No Stupid Questions - 35. Does Psychotherapy Actually Work?

Episode Date: January 17, 2021

Also: how many “selves” is it OK to have?

I ate an avocado in 2018. Why aren't I a vigorous, healthy person now in 2021? I'm Angela Duckworth. I'm Stephen Dubner. And you're listening to No Stupid Questions. Today on the show, how effective is talk therapy really? This calls into question everything that Angela Duckworth and all her colleagues have ever said. Also, is it normal to feel like there are multiple different versions of you?

Yes, I am large. I contain multitudes. So, Angela, I have a question you're going to hate today. I can't wait to hear it. So, there's a new working paper by a trio of economists. It's called The Comparative Impact of Cash Transfers and a Psychotherapy Program on Psychological and Economic Well-Being. In other words, what is more helpful for a population, giving them psychotherapy or giving them money? Okay. What'd they find? them psychotherapy or giving them money. What'd they find? Well, they find, so I should say this was a project in rural Kenya.

They write that one year after the interventions, cash transfer recipients had higher consumption, asset holdings, and revenue, as well as higher levels of psychological well-being than control households, meaning the ones that didn't get cash. In contrast, the psychotherapy program had no measurable effects on either psychological or economic outcomes, both for individuals with poor mental health at baseline and others. The effects of the combined treatments

are similar to those of the cash transfer alone. In other words, psychotherapy, for this population at least, didn't help at all. Giving people money helped them on psychological dimensions as well as economic dimensions. And what's really interesting about this is we usually think of cash or money being useful in part because there's the attendant satisfaction of having earned it, which doesn't even exist here. So this sounds like an arrow to the heart of the efficacy of psychotherapy. I'm guessing that

you, as an academic research psychologist who believes strongly in the power of psychotherapy, that you think this must be terrible news. Well, I think that the cure has to match what the patient suffers from. And I'm guessing, because it's rural Kenya, that there was extreme poverty and that maybe the cure that was needed for that ailment was cash. And that the problem wasn't the kind of thing that people will seek help from a therapist from. Although I should say they do include in their write-up, they found these outcomes both for individuals with poor mental health at baseline and others. And they were looking at economic outcomes and happiness outcomes, etc., right?

Right. So yeah, fair point. But say, for example, I go to some town in Kansas and I randomly assign kids to a literacy program. Half the kids get a literacy program. Half the kids get a literacy program, half the kids don't, and then I find no effects on anything. I guess my question would be like, is that what those kids needed? Was illiteracy the problem? Was lack of literacy training at the core of whatever they needed at the time? And I just don't know enough about these families in Kenya, but I can tell you, Stephen, there are just mountains of data on the efficacy of psychotherapy.

So, Angela, I will say this. The economists who write this paper make a note about the match of the therapy to the population. They write, it is important to note that the psychotherapy program we used was a tried-and-true, state-of-the-art intervention for low-income contexts developed by the World Health Organization and previously successfully tested in Kenya. In addition, the implementation of the program was done by the same NGO, non-government organization, as in the previous study. Thus, implementation differences are unlikely to explain the lack of impact. Rather, it appears that the impacts of this psychotherapy program may be short-lived. This result, in turn, raises the question whether

all psychotherapy programs have only short-term impacts. Gosh, that's bold, by the way. Right? That's basically saying, like, we did our study, all right? Therefore, this calls into question all other studies that have been done of therapy. This calls into question everything that Angela Duckworth and all her colleagues have ever said about psychotherapy. You should probably see a therapist about that. So this paper that was recently published in one community, in one trial,

can't negate decades of research. Okay, so I want you to distill, for those who may be skeptical, and I would probably count myself among them, that the standard treatment of psychotherapy as practiced, let's say, in the United States in the year 2021, on the median patient who engages in it, because it's still a fairly rarefied ecosystem, really. Right, not everyone gets it. Most people don't get it. So considering all those facts, distill for me this mountain of evidence about the efficacy of psychotherapy. Okay. Psychotherapy is going to see a clinician and talking about your problems.

And sometimes it's called talk therapy. And it can be contrasted with, for example, taking drugs, And it can be contrasted with, for example, taking drugs, taking pharmaceutical prescriptions for your anxiety, your depression, your obsessive compulsive disorder, your phobia, etc. So it is a pretty radical idea that you could talk to somebody and actually treat these pretty serious, in some cases, mental health problems. And there's so many studies that they're not only meta-analyses, which are systematic averages of all the studies that somebody could find, there are even meta-analyses of meta-analyses. So because there have been that many data points collected, I think we can have confidence in the finding that there are treatment effects on the order of about a half a standard deviation in size on symptoms of psychopathology. I know that's not the most intuitive metric for

people, but it's sizable. And then there are no studies that I know of that are large in size that say there's no effect of treatment. So give us the best evidence that these effects are causal and not just associative. That, in other words, the people who seek out psychotherapy are in a position to improve, to address problems. They're not just pre and post. So you would worry a lot if it's like, well, this person felt really depressed in January. Then they went to a therapist all the way through June. And in June, we found that they were less depressed because there could be regression to the mean. There could just be like spontaneous remission of symptoms. Like you would just get better even if you hadn't gone. But there are now hundreds of random assignment controlled trials. So there's

now a lot of pretty rigorous experimental evidence showing that psychotherapy is beneficial. Let's just peel the onion layer one or two more and acknowledge that most of this research is done by the psychotherapy community. Is that not true? And if so, it calls to mind the old Upton Sinclair quote about how conflicts of interest, even when they're not evident to ourselves, exist. He said, it is difficult to get a man to understand something when his salary depends on his not understanding it. So, again, persuade me that the guild of psychology and psychotherapy are indeed a positive and valuable and disinterested force when measuring this. Well, quite obviously, there's some difference between like a tobacco company trying to say that their product works because then you really have this very direct line to profit, etc. You could still argue that therapists have an interest in showing that therapy works,

but it's not that they're the therapist themselves. Like they're studying other therapists or there are statisticians who are just doing analysis on data where they had no contact at all with the patients, etc. Look, there's no body of evidence that ever rules out the possibility. Everything is flawed. But there's so many studies. And also, Stephen, it's not just that there are studies with control groups. It's that there are now studies of what happens in therapy that to me are pretty convincing.

Can you talk about that? Talk about the mechanisms by which psychotherapy produces positive change. So there are different kinds of therapy. Freudian psychoanalysis is a tradition in therapy that is sometimes portrayed in movies or sitcoms as like the patients on the couch, they're facing away from the therapist, they're talking about their dreams, and they do this maybe five days a week for years. And in fact, that is not an inaccurate description of some forms of psychoanalysis. But I think the evidence is most clear on a certain kind of

therapy that is very different, and it's called cognitive behavioral therapy. And it was invented actually at the same time, more or less, in history by two different therapists. So one was Aaron Beck, and the other was Albert Ellis. And this is 1950s, 60s? Yeah, thereabouts. I know Beck is in his late 90s now.

I think he was trained as a psychiatrist. He was trying to do psychoanalysis because many psychiatrists then and now still, by the way, embrace the Freudian tradition. And he came to the realization that when a patient comes to you and they're feeling anxiety, they're feeling sadness, loss, depression, hopelessness, that the emotions actually are the product of their thoughts. And he thought, if I can change the way they think, then I can change the way they feel. And cognitive behavioral therapy as it now exists, it's only a few weeks and you have homework and your therapist explains

how thoughts can lead to feelings and why, and they walk you through different thoughts that would change the way you would feel in the same situation. Anyway, there's a long list of kinds of therapy, but at their core, they all have a therapist who's trained and who has experience working with an individual client and then working through their thoughts and feelings in a systematic way, it doesn't seem like magic anymore. It makes it, to me, seem a lot more credible that this can have lasting benefits. What does the literature say about the categories of problems that psychotherapy is best at addressing? I don't know that I could give you that rank ordering. I do know that psychotherapy

for clinical depression and anxiety can be very effective. I know that there are some forms of psychopathology that are pretty tough to treat, like borderline personality disorder. More chronic personality disorders tend to be a little bit more difficult to treat in some cases. I also think there are lots of things that nobody even thinks to use psychotherapy for. So say you're just a slovenly mess of a person and you're late for all your meetings and you keep getting fired. I don't know that that would classify as a mental disorder. And so there's

lots of things that you could say, like, we're not even asking whether therapy might be helpful. One argument I've heard from the psychotherapy community is about what they call the treatment gap, that a lot of people, including the people for whom therapy might be most useful, just don't have access or resources for therapy. So they make it sound as if it's what we might call a luxury good. This presupposes that therapy works, by the way, which I think it does. But anyway, you don't worry about the treatment gap if you don't think the treatment works. Well, but the people who are worrying about the treatment gap are the people who claim it works well. But actually, here's the direction I was going in. I was going to say maybe one reason that therapy is not as effective as some critics say is that many of the people who seek it out are in fact not so bad off and that many of the people who most need it actually don't have access to it. Well, there is obviously selection bias in these studies or frankly just in

the people who go to therapy. Sure. The worried well is a phrase that we attribute not just for psychotherapy but for medical care generally. Yeah, if you're really far gone, it's very likely the case that you don't get it together to or have the motivation to get yourself to a therapist's office for sure. And you could argue that could push the results in either direction, either that we have very conservative estimates because these people are already pretty okay. And so they're at ceiling for what you would help them with, or the opposite. I think it's undeniable that there is some selection bias in who shows up at the therapist's office. And by the way, I think most therapists would agree with me that unless there is some kernel of motivation, there has to be some assent

from the client to want to get better and to believe a little bit in the process. Because you can imagine that psychotherapy ought not work as much, if at all, for somebody who's deeply cynical of the whole thing. What does the literature tell us about the gains of cognitive behavioral therapy versus psychopharmacological treatment, is that it's least as effective, but more enduringly effective. And by the way, on the topic of behavior change and treatment in general, it's naive to look for cures that are truly permanent. Take nutrition. Nobody would say, well, I ate an avocado in 2018. take nutrition. Nobody would say, well, I ate an avocado in 2018. Why aren't I a vigorous, healthy person now in 2021? So I don't know that we should expect therapy to last forever. I do think that the lasting benefits are from insights. I mean, I've been to therapy, Stephen, and I was actually fairly cynical before I went. And I think the things that I learned about myself and

about the nature of my moods and some of the defense mechanisms that I probably ought to have been more conscious of, they were insights that didn't leave me the day that I left my therapist. That you get to keep. If you're on an antidepressant and you stop taking it, that may not be something that you get to keep, as it were. It does seem like being able to talk with a professional about your feelings and thoughts and coping mechanisms, that ought to have lasting effects. And I don't believe that one study in rural Kenya really does call into question all treatment studies of psychotherapy. So how do we reconcile this paper by these economists who make a very bold argument favor of the benefits of psychotherapy? Because for a simple layperson such as myself, do I consider this just a turf war between economists and psychologists?

Do I consider that the two fields just look at the gains to psychotherapy very differently? What am I supposed to think? Well, look, it's data. And I think data are always good. So what can we learn from their data? I mean, the fact that cash transfers had a really sizable benefit for this population in rural Kenya suggests to me that, oh, there must be a structural problem. I mean, just imagine we port their treatment over into midtown Manhattan, and you take 100 really struggling 45-year-olds who are

not impoverished, but really, really unhappy. And then you're like, oh, you're really unhappy with your life? Let me give you $150. It's not the right cure for what ails them. So my guess is that what we learned from that data is that there is no one-size-fits-all when it comes to helping people because what they need likely differs, not just across part of the world, but just across individuals. When do you think social science research will be sophisticated enough to include as a treatment, not just psychotherapy and not just cash, but podcasts? And not just podcasts, Freakonomics podcast. Oh, I was thinking no stupid questions podcast.

Well, I don't know. That's a good question because you and I have actually talked about whether any of this helps people. But I do think that kind of conversation can be helpful. And what we talk about most of the time is human nature. And it's not exactly therapy, but it's not exactly not therapy either, because we're talking about the way the mind works. I know it's helpful to me. After one of our conversations, I always feel a little bit larger somehow. Is that right? Like in what way? I feel like Angela stuck a something in my brain. Could be a needle, could be a plastic straw. Could be a thumbtack, could just be an unshewed piece of gum.

And just pried it open a little bit and blew some ideas in there. And I always feel a little bit like, oh, okay, I do feel a little bit better now. And it's so much cheaper than therapy. It is a lot cheaper than, and there's no commute. And, you know, when my therapist broke up with me, which she did, because she was cognitive behavioral in her training. And she said, you're done? I've fixed you? Oh, yeah. She was like, oh, so when we end.

And I was like, wait, I'm sorry. What? Because I hadn't thought about that. But she was like, oh, yeah, this doesn't go on forever. And I would say that the very last conversation I had with my therapist, I worried aloud whether I would lose the gains that we had made together. And she said, and she looked at me with complete conviction and this really warm smile that she always has. And she said, you won't. And I was like, well, how do you know? And she's like, I know you won't, you don't unlearn what you have learned. And so I kind

of feel that podcast books, great dinner party conversations, when we gain a little ground in our understanding of this thing called human nature, we might slip a little bit, but mostly we get to keep what we gained. Still to come on No Stupid Questions, Stephen and Angela discuss the idea that each person contains multiple modes of identity. Do you feel bad about it when you're the angry at Jason, Angela, versus the happily watching, love actually, Angela? Stephen, I've been wondering about how different I am in different situations. So I have a question for you. Are you ready for it? Yes, I am.

So I wonder about myself, about how different I can act at home versus if I am with colleagues, how different I can think and even how different I feel. And it's as if there are multiple me's, multiple Angela's. And I don't think I have multiple personality disorder or whatever it's called now. But I do think there's like, Angela, who's mad at Jason? Angela, who's not mad at Jason? Angela watching Love Actually. Angela preoccupied with work.

So I think this idea that we can have multiple me's is intriguing. And I wondered whether you have multiple Stevens. And since I only get to see the Steven talking to Angela Steven, I wondered what your other Stevens are that I don't get to see. Well, yes, I am large. I contain multitudes is what women like to say. answer is that, of course, the me that's here talking to you isn't the me everywhere, in part because I am having a particular conversation with a particular person in a particular environment, which as much as you and I might try to not think about it, is a public conversation, even though we talk as if it's not, but we know it is. So again, this is one version of myself. But maybe I shouldn't say, of course, it's one,

because I do believe that some people, not me, not you, plainly, but some people are more likely to have what I would think of as one authentic self. They are, quote unquote, themselves everywhere they go. Yeah, no matter the circumstance. But of course, that's an impossible observation to make because you can't be with someone all the time and you can't be inside their heads either. I will say I admire or used to admire at least the belief in that consistency in people, that authenticity. And I think this admiration came from when I was younger, I was imprinted with this maxim. There were coaches that said versions of this and teachers and probably religious figures. John Wooden, the UCLA basketball coach, I remember reading it in his book.

They all said some version of the true test of a person's character is what you do when no one is watching. So I was personally in search of that internal consistency to be the same person in all circumstances, alone or with others, in good times, bad times. But I'll be honest with you, I feel like I outgrew that belief, and maybe it myself. I am large. I contain multitudes because I think that's what it is to be a human is to exercise some different version of yourself in these different circumstances. But now that you bring up the question, it's making me feel guilty for being so willing to embrace those multiple modes ourselves. Do you feel bad about it when you're the angry at Jason Angela versus the happily watching love actually, Angela? Jason, Angela versus the happily watching love actually, Angela? I'm fascinated by it, actually.

Aaron Beck, the architect of cognitive therapy, had a whole theory of modes. I mean, literally, it was called the theory of modes. I don't know if that's what you were alluding to, but it's a pretty deep conception. A mode is a whole system. It's a whole personality. So it's not only the emotion part. It's your beliefs, your schemas for these insecurities, these goals, et cetera, all activated at once. And his theory is that each of these modes is an adaptation. And we have multiple modes because different situations call for and call upon different selves.

call for and call upon different selves. So this idea that we could contain multitudes has a very real psychological counterpart. You know, it's not just poetry. And he tells a story in this very recent article of a schizophrenic who was just really extreme. There's basically in schizophrenia positive symptoms and negative symptoms. So the positive symptoms are like hallucinations and delusions, and the positive symptoms are like hallucinations and delusions, and the negative symptoms are the inability to experience pleasure, anhedonia, lack of energy, etc. So this patient had both, and they were really suffering. And then for whatever reason, the therapist took this suffering schizophrenic patient to a fast food restaurant to get a burger.

And you would not believe that this person had any psychopathology at all, chatting with the cashier, making jokes, no obvious dysfunction, no hallucinations, no delusions. And then going back to their usual setting, reverted back to this other maladaptive mode. And what's the mechanism there? I think the idea is that in certain situations, a certain mode gets activated in part because it's the mode that we have come to experience as adaptive, but also because of habit. And one of the things that Beck says you need to do in therapy is to figure out a

way to strengthen and activate adaptive modes and then deactivate our worst selves. So how do we get the better angels of our nature to come out and play more? I think for some of us who are not as practiced as Aaron Beck at therapy, we would say, oh, well, get people to suppress their worst selves, their maladaptive selves. But he says that really the trick is to emphasize and to augment and to activate the positive dimensions of ourselves. And just through atrophy and attrition, our maladaptive cells will wither on the vine. Is his argument that one can learn to do this in the moment? So if you're in the middle of an argument, and as we've talked about before, controlling my temper is not one of my virtues. In the moment, can I pivot to calm and thoughtful Angela from Mount Vesuvius, Angela? I think there

probably is something you can do to mentally rehearse that in advance. Like when I am screaming at the top of my lungs, then I will breathe deeply. But I think even more than that, Beck writes about how we need to actually figure out situations that are the ones that bring out our best. So rather than like in the moment trying to pivot, really more like having some meta awareness. So he also talks about having a meta level self that can look down on our other selves. And say like, I should not be here right now. Yeah, a little bit of an executive producer or director function who's like, OK, clear the stage. So let me ask you this. I feel like I know you fairly well. We're pretty

good friends and we do the show. And you know, the Angelo with Steven self. And you talk about this outlandish temper all the time, but I'm starting to have a hard time believing it. It doesn't erupt very often. And I have to say, I'm literally counting. It's been two years and one month since my last real eruption. Congratulations. Thank you very much. I'm learning all the cognitive tricks and all the situational tricks to make sure that citizens' lives are not lost because of my temper. So walk us through it. Give me a situation that two years and a month ago might have provoked a real outburst. And what would happen if you were to enter that situation today? So always in these temper tantrums, I'm trying really hard.

I'm feeling very virtuous and tired. And I'm feeling probably a little bit of self-righteousness. And then I'm feeling especially underappreciated. Someone else is not pulling their weight. They're not pulling their weight. And here's my kryptonite. I really don't like feeling lonely. For example, this is something that two and a half years ago might have blown my temper. So my family is going to go skiing at some point soon, like a couple days from now. And I'm not because I don't want to go skiing. But I think two and a half years ago, I might feel abandoned. I might feel underappreciated, like pouring myself

a bowl of cereal for dinner and tears mixed in with the milk. But now I, first of all, can anticipate that this is the sort of situation in which lonely Angela potentially could be the self that gets to play at center stage. And I don't want that. So I'm thinking already of ways to avoid that, you know, figuring out like— How many times you'll watch Love Actually while they're gone, for instance. Yeah, that's right. Buying the pints of Ben & Jerry right now.

Maybe you can find a gallon. Maybe that's why they don't make Ben & Jerrys by the gallon, just as a public health measure. But yeah, I'm thinking in advance, like, how do I avoid the activation of a self? But what do you do? Do you plan events? Well, I planned work, actually. I know that sounds really pathetic. And I can just see you at your desk that day. You're going to be those f***ers on the f***ing ski mountain. Let me work. Yeah, I'm just going to open another Google Doc. You know, I love that you dismissed Whitman as, you know, this isn't just a poem that talks about how one can toggle between the different selves. And I appreciate that poetry doesn't stand up to psychology, literature, in your view. But I do want to offer one description of these different selves that I found really interesting.

And this dates back to David Hume, the Scottish philosopher. This is from Treatise of Human Nature. He wrote this about our different elements. I may venture to affirm of the rest of mankind that they are nothing but a bundle of different perceptions which succeed each other with an inconceivable rapidity and are in perpetual flux and movement. Our eyes cannot turn in their sockets without varying our perceptions. Our thought is still more variable than our sight, nor is there any single power of the soul which remains unalterably the same, perhaps for one moment.

The mind is a kind of theater where several perceptions successively make their appearance, pass, repass, glide away, and mingle in an infinite variety of postures and situations. So, I don't know, infinite might be an overstatement, but I don't think you need to get rid of too many of your Angelas, honestly. And if you are cleaning out the closet and getting rid of a few Angelas, hang on to this one because I like her fine. Aww. No Stupid Questions is part of the Freakonomics Radio Network, which also includes Freakonomics Radio and people I mostly admire. This episode was produced by me, Rebecca Lee Douglas, and now here's a fact check of today's conversations. Angela forgets the modern

term for the mental illness previously known as multiple personality disorder. That phrase was used until 1994, when creators of the new Diagnostic and Statistical Manual of Mental Disorders replaced it with Dissociative Identity Disorder, or DID. The change was made to reflect an understanding that the disorder is a fragmentation of identity, rather than the growth of separate personalities. Individuals with DID experience two or more distinct identities that may have their own personal history and self-image the other identities often known as alters may also have different names ages genders general knowledge vocabulary and predominant mood than those of the primary identity later angela and steven lament that that Ben & Jerry's does not come in gallon containers. Distributors do offer 2.4-gallon packages of the ice cream, but unfortunately, they're not sold

direct to consumers. However, in the spring of 2020, residents of the United Kingdom were able to purchase 4.5-liter tubs of Ben & Jerry's for only £3.50. That's approximately one gallon of ice cream for $4.30. The containers were meant for movie theaters and restaurants, but when the coronavirus pandemic forced these venues to close, they were sent to local grocery stores. For a limited time, customers were able to purchase gallon tubs of baked Alaska, Muforia, and chocolate cookie dough. The tubs sold out quickly, but in September of 2020, even more flavors were shipped to grocery stores, this time selling for £5, or $6.49 in U.S. dollars.

It's unclear whether Ben & Jerry's plans to do this again in 2021, but if they do, we'd like to volunteer New York and Philadelphia as potential points of distribution. That's it for the Fact Check. No Stupid Questions is produced by Freakonomics Radio and Stitcher. Our staff includes Allison Craiglow, Greg Rippin, Mark McCluskey, James Foster, and Emma Terrell. Our theme song is And She Was by Talking Heads. Special thanks to David Byrne and Warner Chapel Music.

If you'd like to listen to the show ad-free, subscribe to Stitcher Premium. You can also follow us on Twitter at NSQ underscore show and on Facebook at NSQ show. If you have a question for a future episode, please email it to NSQ at Freakonomics.com. And if you heard Stephen or Angela reference a study, an expert, or a book that you'd like to learn more about, you can check out Freakonomics.com slash NSQ, where we link to all of the major references that you heard about here today. Thanks for listening.

So I would say to you, tell me what the self-talk is that goes to your head, and then you would say something like, oh, nobody likes me. Everybody hates hates me guess i'll go eat worms again stitcher