Therapy part 1
Toxic and therapeutic doses
Every treatment has a therapeutic dose and a toxic dose. The dose makes the poison, goes the adage attributed to Paracelsus, the legendary Renaissance physician. For that reason, nearly every health intervention has an established therapeutic dose range. One notable exception today is therapy. I’ll discuss why we need individual limits to therapy today and leave the societal effects of too much therapy for another part.
Limiting interventions is prudent for both individuals and society. Usually, when establishing a drug’s safety profile, researchers first examine its toxic and therapeutic effects on the individual level. Individual adverse effects are often analogous to larger effects.
For instance, antibiotics can alter individual gut microbiomes, killing beneficial gut bacteria while leading to overgrowth of antibiotic-resistant inflammatory bacteria.1 Similarly, overuse of antibiotics among a population leads to emergence of dangerous antibiotic-resistant “superbugs.” Yet, antibiotics save millions of lives and were a main driver of the Golden Age of Medicine, demonstrating how our most valuable interventions need stewardship if they are to remain beneficial and not harmful to us. They are extraordinarily useful so long as we take them in extraordinary circumstances.
For mental health interventions, popular culture takes the opposite approach. Sleek ads abound for on-demand therapy. Young people share and compare therapists like gossip. Some even see not going to therapy as a dating or friendship red flag, though this pressure has rightly received pushback.
Removing stigma to improve access to mental health services is important but shouldn’t remove critical thinking about risks and benefits. It’s not a given psychological interventions will be helpful for all individuals. Even vitamin supplements have individualized tradeoffs, so we make informed decisions to take them.
Too much of a good thing
Where did this assumption of limitless therapy being a good thing come from? I’m not sure, though I have some ideas. Perhaps commercial interests profit from pathologizing normal parts of life, especially now that online therapy platforms are popular. Maybe the sociocultural trend of atomization has made reliance on friends and family taboo and outsourced their everyday support to therapy. Or, once-widespread effects of religion—community, moral frameworks, organizing life path narratives, etc.—are gone, leaving a void replaced with therapeutic coping mechanisms.2
Regardless of how this therapeutic expansion happened, its effects on individuals show the consequences of too much of a good thing. Unbounded use of therapy leads to stasis and complacency. People would rather talk than take action to change: having therapy always available means always an opportunity to talk, removing the impetus for timely change.
Therapy can also lead to emotional fragility. Reliance on the presence of a therapist to deal with events and emotional reactions to events can become an ingrained habit. Some reliance (transference) is a necessary part of the therapeutic relationship.3 It’s like training wheels for emotional regulation, so that one can learn a regulated response within the relationship before learning to self-regulate. Real personal crises can certainly require brief reliance on that relationship to get back to equilibrium. However, treating that relationship as the main automatic response to stress keeps a person emotionally dysregulated towards everyday events. If I learn to cope using the therapy itself and not the skills I learn in therapy, I lose the ability to see events in perspective and evaluate them as things to which I can control my response. Losing that response control will mean more and smaller things can set me off.4 When something truly big comes along, I’ll have lost the ability to cope with it.
Furthermore, there’s a risk of the therapization of life. This risk will become more important regarding social effects (stay tuned for part 2), but it’s still a problem for individuals. Psychology is just one way to look at the world, not the way. Seeing the world in exclusively psychological terms is a path to cynicism and an impoverished view of the world. There are transcendent parts of the human experience, and whatever is beautiful, good, and true extends far beyond psychology’s bounds. Turning therapy or psychological thinking into one’s personality is unhealthy.
How to dose
One could argue that these effects only result from bad therapy. Yet, good therapy is necessarily dosed. Effective therapy, as with any treatment, has doses and delivery methods corresponding to specific goals and diagnoses. Cognitive behavior therapy (CBT), for instance, started off with dosing. Aaron Beck and colleagues, who developed CBT, saw disadvantages to the more meandering, unstructured approach of analysis. A dose of 8-12 sessions moves progress and allows checkpoints for assessing the therapy’s effectiveness.5 CBT currently has the most robust evidence base and has long-lasting benefits. Its average time to resolving a depressive episode is 3-6 months.
Contrast that with traditional psychoanalysis, which lasted on average 5-7 years.6 That’s at least five times longer than the average depressive episode takes to resolve without treatment, which is 6-12 months.7 It would seem then that unlimited dosing might even prolong depression!
Interestingly, the current-day inheritor of the analytic approach, psychodynamic therapy, is quite effective, with outcomes at least as good as CBT depending on the condition; it, too, often has a prescribed dose of 12 sessions.
Not to say doses have to be rigid. Good treatment adapts to individual variations and situations. Patients and clients should also feel free to re-dose and seek help as needed if significant mental health problems emerge. But one should know that re-dosing is for a specific condition one is having evaluated.
Several months ago, I was asked to summarize a review article of an online therapy topic for another journal. One of the studies included in the review noted an increased risk of adverse effects with online therapy. The study was small and very uncertain, and I initially didn’t think of mentioning it. At the time, adverse effects from therapy sounded ridiculous! After doing some more thinking and reading, however, I can now imagine various ways problems might develop. Online therapy is both the most available and the least embodied form of psychotherapy so far. While improving access is good, using therapy judiciously becomes more difficult if I have it at my fingertips. And, by making everything a potential indication for therapy, we make therapy less effective, or even an anti-therapy that makes us less resilient.
To help therapy work for us, we need to bound it and give it a circumscribed place in our lives. It’s one occasional intervention among our normal, everyday support networks of friends, family, and community that make up much of human flourishing.8 Therapy shouldn’t supplant them but should encourage us to venture into deeper involvement with the people given to us. Using therapy this way, we’ll have a better chance at the mental clarity we seek.
Update: See part 2 here.
Families and therapeutic authority
We can find solutions to atomization in the very origins of therapy, which would have us realize and affirm the family’s authority.
If you liked this post, please share it and help grow my newsletter!
Ramirez et al 2020, “Antibiotics as Major Disruptors of Gut Microbiota,” Frontiers in Cellular and Infection Microbiology. https://www.frontiersin.org/articles/10.3389/fcimb.2020.572912/full
See Philip Rieff, The Triumph of the Therapeutic and Carl Trueman, The Rise and Triumph of the Modern Self.
Transference, or relating to the clinician as to a parent or authority figure, has been a key element of psychotherapy from the early days of its development. Jung, Collected Works Vol. 7: Two Essays on Analytical Psychology, Princeton/Bollingen 1966, 64.
Schreiber, Grant, and Odlaug 2021, “Emotion Regulation and Impulsivity in Young Adults,” Journal of Psychiatric Research. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3334448/
Judith Beck, Cognitive Behavior Therapy: Basics and Beyond, 3rd ed., 21.
Werbart and Lagerlöf 2022, “How much time does psychoanalysis take?” International Journal of Psychoanalysis. https://www.tandfonline.com/doi/full/10.1080/00207578.2022.2050463
See Kovacs et al 2016. https://www.sciencedirect.com/science/article/abs/pii/S0165032716300313?via%3Dihub
Tyler Vanderweele 2017, “On the promotion of human flourishing,” PNAS. https://www.pnas.org/doi/10.1073/pnas.1702996114