using that feedback to guide treatment. I don’t have access to training in FIT but I am interested in it, so I found this powerpoint developed by the founder of FIT, Scott D. Miller, Ph.D. This essay was developed after I lost my mind about a little part in it for which I have little context:
If you come to therapy at a practice using feedback-informed treatment and your intake scale reflects that you are doing pretty well individually, interpersonally, and socially, FIT dictates that many treatments are actually not appropriate for you. I wish I had more information on this right now, but this seems too important to not bring up. I love “depth-oriented” treatments, and they also open a can of worms. It is part of informed consent to warn of the risks of certain treatments, and I honestly don’t think that therapists in general are great at taking that seriously. But I’m deeply grateful for the newfound tension I’m feeling- is it better to help someone solve an urgent problem and then tell them to leave their relationship with their grandparents alone?
Therapist culture is in an era of pushing back against insurance companies’ preference for short-term manualized therapies. We’re idealizing long-term treatment, and holding respect for lifelong attachment-based issues and intergenerational healing. I think this is a good trend on the whole, but I also think it’s deeply unethical for therapists to hold beliefs about therapy as a years-long relationship if their clients are unaware of that and unaware of how other therapists may think differently about it. Maybe they’d rather not get into a deep personal relationship if they knew the treatment plan was that extended. Maybe a different therapist down the street would be willing to see what 6 months in treatment does. Maybe some people just want their Wednesday nights to be free again after awhile. Those copays add up, too.
This is controversial, but I’m of the belief that we don’t need to unearth everything outside of our consciousness. We do best when we make ourselves able to receive messages from what is underneath so we can chose to understand and integrate them if we chose to.
In the spirit of all this, when I finish Man and His Symbols tonight1, I am going to heed the words of some Jungian scholars and leave some Jung for my middle age. If I am for some reason not lucky enough to get there, that will be okay as I couldn’t have forced the wisdom of middle age at this point no matter how hard I strived.
Both
“Until you make the unconscious conscious it will direct your life and you will call it fate” - Carl Jung
and
Stop picking at it!
I wrote this all in one day like 6 months ago, I haven’t published it because it’s not perfect yet or not important or something or whatever, and I still haven’t finished the last couple books.
Yes, I absolutely agree and appreciate your post on this topic!! I’ve seen more therapists and journalists coming out with versions of this same opinion: not everyone needs therapy, and, in fact, going to therapy past when you *need* it can lead you to worsen and become dependent on the therapist. Therapy does not always help! The other argument I’d add for ‘why’ people posit this opinion is that “it can harm children who have not yet otherwise learned how to be resilient and overcome challenges without the support of a mental health professional.” I think this is interesting and definitely worth further consideration when asking whether children *need* therapy or not.
Thanks for writing :)