Pop Psychology Isn't Your Friend, But Genuine Psychotherapy Can Be | Tom Woods Show #2573

I think your last statement is pretty accurate.

Okay, I want to just hit one thing right off, which is, you know, it's subtle but it happened very quickly: this equation of what happens in therapy with obsessing or ruminating, right? So that's an assumption that I think you're repeating, an assumption out of the starting gate, as if the only alternatives we have are, you know, to toughen up and ignore things and push on, ignore the difficulty, or to obsess and ruminate about them. And one of the things that happens in what I'm going to call real psychotherapy or meaningful psychotherapy — because there's a lot of stuff going on that's called therapy that I don't think is legitimate psychotherapy — one of the things that happens is that we create choices and options that aren't initially evident or apparent, right? So when we say, well, the choice is to toughen up and, you know, move on or obsess and ruminate, that's a false dichotomy, and real therapy would help a person to recognize that there's alternatives to that. So let's — let me take an example. I got so caught up in — I got so caught up in obsessing and ruminating now I lost track. What was the question?

So I have profoundly mixed feelings about that, because I hear people say that a lot, and the mixed feelings are based on what a lot of people are seeing and what's represented as therapy, you know, in public and social media. I don't blame them one bit for coming to those conclusions, right? There's a lot of hokey pop culture nonsense that's pretending to be about psychology and psychotherapy, so I understand where that point of view comes from. On the other hand, what they're seeing, what they're responding to, what they think is therapy has almost nothing to do with legitimate psychotherapy. And, you know, unfortunately, for a variety of reasons that we could talk about if it's of interest, the mental health professions have been in free fall for more than 20 years, 20, 25 years. There is no universally agreed-upon thing anymore called therapy. There is no universal standard for what it means for somebody to call themselves a therapist. Therapist is actually not the name of a profession, right? There is no consensual, you know, shared curriculum in terms of training and education that people who call themselves therapists get. It's the wild west out there. And what we have now, unfortunately, and it honestly breaks my heart to have to say this, is that the field is just glutted with people of all kinds of different backgrounds and training who call themselves therapists who really have very, very minimal training or understanding or skill. De facto, the therapy professions are not regulated in a meaningful way. I mean, it would — right. So what most people encounter in public spaces, and including and especially in social media, encounter that's called psychology or psychotherapy is, to me, kind of a bad joke.

One of the things that serious psychotherapists understand is that there's a difference between the problems on the surface that bring somebody to therapy — right, somebody comes in and says I'm depressed or I'm anxious or, you know, my eating is out of control or I'm having panic attacks or whatever it is, right — and the underlying psychological issues that are driving that or creating the vulnerability to the problems. So, you know, we could talk about problems that are upstream and problems that are downstream, right? And this is a bit of a generalization, but it's true far more often than not. The most common diagnosis recorded in the United States and North America is some form of depression. Depression is an effect, not a cause, right? It's downstream from something else. So a real psychotherapist, somebody who's genuinely skilled and genuinely well trained, we're not in the business of treating depression, right? Because it's an effect. We're in the business of figuring out what's going on psychologically, right, upstream from the depression, right, that's coming out downstream, right, in the form of what we call depression. So we can make a distinction between what you see on the surface of things and the underlying psychological processes that are giving rise to them. And, you know, we could say there's, you know, two kinds of people in the field who are practicing psychotherapy or what they call psychotherapy: those who think that the problem that you see on the surface is the problem, and those who understand that there's something upstream from that problem and that that's really the focus of our attention if we're doing serious work in psychotherapy. And what I mean by serious work in psychotherapy is ultimately we're trying to change something about the person, right, who they are and how they function in the world, right, not just this or that symptom or behavior that they have, but something about who we are as people, right, to become a better and freer and more whole version of ourselves that doesn't have to be vulnerable to the kinds of symptoms that show up and often get identified in treatment as the problem.

I'm not sure any critical thinking, serious scholar or scientist ever took that seriously. First of all — yes, I always doubted it, but so did damn near everybody else that I respected. This idea of a chemical imbalance — this is not a scientific finding, this is not a clinical discovery. I mean, truth be told, this was a marketing campaign by pharmaceutical companies selling medication, and these marketing campaigns, these narratives were extraordinarily successful, and they succeeded in convincing vast numbers of people that depression is a chemical imbalance. Even in the heyday of, you know, when people were saying that, which would be like the early 1990s, you know, very, very few people, including in psychiatry, ever took that seriously. I mean, at this point it's been completely debunked. Now, let me make a clarification: that doesn't mean that antidepressant medications aren't helpful for some people sometime. What it means is, however they operate, whatever they do that is helpful for people, that's not the mechanism. Nobody even knows what chemical imbalance means other than as a marketing slogan.

And that's a very common way — I mean, people experience it just the way you described. But you added something, you prefaced it with something else. You said, you know, it's a freestanding thing, it's like they've come down with a case of depression, you know, the way somebody might, you know, come down with influenza or COVID or Ebola, right? That's where there's some slippage. So we have to understand — this goes back to what I said earlier, that depression is downstream. There is no single unitary thing called depression, right? It's not like having a bacterial infection or influenza or diabetes. It's not one thing, right? It's sort of the final terminal outcome or result of quite a lot of very different underlying difficulties. So the way I think it's more helpful to think about it, and the way I teach it to my own students, is, you know, if we're going to use a medical analogy, you know, and think about it in terms of symptoms and diseases, I think it's much more helpful to understand depression as a non-specific symptom like fever. Okay, so medically, what is fever? What is the definition of fever? It's a non-specific physiological symptom that can be caused by an enormous, enormous range of underlying medical conditions, right? They all cause fever. So if you have fever, you know, the underlying condition could be anything from, you know, the common cold to Ebola. Fever is a symptom, a physiological symptom. Depression, I think, is best thought of as the psychic equivalent of fever. It's a non-specific symptom of an enormous range of underlying difficulties, and what a serious, skilled mental health practitioner does is try to understand and address the underlying difficulties.

Well, it depends, a lot depends, right? Because again, if depression is a symptom, right, and not a cause, right, then I mean, then we get in the business of, you know, investigating possible causes, and as we investigate, it might take us down quite a lot of different pathways. So there isn't a universal answer. I do want to say that the complaint that you're echoing, you know, that's about managing symptoms and not dealing with the actual underlying problem — unfortunately, that's often true, right? I mean, what we've done is we've tried — I say we, I mean, a lot of this goes back to the economic interests of health insurers and pharmaceutical companies. We've tried to shoehorn psychological difficulties into a medical treatment model and act as — right, and what we're doing really when we try to manage the symptoms, you know, often this is a generalization, but often we're providing people with first aid, you know, something to help them feel better in the relative short run, but not actual — right, in medicine everybody knows the difference between, you know, what's first aid, you know, and what's medical treatment for the real condition. In mental health, it's like those things have gotten very, very blurred, and people are given first aid and told that they're getting treatment. So I think actually the criticism is very valid.

Yeah, I mean, first of all, things have been in flux. In the old days, you know, like a generation ago, most psychiatrists provided psychotherapy, and many of them became very highly skilled psychotherapists. There were very major differences in training, the pathways to get there, right? Psychiatrists are MDs and are trained as, you know, and have medical background. Psychologists were PhDs or now PsyD, Doctor of Psychology degrees. Anyway, they have doctoral-level academic training, so they're really very different pathways, right? Psychologists aren't medical doctors, they didn't prescribe medication, right? But really there was quite a different trajectory that led to becoming treatment providers. Because of economic changes over the last, you know, generation, driven largely by the pharmaceutical and the health insurance industries, a relatively few psychiatrists practice meaningful psychotherapy anymore, right? A lot of psychiatrists — many would, you know, deny this or want to argue it, but it's just empirically a fact. I mean, relatively few psychiatrists these days who provide much in the way of psychotherapy. Many of them are, you know, almost entirely in the business of prescribing medication.

Yes, to both. So one thing that it's important for people to understand that people don't understand, you know, people will use words like psychologist and therapist or psychotherapist interchangeably. They're not interchangeable. A psychologist has a doctoral degree, has to meet pretty stringent training requirements, and be licensed as a psychologist. The word therapist actually has no professional meaning. It's not a credential, it's not a protected title, it's not the name of a profession. So what we have are many, many different professions, all of whom — people in all of these different professions practice therapy and call themselves therapists. And if that's all you know about the person, you know less than nothing about their training and background. So I took an interest in this because of something that happened on Twitter, but I started looking at different kinds of licenses, and they're all, you know, they're all signified, denoted, you know, somebody's name followed by a collection of letters, you know. And I found something like 65 different kinds of credentials across 50 states. Then I just got bored and stopped looking. So more than 65 different kinds of credentials and professions that authorize people to provide psychotherapy. The most common ones are PhD and PsyD psychologists, licensed clinical social workers, LCSWs, licensed marriage and family therapists, licensed professional counselors, dozens and dozens and dozens of variations thereof. And not only — and the differences in training are just vast. And even with that mess going on, in most states in the United States, right, therapist doesn't mean anything. Anyone can hang up a shingle and call themselves a therapist without any degree, without any license, without meeting any credentials. I don't know what state you're in, but the overwhelming likelihood is you could hang up a shingle tomorrow and call yourself a therapist, right? And that's bad enough. The real tragedy to me is most people, the public, people who might be in need of mental health care, don't know this. They go to someone who's identified as a therapist, and God knows what they're getting by way of so-called treatment.

Yeah, so it's not my term at all. I actually have some real issues with the term. Let me zoom out for a moment and give you the context. So the term evidence-based actually comes from medicine, not psychotherapy or mental health. It gained traction in the 1990s, and really it was a call — right, because medicine was a very orthodox kind of profession where, you know, sort of ways of doing things, and you learn to do things the way your teachers did them, who learned it from their teachers, etc. Originally, evidence-based medicine was a call for critical thinking in medicine, and the intent of those who initially promoted evidence-based medicine was that treatment decisions shouldn't just be made because that's the way we've always done it, but they should reflect, number one, the best available evidence, scientific evidence from empirical research; number two, you know, the clinical judgment and knowledge and hopefully wisdom of the physician or the healthcare provider; and number three, you know, the needs and values and preferences of the patient. So you could think of it as a Venn diagram where those three elements would overlap, right? Empirical evidence, clinical skill and experience, patient desires and preferences. And evidence-based medicine was supposed to be the intersection of those things. The term then got picked up and adopted in psychology. It came to mean something de facto a little bit different. Typically, when people refer to evidence-based therapy, it refers to therapy — modes of therapy, a modality of therapy that have been studied in a randomized controlled trial. So basically the same kind of research design that's used for medication trials, right, where people are randomly assigned to a treatment group who gets, you know, the treatment of interest, and some kind of comparison control group that doesn't get the treatment, right? So when somebody says evidence-based therapy, it means that there have been randomized controlled trials demonstrating that the treatment is more effective than a control group. I'm going to say a lot about this because the term, at least as applied to psychotherapy, has really morphed into a marketing buzzword, right? So when I think the layperson actually — even a lot, not just laypeople, also a lot of clinical practitioners, they hear the term evidence-based therapy, and what they think it means is we have scientific evidence that people get meaningfully better. That's actually not what it means. It's basically become a kind of branding for a certain — kind of branding for a very particular model and approach within therapy that actually isn't — like actually doesn't work for most people most of the time. But that's a whole other issue. I'm not sure you wanted to get into that issue.