Truth, Effectiveness, And Mental Health: Part One

Every couple of months, some "alternative healing" devotee wanders into my consulting room simply assuming I'm down with the latest New Age miasma. Once in awhile I'm approached by people who ask me to testify that they should not have to go to conventional mental health treatment in order to collect psychiatric disability. I've even had an impaired physician wanting me to go before the medical board on his behalf to get him out of treatment.

Since I argue that mental health care lacks the scientific basis that it claims, but still does good things, some people assume that I'm sympathetic to nonsense. I guess it's the old, "The enemy of my enemy is my friend," thing. If we do good things without science, they reason-I guess-then any old thing flies.

They have a point, though I don't like it. Ideas do not have to be true to inspire, to give meaning to life, or to promote happiness. People find purpose, meaning, and joy under the guidance of the most obviously false beliefs.

Helping people feel better is fairly easy, if you're not too concerned with truth. You can be an extremely effective therapist, running a wildly successful practice, whether or not what you believe and purvey is true.

Indeed, I believe the best way to get wealthy as a therapist is to tell your patients that, of course, they are right and good and special, that they have been misunderstood and unjustly treated, and that if only the world appreciated them as you, with your expert insight, appreciate them, they would receive all the wonderful things they so deeply deserve-and their failures to believe as strongly in themselves as you do simply shows their low self-esteem.

More responsibly, every therapist who has been in business long can think back on patients who were helped by ideas the therapist no longer believes to be true. And every therapist who has been in business long, no matter his or her therapeutic beliefs, has hundreds of satisfied customers-which means patients have been helped by people who believe drastically different things.

Should we, then, simply abandon the idea that therapists should seek to hold and purvey true ideas? Is "effectiveness" enough?

Well, it's easy to show that "effectiveness" isn't enough: we can have very effective cures that no one in his or her right mind would ever endorse. Think about warts in the fingernail bed-very uncomfortable, and very hard to get rid of. Unless, of course, you simply amputate the finger. One hundred percent effective. Some of our effective cures in mental health may be about that drastic. (If you doubt it, think of how many marriages therapists have urged patients to end, or how many estrangements from parents they have supported.)

Still, lots of effective work is surely respectable enough. For instance, as I pointed out in an earlier article, we have very good scientific reasons to disbelieve the main tenets of cognitive behavioral therapy-but it's effective, and it doesn't seem intrinsically egregious in its effects. Probably the same can be said for plenty of other care.

So if care is effective, without being obviously egregious, is that enough?

In one sense, the answer, obviously, is yes-it's enough to keep patients happy, therapists busy, and the social status of the mental health professions secure.

We can claim that if we had true ideas, we would do more effective care-but that's ideology, wishful thinking, a hope about how the world works. We hope that truth makes for better care. But is there really evidence for that?

If we're going to care about truth, it won't be from any glaring therapeutic imperative. Concern for truth is an ethical commitment, not a pragmatic necessity. If we're going to bother with truth, that will be because we want to be decent people. We don't receive an exemption from the moral imperative to be truthful simply by becoming mental health practitioners or patients.

Why being a decent person requires truthfulness is a whole other question. But we all know that, except in certain extenuating circumstances, it does.

Still, what does that amount to in the therapy room? If we do not, in fact, possess a full, true account of suffering and its relief, what does it mean to be truthful in seeking to relieve human suffering? More on that next time . . .