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How We Became Addicted to Therapy

How We Became Addicted to Therapy
How We Became Addicted to Therapy

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A few months ago, as I was absent-mindedly mending a pillow, I thought, I should quit therapy. Then I quickly suppressed the heresy. Among many people I know, therapy is like regular exercise or taking vitamin D: something a sensible person does routinely to clear out the system. BetterHelp ran an ad where a woman says she’s ignoring a guy’s texts because he doesn’t see a therapist. “Hard pass,” she explains. “Red flag.” Therapy for many people has no natural endpoint. It’s just “baked into my life,” as one patient told the psychiatrist Richard Friedman, explaining why he’d been seeing a therapist for the past 15 years.

Therapy is so destigmatized now that a lot of us sound like therapists. We’re “codependent,” “triggered,” “catastrophizing.” We cut off our friends who are toxic. Justin Bieber doesn’t fear an exposé on the damage of childhood fame; he freely discusses his trauma and healing. Oprah wonders what happened to you. And once you figure it out, you’ll find hours of free advice on TherapyTok.

Friedman, who has been teaching and seeing patients for more than 35 years, is pleased about the new openness. But he’s also worried for us. Treating therapy as routine has led to the “medicalization of everyday life,” he says. On this week’s Radio Atlantic, Friedman proposes a radical idea: A lot of people could probably quit therapy.

Listen to the conversation here:


The following is a transcript of the episode:

Hanna Rosin: Now, you know that this interview is a kind of wish fulfillment for anyone who’s ever been in therapy because I get to ask you questions and find out all about what you’re up to.

Richard Friedman: Yes, indeed.

Rosin: [Laughs.] Do you recognize that? I just want to make that clear.

Friedman: I do.

Rosin: Okay, great.

Friedman: Yeah.

[Music]

Rosin: This is Radio Atlantic. I’m Hanna Rosin, and that is Dr. Richard Friedman.

And what do you do?

Friedman: I’m a psychiatrist.

[Music]

Rosin: Friedman runs the psychopharmacology clinic at Cornell. He’s been a psychiatrist for more than 35 years. But in a recent story for The Atlantic, he made a shocking and terrifying proposition: that lots of people could quit therapy, right now. As it happens, I’d had that thought myself recently: I could quit therapy.

Friedman: Uh-huh. And how long had you been afflicted by that thought?

Rosin: [Laughs.]

Friedman: I’m just kidding.

[Music]

Rosin: It came to me a little while, and I will tell you at the end what I decided to do and what my thinking was, but—

Friedman: Oh, good.

Rosin: I was so delighted that an actual professional was addressing this question that I just popped up in my head. So essentially the question that you are thinking about—or how I frame the question that you are thinking about—is should we think of going to therapy like physical therapy, like something you do for a while when you need to address an issue? Or like going to the gym, like something you should always do because it’s part of just staying healthy?

Friedman: Yes.

Rosin: Is that fair?

Friedman: Yes, that’s exactly right. Is going to therapy like working out with a trainer? If the model of therapy is you go in with a goal, and then things get better, and you meet the goal, you could say, Okay, it’s time to call it quits. I’ve done what I thought I wanted to do. And so in that sense, it wouldn’t exactly be like training with a physical trainer, because one element of a physical trainer is not just the skill and the knowledge you get, but the motivation by having a person with you.

And I’ve asked friends this, and they’ve said the same thing to me, No, no, I don’t want to give up my physical trainer, because if I do, even though I know the moves and I know the sets, etcetera, I just won’t maintain that level of exertion, and I won’t be as fit.

So does that apply to therapy? And maybe for some people, it might, maybe a very small number of people. But it’s designed to give you something: self-understanding, better relationships, better X, Y, or Z. And then you can generalize it and take it out, meaning I thought of therapy as you become your own trainer, in effect.

Rosin: Oh my God.

Friedman: You internalize it.

Rosin: [Laughs.] I’m getting anxious just listening to you say that, as I’m sure many, many people are.

Friedman: [Laughs.]

Rosin: It’s so interesting and so important, but it does make people anxious. It is like losing the person you talk to, and that’s either because our lives have changed, or therapy—I don’t know—but that’s what we’ll explore in this conversation because you’re saying it very calmly, but I think it would land on a lot of people who are listening as a kind of radical, radical notion.

Friedman: It is. I mean, even saying goodbye to your trainer. I swam with a master swim team—I love swimming—and I loved the Russian coach. I learned a lot. And although I don’t probably swim with the same intensity I would’ve when I was swimming with this group, he’s still in my head. But I miss him. And I get that. It’s very emotionally wrought.

Rosin: Mm-hmm. So how did this come up more recently in your practice? Did you have a conversation recently with a patient about quitting or not quitting, or how did it come up?

Friedman: So it actually came up with residents. I do a fair amount of teaching and training residents at Cornell, and it came up in this setting—not of therapy so much as in using medication. And it occurred to me, We’re really good at starting treatment, but we’re not so good about thinking how long we ought to treat or even thinking about stopping medicine when we should.

And then I thought, Wait a second. Why am I only applying this to psychopharmacology? Isn’t it also true in any form of treatment? When is it time to stop? When are you done?

Rosin: Right. When are you done?

Friedman: When are you done?

Rosin: Yeah, it is a question that’s really hard to answer. And is this your particular idea, or is this debate widely held among therapists and it’s like a trade secret that you just decided to share with all of us?

Friedman: Oh, my colleagues talk about it a lot, and one of them joked with me in the elevator the other day—who’s a psychoanalyst, the group that you would think would be the most unhappy with this thesis—and she said, Oh, you’re trying to kill off therapy, joking. She said, No, actually, I really liked your piece. In fact, she said, Winnicott himself, the great British psychoanalyst himself, talked about “the good enough,” “the good enough mother,” what is just good enough? What is the concept that something may not be perfect, but it’s good enough, it’s finite?

Rosin: Can you maybe describe a patient who brings up this dilemma?

Friedman: Sure. This was someone that I wrote about. It’s someone I saw a couple of years ago, and he’d been in therapy for, I don’t know, 10 to 15 years. And what sent him to therapy initially was he was an anxious, depressed person, but that actually got much better, and his therapy just continued. He enjoyed his therapist. He enjoyed the conversation.

And it was his friends. He said to his friends, I’m not really sure that I need to go. I’m not sure what I’m getting out of it, but I enjoy it. And the friend said, Hey, maybe you should have a consultation with an independent person, which is how he came to see me.

And I asked him, Had you thought about stopping? What are you there for? What are you getting from this? And his answer was, It’s just part of my life. I don’t know what I would do without it. Almost like a talisman. Maybe he had the belief that the reason he was continuing to do well was because he had remained in treatment.

Rosin: Right. I think that’s what a lot of people think.

Friedman: Yeah. Yeah.

Rosin: Is there any research out there that exists about duration? Should you go for a long time? Should you go for a short time? Has anyone ever looked at that in a systematic way?

Friedman: So there is for short-term therapy lots of evidence that they’re effective. And even long-term therapy has been studied. Dynamic therapy has been studied, and in some studies has been shown to be more effective than short-term therapy. But the studies are actually limited, and there’s really no consensus.

Rosin: Have you come across any research or studies showing that staying in therapy too long can be harmful?

Friedman: Not specifically. No one would do that study, and no one probably would get it funded, but you could imagine some of the things that might be downsides to being in therapy too long. The cost is one thing, but obviously if you’re in it, you’re unlikely to financially ruin yourself because you’d have to stop. You know, one is: Therapy is a scarce resource in this country. There’s not that many psychotherapists.

Rosin: So maybe this is the moment where we need to raise social class and what social class you and I are talking about when we’re talking about the desire to stay in therapy indefinitely, because not all insurance covers it. There is a shortage of therapists, as you said. So what social class are you addressing when you’re talking about indefinite therapy?

Friedman: Oh, we’re talking about a luxury good in a way, of people who are paying out of pocket and it doesn’t matter to them.

Rosin: Right, so we are essentially talking about the class of people who are in some way able to afford long-term therapy, not like a 14-week cognitive behavioral intervention, but longer-term, open-ended therapy.

Friedman: Yes, exactly.

Rosin: Okay. So the expectation that people want therapy to go on forever—you’ve named a couple of reasons—is they don’t want to break off a relationship, but is there something that it’s replacing? Is there some reason you think that people can’t just talk to their friends about this range of problems?

Friedman: Let’s say we had data that it was true, that there really is a trend that people view uninterrupted, long-term therapy as a good. It would make you think if the nature of social networks are changing. Attendance in all these groups that normally were the social glue have really dropped, like churches and places of worship. I think there has been a change. And then you have books like Bowling Alone. We keep hearing that loneliness is an epidemic.

Rosin: It’s funny. I want to believe those theories, and then pops into my head the thought, Did people really used to talk openly about all of their feelings in church or in the bowling club? It doesn’t quite totally track to me that those would have solved our deeper problems. Maybe they just would’ve solved a feeling of social connection but not necessarily an exact substitute for what you would do in therapy.

Friedman: Yeah, I think it’s a wonderful question because it opens up into something else, which is: Has the nature of tolerance of discomfort changed?

Rosin: Interesting. What do you mean?

Friedman: So I started the student mental-health program at Cornell about 23 years ago. I ran it for about 22 years. And one thing I noticed over, you know, seeing cohorts over many, many years—the groups of students—is the things that people considered worrisome about everyday life had become different.

And in particular, what happened is students would come in complaining of everyday stress that previous students would never have come and mentioned to me—for example, worrying about class, having trouble falling asleep a couple of nights, being upset about a breakup. They think that everyday stress is somehow an illness or a condition that needs to be treated.

Rosin: Interesting. Or therapy used to be thought of as something you do if you’re in distress. Both of them have shifted at the same time. So there used to be this idea that you would go to therapy because there’s something wrong, and now there’s an idea that there’s something wrong if you don’t go to therapy.

Friedman: [Laughs.]

Rosin: You just go to therapy in order to get over this rough patch. Like, why not seek professional help in getting over a breakup?

Friedman: If you’re having trouble doing it on your own, why not indeed? To that point, I actually had a very close friend growing up whose parents were both psychoanalysts. And they sent him and his older sister, who were perfectly adjusted, happy, energetic kids—he was a delightful person—to a weekly session with a colleague of theirs.

Rosin: Oh, no. [Laughs.]

Friedman: Because they thought people should be acquainted with their inner lives, and this would somehow protect them against the stresses and make them more fit for dealing with stress down the road, almost like a prophylactic intervention.

Rosin: Yes, I think I get that. I mean, I know the stereotype about the children of analysts, but I can roll with that thinking.

Friedman: It sounds nice, however, well, in their case, I can tell you how things ended up.

Rosin: [Laughs.]

Friedman: They were both highly neurotic, obsessional, anxious people, not entirely happy, very successful. And I sometimes think, Now, what would their parents have said, confronted with the outcome? They probably would’ve said something like, Yeah, well, but they could have been worse if they hadn’t had it.

[Music]

Rosin: After the break, we take a brief detour into the history of therapy speak, clinical talk that has made its way into everyday language. You know the terms: toxic, trauma, gaslighting. And I finally tell Dr. Friedman if I did, in fact, quit therapy.

[Break]

Rosin: Okay, let’s take these kids who got, let’s say, an early, preternatural education in their inner lives, and who got a lot of language to describe their inner lives—these two people. These two people, I feel, are now the culture. Are you familiar with the term therapy speak?

Friedman: Yeah.

Rosin: So just basically, clinical terms which have permeated the culture: toxic, triggered, most especially trauma. So a lot of us are a lot more fluent in pretty standard, what used to be clinical terms and are now just social terms.

Friedman: Yes.

Rosin: Have you watched that shift? You said you’ve been practicing for a few decades, so have you seen that bubble up amongst your students or just people you know?

Friedman: Yes, my way of thinking about it is therapy speak to me is the medicalization of everyday life. So an upsetting experience where they’ve run out of an entrée at the restaurant is traumatic. Well, it’s upsetting, it’s not traumatic. Traumatic means, to me, serious threat to one’s safety and even life. But it’s kind of an inflation of all these terms, and so everyday discomfort is turned into a term of art, what we think of as a problem.

[Bell]

Rosin: Okay, before we get too deep into therapy speak, we interrupt this program for an important message. But I promise it will be a short, important message.

We’re going to take a quick detour into the brief, reductive, and nonjudgmental history of some linguistic shifts that have taken place since the ’80s, when Richard Friedman became a doctor. We’ll start with another psychiatrist, a man named Bessel van der Kolk, who’s now best known as the author of the mega-bestseller The Body Keeps the Score, which was published in 2014.

Back in the ’80s, van der Kolk was working with Vietnam vets. And he noticed that these men had memories that would intrude on their lives in really unusual ways—little shards, like a vision or a smell that would put them immediately into a panic. He tells the story of a man named Tom who came to see him, who seemed like a stable family man, and then he confessed this to van der Kolk.

Bessel van der Kolk: I have become a monster. Nobody is safe with me. I blow up at my kids. And maybe the most scary thing is that I sleep with somebody at night, and suddenly in the middle of the night, that person touches me and I strangle them, and I try to kill them.

Rosin: Van der Kolk eventually founded the Trauma Center. He also began treating women who had these similarly fragmented memories, and then they remembered being assaulted as children.

Fast forward to 2021. The Body Keeps the Score is now at peak popularity. This is partly pandemic, but it’s partly because we were ready to receive it. The book is written with clinicians in mind, but we had all started speaking a little more like clinicians: Your friend is toxic. Your mother’s a narcissist. Your boss is not respecting your boundaries. If you’re a celebrity and you haven’t shared your trauma, then there’s something suspect about you. Even royalty, the formerly stiffest of upper lips, is sharing their childhood trauma.

Prince Harry: The trauma that I had, I was never really aware of. It was never discussed. I didn’t really talk about it, and I suppressed it like most youngsters would’ve done.

Rosin: Buried trauma started showing up more in novels and on TV, like in Yellowjackets or I May Destroy You.

Meanwhile, there was a lot of talk about other categories of trauma: Developmental trauma, meaning your parents were neglectful or abusive. Cultural trauma, meaning the impacts of racism or discrimination on a community. Collective trauma—the pandemic is the obvious one.

Trauma as a term started getting used more loosely, and its boundaries felt hazier, less centered on a singular, specific event that happened, like a bomb or an assault, and more on the person’s degree of distress. So a person could be traumatized if they said they were traumatized. Thus we entered the era of what Atlantic writer Derek Thompson calls “anxiety as content.”

TikTok creators: Breaking news to all the people who say that they hate themselves, especially the neurodivergent folks. I hate to be the one to break it to you, but you actually love yourself … I’m a licensed therapist, and this is the test to tell if you have trauma … Trauma response … Trauma responses … Is it my trauma? … From a trauma-informed coach … Mental-health therapist here with a “Put a Finger Down” Trauma Response Edition … It’s your daily dose of Trauma Time … Are you hurting? If the answer is yes, you have trauma … Like for part two!

[Music]

Rosin: One theory for what happened next is called “prevalence inflation.” People who were bombarded with all this information about anxiety disorders became more sensitive to spotting these symptoms in themselves, creating an actual snowball of anxiety, a trend that some experts, like Dr. Friedman, are watching with growing anxiety.

And now back to our regularly scheduled program.

[Bell]

Friedman: We’re incredibly easily influenced, at some stages of life much more so than at others, but it doesn’t mean that when that happens and your “body keeps the score,” you’re registering all of these experiences, that it produces illness. My view is people are far more resilient than they actually believe that they are.

Rosin: Interesting.

Friedman: For example, it would surprise most people, I think, to learn that following trauma, the vast majority of people who are exposed to traumatic events, like assaults, threats of various types, don’t actually get PTSD.

Rosin: Interesting. Are you saying it’s an unpredictable pattern or that rather than be typical of the majority of people who go through incidents, it’s actually quite anomalous?

Friedman: It’s anomalous. PTSD as an outcome from trauma is a minority response.

Rosin: Now, here is what is really tricky. And I’m not a clinician like you, so I have no idea if this is an appropriate question, but could it be that once we set the framework for what trauma is, we walk into that framework? A lot of emotions are culturally determined, so if we say that things are traumatic, then we experience them as traumatic and think of them as traumatic, and that changes us in some way.

Friedman: I mean, yes, I think what it does is it tells people that their experience is now a clinical state. But I don’t think it intrinsically changes, let’s say, the symptoms a person experiences or even the internal neurobiology that they undergo when they have an experience.

Rosin: Okay. So how does this relate to what we initially started talking about? Because we’ve gone off into wider-ranging territory. But how does this relate to what you initially said, that people feel like therapy has to be baked into their lives?

Friedman: Yes, the question of, When am I done? is then seen as either superfluous or hostile. What do you mean, “When am I done?” I enjoy it. It helps me. Why should I be done?

Rosin: But is it also because if you are subject to a lot of trauma on a day-to-day basis, or what you are perceiving as trauma, then why would you ever be done?

Friedman: I think if you define life as very challenging psychologically from the point of view that you need help in order to navigate it, you never can be done, right? So, I think that’s the hazard of this.

Rosin: Yeah, I find myself torn because I think in past generations, probably a lot of people couldn’t even take the very first step of identifying that a trauma was affecting them.

Friedman: Yes.

Rosin: So is there any part of this that you see as a positive development? That people can name the emotion, name the trauma, and work through it?

Friedman: Yes. I think if we have to err, it’s better to err on the side of encouraging people to get help, even if it turns out that many of them won’t have a clinical condition. And we want to be much more welcoming and encourage people to do this mainly because—and we know this—we’re talking about the small number of people who are essentially not very sick; they may have minimal symptoms who are in these long-term therapies. But very high rates of people with really serious psychiatric problems don’t get any help at all.

Rosin: Right, right. Oh, that’s guilt-inducing. [Laughs.] This is like every rich patient’s worst nightmare, is that their therapist is thinking, Oh, they come in here to complain about their home renovation, and there are people who actually need therapy.

Friedman: Right, so on the one hand you’ve got two opposing trends: One is people with serious mental illness are undertreated, and those with mild illness may be, depending on your view, overtreated.

Rosin: I’ve asked this question and I’m going to ask it again: So what is the harm? I can see why it’s not beneficial—it’s not necessarily helping you—but what is the harm or the problem in staying in therapy too long?

Friedman: There isn’t a harm if you conceive of harm as physical harm or deep psychological harm producing, let’s say, a terrible clinical state. The only harm is a relative one, which is: You never really get to discover that you are more capable and independent than you think that you are.

Rosin: I see. And have you ever had an experience where someone’s in therapy and you felt like somehow the therapy was prolonging something that shouldn’t be prolonged?

Friedman: Yes, many times.

Rosin: Can you say a little more? What does that look like?

Friedman: Sure. It looks like the following: the person—and I’m thinking of one patient in particular, without giving any identifying data—who’s long past the problem that drove him into treatment and doesn’t really have any symptoms but really enjoys our conversation. And I’ve said many times to him, If you think back how far you’ve come in all the areas that bothered you when you first came to see me—those problems, what do you think about them? He said, Oh, no, no. Now we’re dealing with speculation about all these other things in my life that could be better. It’s not that I think something is wrong; it’s that I think I could be even better.

Rosin: Oh, I see, that staying with you would allow them to grow continuously in some way?

Friedman: Yes. Yes.

Rosin: And what’s the problem with him thinking that? That seems reasonable.

Friedman: It’s reasonable. It might not be true, and he may be able to do it without my assistance. And if he doesn’t have the opportunity to test that, he’ll always feel that he needs either my assistance or someone else’s assistance to thrive. And he’s probably able to afford having that for the rest of his life, if that’s what he wants to do.

Rosin: Yeah, this is a lot like what people say about parenting. What you’re describing is the child turning the parent into an overprotective parent. They’re wishing for a helicopter parent almost.

Friedman: Well, what would happen if your kid said to you, You know what? I never want to leave. You’re such a lovely, wonderful, loving mother. How could I possibly leave home?

Rosin: [Laughs.]

Friedman: I should just stay here and get married, and my partner can come live here, too. Why should I leave? Isn’t that the same argument?

Rosin: Yes, I guess you’re right. It would seem weird.

Friedman: [Laughs.]

Rosin: Okay, here’s the place where I myself seek validation. So I told you at the beginning that I had this thought popped into my head, and almost exactly what you said. I thought, Oh, well, I’ve learned all these things. It somehow seems like the right thing to do, to just incorporate them and go out and be. You know, just see how I can navigate life and how I can navigate these various relationships on my own without this help. It felt scary, but I talked to the therapist about it and I quit.

Friedman: And what do you think of the outcome?

Rosin: I think that it is exactly what you said. There are definitely moments when I think, Oh, there’s a thing I’d like to talk to the person about, or, What would she say about this? She’s in my head, this therapist. I remember a lot of her lessons and ways that she’s guided me through things, but basically it’s what you said. It’s a little nerve-racking, but it’s a really great experience to be able to incorporate some of this and try it myself. It does have a child-out-of-the-nest vibe to it.

Friedman: Yeah, but I think all good therapy involves, in a sense, becoming your own therapist. You’ve internalized them. They’re in your head. They’re very much in your head. You still have a relationship with them. It doesn’t end. It continues. It’s inside.

Rosin: So you should think of the therapist as someone who died who you used to like. [Laughs.]

Friedman: That’s exactly right. It is like death. Except they’re still alive.

Rosin: Exactly, so you can go visit them.

[Music]

Rosin: Well, that was tremendously helpful. Thank you, Richard. I really appreciated that.

Friedman: It was a pleasure.

[Music]

Rosin: This episode of Radio Atlantic was produced by Jinae West. It was edited by Claudine Ebeid, fact-checked by Stef Hayes, and engineered by Rob Smierciak. Claudine Ebeid is the executive producer of Atlantic audio, and Andrea Valdez is our managing editor. I’m Hanna Rosin. Thanks for listening.

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