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Tuesday 23 October 2012

Replies: The Goal of Therapy

Reader Sophia M has commented on the September 25 post on The Marshmallow Test. For our discussion, see that post.  In the course of our exchange she wrote this:

"There is the idea that the aim of psychotherapy is to help people overcome their neurotic unhappiness and to become ordinarily unhappy. How do you view that?"

I like the idea of turning the blog into as much of an exchange as possible, so I said I'd make my reply a new post. All readers: Take this as an encouragement to write questions, raise issues, and comment freely as part of this site.


A therapeutic pessimist?
The idea Sophia mentions comes from Freud, who once wrote "much has been gained if we succeed in turning your hysterical misery into common unhappiness." The remark has significant resonance and has lived on as one of his most oft-repeated quotes.

This remark is sometimes taken as an indicator of Freud's own pessimism about the utility of therapy. He seems to set the bar rather low in terms of his goals for psychoanalysis, perhaps sensing the weakness of his methods.

But I think this would be an attempt to take Freud out of context and use his words against him. Much of his work can be criticized for various reasons, but I think here he was trying to say something reasonable. And it may be even more relevant today.

The Function of Emotions

The emotions we experience seem to function as a kind of behavioural guidance system. They tell us what to do next. Fear tells us to get the heck out of here, anger tells us to attack, and happiness tells us to "do more of whatever you just did." Many of the impulses we get from our emotions are not very helpful, presumably because we live in a very different environment than the one in which they evolved.

From this we can see the shallowness of the idea that we should be happy 24 hours a day. First, we are simply not wired to experience unrelenting happiness. Second, the guidance function of emotion would be lost if we only experienced one thing. No one would buy a navigational system that could only say, over and over, "go left, go left, go left, go left."

The problem we see in our culture (and in therapists' consulting rooms) is that people often seem to be extremely prone to certain painful emotions and seldom get to experience the positive ones. The terms "hysterical" and "neurotic" have become pejorative since Freud's day, but essentially just mean (when applied to misery) unhappiness that proceeds not from the essential nature of our circumstances, but from our own minds.

For example, on any given day we might be perfectly safe and most of our needs might be satisfied, but we can still be horribly unhappy because a tendency of the mind causes us to focus only on the misery of an unhappy past, or the prospect of losing everything in an unhappy future. Or we might focus on certain elements of the present (a friend is displeased with me at the moment) and ignore the rest of the picture (I am employed, I have other friends who care for me, and I'm tasting a lovely bagel).

It is usually this misery that we are trying to work with in therapy.

Ordinary Unhappiness

Life is difficult, and it can be a bit odd to respond to all losses, illnesses, and tragedies with complete equanimity or manic cheerfulness. Recently there has been a controversy about a proposal for normal grief to be diagnosable as a depressive disorder in the upcoming DSM5 psychiatric guide (I wrote about it here). If one's beloved spouse dies, surely it would be more abnormal to be unaffected than to experience grief.

Life has routine disappointments, ranging from "this bagel's not as good as the last one" to "my child has been diagnosed with a life-threatening illness." We don't need to maximize our misery in response to these situations, but it is normal to feel disappointment, fear, sadness, grief, guilt, shame, and anxiety at least some of the time. I think this is what Freud was mainly talking about when he used the phrase "common unhappiness." Not a disorder, therefore not to be treated. Therapists can still have a role, but more one of a midwife to misery rather than a surgeon trying to excise it.

The field of Acceptance and Commitment Therapy (ACT) and a growing number of other clinicians have pointed out that the field of mental health may have inadvertently perpetuated the idea that uncomfortable emotions are bad or pathological. This removes their signal value - from "Ah, whenever I go into work I feel down - perhaps I need to think about a job change" to "Ah, whenever I go into work I feel down - clearly I have a biochemical imbalance that needs treatment." It is as though we have made a perfectly normal aspect of being human - say, having opposable thumbs - and redefined it as being a disorder. "Those aren't thumbs, they're tumours!"

I think Freud was also a bit of a pessimist about how happy most people could be, and if you look at the time he was practicing, this is not a big surprise. World War I, the Depression, the gathering clouds of World War II (he died in 1939) - cheerfulness would be a chore. Our own day seems much more comfortable, but perhaps this is only because we cannot see the future.

I think that therapy should most often focus on "unnecessarily and unhelpfully severe unhappiness" (to use a term that gets away from Freud's "hysterical misery").

But I also see room for Positive Psychology and its emphasis on optimal functioning and improvements in happiness and life satisfaction. Positive Psychology has a fair share of detractors ("Feel happy all day long and to hell with creating a better world") but any field can be dismissed if few enough brain cells and words are used ("Evolutionists are saying I'm descended from a monkey!").

The evidence suggests that indeed we can improve our life satisfaction, and that doing so is likely to make us more energetic and more capable of making a positive impact on the world. There are risks, certainly. We can become so focused on our own daily enjoyment that we ignore the contributions we can make to others. The whole exercise can become yet another element of our cultural narcissism. But depressive lethargy seldom promotes action or positive change; enthusiasm and realistic goals do a better job.

So: Can we get rid of everyday unhappiness? No, nor should we. It's useful and, coupled with careful thought, can help guide our lives. But we can work on the mix of happiness and unhappiness to become more capable of dealing with life's challenges.


  1. One thing I find very concerning about the Pollyanna perspective and how it seems to be finding its way into the basis of psychiatric evaluations of normalcy, is how it can induce a kind of witch-hunt mentality in people.

    Historically, in the time of witch-hunts and religious disputes and wars, people would denounce each other to the authorities for being of the "wrong religion" or for "witchcraft."

    Nowadays, a person can easily find themselves accused of some serious mental disorder.

    If one doesn't always think, feel, speak and act the way some people expect one should, then, even if one hasn't done anything illegal, some people will be quick to publicly accuse one of psychopathy, sociopathy, narcissism and such.
    And once they start thinking that way, they tend to interpret one's every word and action as further evidence that the diagnosis is correct.

    It is a stigma to one's reputation that is very difficult to wash away, and can have serious consequences (such as bullying in the work place, job loss).

    So I think part of the reason why some people are eager to maintain a Pollyanna perspective is because they fear the socio-economic consequences of what may happen in they don't.

  2. "But we can work on the mix of happiness and unhappiness to become more capable of dealing with life's challenges."

    - But to what end?
    If we are supposed to believe that when the heart stops beating, the brain stops working and we're pronounced "dead," it's all over, and death can happen at any time, how then can we appreciate life and its mixed pleasures and struggles?
    Why bother, why struggle - if we could die anytime?

    Many people say that such wondering is "just depression talking."

    Yet throughout history, all major religions and many philosophers have addressed these topics, without automatically considering them to be the products of "sick minds."
    And unlike some common modern approaches to treating depression, those traditional ones didn't propose that the solution is essentially in getting the depressed person back on the treadmill of life, and in denying whatever insights or concerns they may have gleaned in their depressed states.

    One such example is traditional Buddhism.
    Was Prince Siddhartha wrong when he was so radically dissatisfied with the way life is usually lived?
    Was he wrong to embark on a search for happiness that would be beyond the usual ways of pursuing happiness, which always result in merely temporary happiness?
    Is the Buddhist Pali Canon really "just depression talking"?

    Could you please read an essay on this topic by a Buddhist teacher from a conservative Theravadan tradition, and comment on it (it's about three pages) -
    "Affirming the Truths of the Heart: The Buddhist Teachings on Samvega & Pasada" ( )

    Thank you.

    1. I suspect that each person has to confront the question of "why bother, if we can die anytime" - particularly given that this is not a conditional statement, but the truth.

      To ask, given this, "how then can we appreciate life and its mixed pleasures and struggles?" implies the answer "We cannot." But this denies the experienced reality: We DO. In fact, it may be that life's transitory nature is precisely what makes it appreciable. If diamonds littered every street and beach, would anyone equate them with luxury? It is rarity and ephemerality that defines luxury. So we can enjoy a family get together knowing that soon it will end, we can enjoy a movie or play knowing that it is only two hours long, and we can enjoy our partner knowing that both we and they will die and we will be parted.

      I think your post is asking about lasting or permanent happiness, more than what I believe the emotion of happiness to really be: a transitory emotional state evolved to tilt an organism toward certain types of behaviour. But my equation of happiness with an emotion is not obviously correct. Many writers have discussed the search for happiness as more of a search for the means of "right action" regardless of the emotion these actions produce. This is a completely reasonable way of approaching the issue, and perhaps more important in the long run.

    2. This comment has been removed by a blog administrator.

  3. In the light of the goal of therapy -

    What should the therapist be seen as?

    As an enlightened being who knows everything, as a cognitive and moral authority?

    1. I hope not, as few of us live up to that job description!