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To Be or To Be 'Well': How Therapy Works

Should psychotherapy grow a life or stunt a symptom?

A guy walks into a therapist’s office -- sadly this is no joke -- and says, "I just read an article in the New York Times, and I’ve got some questions. What do you know about my condition? What's your success rate with people like me? When will I get well?"

More and more, psychotherapists are fielding such questions due to the recent onslaught of articles proclaiming that short-term "evidence-based" practices -- e.g., Cognitive Behavioral Therapy, or CBT -- "work" better than long-term psychodynamic treatments. The bottom line is, there is "evidence" supporting the efficacy of both. But I don't intend to go there, or to define "CBT" and "psychodynamic" for the many people who have no idea what the terms even mean; to do so would only fan the flames of the Republican vs. Democrat-style wars between the two. Instead, I'd like to discuss how therapy works (all therapy) as opposed to why it works, and how specific people, such as those in the LGBT communities, are affected when we presume to know what makes someone mentally and emotionally "well".

First, what does “well” even mean? We can all agree that our bodies are unwell when attacked by the common cold, cancer, or even ourselves (e.g., self-mutilation or starvation). But who determines the wellness of the boy who feels more like a girl, or the girl who wants to marry a girl, or the girl who feels ostracized for lacking “sex appeal”? One such arbiter is presumably Harriet Brown, the latest writer (and non-mental health professional) published in the Times this month, who asserts that motivational therapy techniques based on “scientific research” are “working," while clinicians who are “good with people” -- as opposed to being “scientific” in their approach -- are wasting your time. The idea of wellness underlying Brown's op-ed piece is summed up in comparisons she makes between psychotherapy and buying a car: Brown quotes a psychologist who cites studies indicating that less than half of psychotherapists use "motivational techniques", and who reasons, "You wouldn't buy a car under those conditions".

This is a conveniently tidy analogy, but the wellness of a car is objectively determined and the emotional wellness of a human being is, obviously, not. Cars have malfunctions, not subjective experience. They don’t have to conceal their sexual desires fearing discrimination or physical attack. Cars do not privately suffer from identity conflicts or body dysmorphia. (I’ve yet to hear of an anxious SUV that feels like a Mini Cooper on the inside.) If “well” for us means our “parts” are in order, who gets to decide what our sexual, emotional, and gender-expressive “parts” should look like? Who can say if we’re running properly?

When a client enters my office I don’t know them until I know them, and knowing a person requires time, patience, and the wisdom to dispense with assumptions. I may use “evidence-based” directives at the beginning of a treatment with someone who can’t focus, or washes her hands until they bleed, or starves himself (and may refer them for medical treatment, if necessary). But even if such a client were to increase focus, reduce hand washing, or begin to eat, is that where treatment ends? Is she well? Engine fixed, exterior painted, let’s sell this car?

Let’s say a lesbian-identified client with severe anxiety enters therapy. We could use scientific research to explain why there are more straight-identified women in the world than women like her. We could also find studies that explain why she might have anxiety as a result. We could even prescribe evidence-based techniques to help reduce her symptoms. But would any of this validate her unique experience or give her space to discuss how she lives, how she struggles, and how she survives -- not all lesbians with anxiety but She, with her specific history and challenges?

The benefits of psychotherapy are in being seen, heard, and having the space to, as psychoanalyst Donnell Stern says, “formulate experience”-- often, experience that never before had the chance to breathe. Therapy is ideally a safe relationship in which to discuss how our bodies, desires, and sociopolitical contexts impact our lives. It is an opportunity to discuss the undiscussable and how this very lack of discussion has influenced our behaviors -- a point I have made elsewhere regarding the discourse on guns and mental health. No matter what method, style, type, or technique is being used, good therapy allows one to be; to awaken to one’s adaptive, or perhaps maladaptive, patterns; and to consider the propensity for these patterns, once “healed," to strike again in another form. (Not unlike fat cells accumulating in one's arms after one has had liposuction everywhere else-- I’ve seen it happen.) Therapy helps us to be us, to genuinely be, feel, and think in relationship with another.

As I stated above, a variety of therapy approaches can be useful at different times, but to be inundated with New York Times-endorsed articles about types of therapy that “work," fix," or make us “well,” to the exclusion of other types, is damaging. It is damaging not only for therapists who have dedicated their lives to the art of empathic recognition, but also for the multitude of people whose complex stories, needs, and longings remain unsung -- including lesbian, gay, bisexual, or transgender people who are regularly told that they are “not well” by much of society.

Renowned psychiatrist and psychoanalyst Jack Drescher once explained in a paper how “traditional scientific viewpoints discredit personal voices” and, consequently, how his approach to therapy had shifted from “a scientific view…toward a hermeneutic one," particularly because of his identity as a gay man and his desire to help other queer people.

All of us deserve to have our unique stories heard in a therapeutic context, beyond our “symptom” pictures and beyond the “scientific” solution to our “problems.” As a client recently said to me, “getting well implies returning to the way I once was, but therapy has helped me to adapt and to grow. Simply erasing my symptoms would be like retreating, and why would I want to do that?"

Copyright Mark O'Connell, L.C.S.W.


Brown, H. (2013) Looking for Evidence That Therapy Works. The New York Times. Retrieved on April 17, 2013, from…

Drescher, J. (1997) From Preoedipal to Postmodern: Changing Psychoanalytic Attitudes Toward Homosexuality. Gender & Psychoanalysis, 2(2):203-216.

Leichsenring, F., Rabung, S. (2008) Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis. Journal of the American Medical Association. 2008 Oct 1;300(13):1551-65.

O'Connell, M. (2013) Deathwish Recognized: A Case for Longterm Treatment. The Huffington Post. Retrieved on April 17, 2013, from…

Stern, D. (2010), Partners in Thought: Working with Unformulated Experience, Dissociation and Enactment. New York, Routledge

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