How I Learned to Trust in Therapy—Even Without Homework

This is DATA, a monthly column by Angela Chen on numbers, nerdery, and what it means to live an evidence-based life.

If you went to the psychologist Albert Ellis and told him the tragedies of your life, he might offer you this advice: “Nothing can be 100 percent bad, because it invariably could be worse. If you are raped and killed, that is very bad, but not 100 percent bad, because several of your loved ones could also be raped and slaughtered, and that would be worse. If you are tortured to death slowly, you could always be tortured to death slower.”

Ellis died before I started therapy in 2013, but his words live on in How to Make Yourself Happy and Remarkably Less Disturbable, the book my first therapist asked me to read. I did. My grandmother died a few weeks later. It could be worse, I told myself gamely. Several of my other loved ones could also be dead.

The famously cranky Ellis founded “rational emotive behavioral therapy”—a variant of cognitive-behavioral therapy that I chose precisely because it had the word “rational” in it, and because I was already so good at it. I loved systematically picking apart my thoughts. I was eager to remind myself that I was not being tortured to death slowly or quickly. I overfilled worksheets to show off how rational I was capable of being even while mired in a depression I saw as wholly irrational.

I was doing everything “right” but I was not feeling better, and so one morning I sent a polite email thanking my therapist and terminating the relationship. She sent an equally polite response. I wouldn’t try again for two years. When I did, I ended up in the form of therapy I disdained: not the grounded, practical cognitive-behavioral therapy, but the kind where you sat and talked about whatever came to mind, something my friends and I already did for free.

Initially, I had chosen “evidence-based” CBT because it addressed concrete problems, and I trusted the data on which types of therapy were most effective. But it was psychodynamic therapy—the form I feared, that studies deem less effective—that changed me for the better.

*

Over a century after Freud set up his first practice, there is still little consensus on the value of therapy. Psychologist Hans Eysenck fired shots in 1952 when he wrote that data “fails to prove that psychotherapy, Freudian or otherwise, facilitates the recovery of neurotic patients.” Eysenck wasn’t the first to do so, and there’s no end in sight. For every study suggesting therapy works, there’s another one claiming overblown promises. In February, a meta-analysis of 247 psychotherapy studies concluded that most studies that show a benefit are biased. Even more damning, another recent study suggested that people in long-term therapy become more neurotic and less confident.

One problem is that “therapy” is an umbrella term—there are over five hundred forms—with so many different components. Some propose all psychotherapy is a placebo or that people feel better not because of therapy, but because they went during their lowest points and life improved on its own. Others say most forms are equally effective, or that it’s the bond between the therapist and the client that matters and not the school of therapy.

But if there is any agreement to be found, it is that cognitive-behavioral therapy is the most empirically supported method—the one that, in the jargon, relieves anxiety and depression. The weight of evidence is vast, to the point when sometimes “evidence-based therapy” is shorthand for CBT itself. It’s not hard to see why. There’s minimal talk about whether you got enough love as a child. CBT says: It matters little how you got here. Let’s focus on the fact that you are here and that there is work to do. Have some worksheets.

Say you wave at a friend, she doesn’t wave back, and you think she’s mad at you. CBT tells you to write down all the other reasons she might have ignored you and focus on these instead. There’s wisdom in this approach, and many other forms of therapy integrate such techniques. Crucially, CBT is usually the cheapest form of treatment and is known for producing results relatively quickly, so it’s also accessible for many.

My own belief was simple: If you try something, might as well try something proven to work. Growing up with my mother’s Eastern medicine advice—and discovering that nothing happened when I ignored her warnings—I developed a horror of anything that didn’t come armed with five citations. Not only did CBT have papers to back it up, I understood exactly why it worked. You believed the wrong things, then the right ones, then felt better. It was unclear how unstructured talking solved anything, so any “success” from that must be a delusion.

*

Because I have always lived with myself, almost every thought that floats through my mind is familiar. So it caught my attention when, during a particularly difficult night, I encountered one I didn’t recognize and couldn’t easily explain: I feel so left behind.

Sara, I knew, would be interested in this.

Sara is my second therapist, someone I picked from the Psychology Today directory because her office was close to work and she didn’t focus on CBT. I specifically wanted something new, yet remained plagued by the thought that I was wasting my time. In our weekly sessions, I desperately cast about for conversation topics and ended up updating her on my friends’ lives and contemplating how ludicrous it was that in this day and age we still needed to print out, sign, and scan contracts.

Worst of all, Sara seemed entirely too interested in my childhood. I wanted to know why I felt angry and sad when I should feel grateful. She wanted to know what it was like to be raised by disapproving grandparents after my parents immigrated to the United States when I was two. Don’t remember, don’t care, I thought. It matters little how I got here. Let’s focus on the fact that I am here and that there is work to do.

I can’t pinpoint when I stopped resisting and started talking about my family, or when—between the seemingly aimless chats about friends’ dating stories and work incidents—things started to shift. Pushing past that resistance to talking about the past enabled me to speak about other things I had been too self-conscious to discuss because they seemed trivial (no one was being tortured, slowly or quickly). Grappling with embarrassment at feeling left behind and addressing those feelings gave me a framework to understand my fears and the neurotic behaviors that arose from them.

All that time, I thought nothing was changing because what I was doing didn’t look like work—it wasn’t filling out worksheets, it wasn’t diagramming behaviors. But without my conscious knowledge, a hidden process was taking place.

*

It is so hard for me to have faith.

It is a form of faith to trust in lived experience when it does not align with the statistics. Each time my experience contradicts that of “science,” I question myself: Despite several negative experiences with birth control, studies on the link between birth control and depression are inconclusive, so I still wonder whether I was wrongly assigning blame. Stray too far, focus too much on what you see and believe, and, I fear, that way lies believing that vaccines cause autism. I want to believe I am like everyone else, to erase the specificities. If what works for the majority works for me, the answers are within reach and I am saved from having to explore more.

Data is crucial, but its purview is limited; its collection methods biased. When my mother called to warn that Asians are more sensitive to negative side effects from antidepressants, I dismissed this as more superstition. When I looked it up later, she was right. How many other findings had I assumed applied to me when they didn’t? How many things that might have improved my life had I dismissed because they lacked the stamp of a certain kind of evidence?

In philosophy, there is a concept called the “pessimistic meta-induction from the history of science.” This is a fancy way of saying that the majority of scientific theories in the past have proven to be false, so there’s little reason to believe that today’s scientific theories will remain accurate. Science is not fixed and immutable and always correct. As a science journalist, I’ve seen firsthand how many retractions there are for scientific papers, how common it is to massage data to produce statistically significant results, how many studies that build up entire fields cannot be replicated. Pessimistic meta-induction is a sombering thought, but also a useful reminder of how much we have yet to learn, that it is important to be humble and also hold onto what we know firsthand.

Perhaps CBT would have worked for me eventually, and my first therapist was simply a bad fit. There are so many different factors—Sara; the school of therapy; life events; the simple act of growing older—that it is impossible to tease out the distinct reasons why one thing worked and another didn’t. I know that psychodynamic therapy has enriched my life more than almost anything else these past few years, yet when asked to explain why, I still feel a flicker of fear. Unlike with CBT, I don’t understand the underlying mechanisms of why it works. I can’t say exactly how, or why, this form of therapy has improved my life. I know only that it has.

*

Upon leaving my job six months into my second round of therapy, I wrote Sara a polite email ending our sessions due to finances. This time, there was no equally polite response wishing me the best. She asked me to come in and discuss, promising I could end things afterward if I wished. I went, reluctantly.

This wasn’t just about the money, she said, though of course money was a legitimate concern. It was about the email itself. It was that I had trouble asking things of people, had not even questioned whether she would consider a sliding scale. It was that I had not only ended a relationship via email, but sent that email while she happened to be away on vacation.

I slumped into the couch pillows, surprised in spite of myself. She was right, and, what was more, it was all so obvious. I had never ended any relationship face-to-face. I shied from negotiation, opting to privately decide what I could tolerate and then, once I could tolerate no more, try to exit as cleanly as possible. In an email like so many others I have sent throughout my life—polite, grateful, fair, but ultimately a gracious shove out the door—she saw the very issues I would need to work through, am still working through.

CBT likely would not have seen this. My worksheets couldn’t have revealed it. Maybe it’s something that could only be borne of a relationship of the type I didn’t like, the type I once viewed with skepticism, the type that insists: It matters where you’re going. It matters where you’ve been.

• 0