Over the past three years, Rob and I have returned again and again to the concept of tradeoffs, whether in discussing how to allocate scarce resources, how natural selection designs organisms, or how people decide what is worth suffering for.
There are tradeoffs, too, in accepting cognitive behavioral therapy (CBT) as the gold-standard psychotherapy. The benefits hardly need repeating, as CBT proponents never stop talking about them. The costs, however, are not only that core components of CBT theory are wrong, as I argued in Part I, or even that CBT is lame, as I argued in Part II. The larger cost may be the opportunity cost: CBT’s dominance crowds out alternative ways of understanding pain, leaving us with a narrower and more fragile therapeutic imagination. This “imaginative foreclosure” is the focus of Part III.
Every dominant therapy teaches a culture not only how to treat suffering, but how to conceptualize it. CBT has taught us to understand psychological suffering as:
internal
diagnosable
measurable
avoidable
treatable
The implication is that if suffering persists, something has not yet been properly identified, measured, treated, or practiced—pretty much the opposite of Charlotte Joko Beck’s sentiment that “what makes [pain] unbearable is your mistaken belief that it can be cured.” Yet this way of understanding suffering must be seen for what it is: a frame, not a scientific finding.
CBT’s frame of suffering is winning, however, not because CBT’s methods have been shown superior to those of rival orientations, but because CBT best accommodates the pressures to package, manualize, study, sell, and scale mental health treatment. Alongside rising psychiatric-medication use, psychotherapy has become, as historian Marcos Ramos puts it, “more pill-like itself: standardized, quick, corporate, and cheap.” In other words, McTherapy.
In a world desperate for better mental health faster, CBT has the obvious advantage. It can say: “Your bad feelings are the result of irrational thinking, which can be fixed in around ten sessions.” Meanwhile, the psychoanalyst, existential therapist, or interpersonal therapist hesitates and says, “Well, it’s complicated, and it depends.”
Decision over.
But it’s not only other psychotherapeutic orientations that are being displaced. Over the past century, psychotherapy itself has increasingly crowded out older traditions for interpreting suffering, including religion, philosophy, and literature. The same current that has brought CBT to our shores has pushed the English major out to sea.
Yet the question of how to find meaning in an inherently painful and frustrating life has been addressed for thousands of years. It would be one thing if our current science were so far ahead of these older traditions that we could discard them alongside flat-earthing and geocentrism. But it isn’t. So I see no reason to rush past what these traditions have to say, especially when what they have to say is often so much better than CBT.
To be fair, I was an English major, so perhaps you’ll think me biased. But I tend to think the opposite: my quick transition from literature to clinical psychology made the comparison unusually clean. I could place, almost side by side, the descriptions of the human condition I had encountered in novels, plays, and poems beside the descriptions I was being offered in treatment manuals, diagnostic categories, and graduate lectures.
My conclusion was strong then and has only been confirmed since: writers usually understand the human condition better than psychologists do. When the day finally comes that we are able to formalize psychological insights, I’ll eat my hat if there aren’t more to be found in the short stories of Edgar Allan Poe than in the volumes of Aaron Beck.
But as my English teachers always advised: show, don’t tell. So, in what follows, I’ll give three literary examples to show what art understands about suffering that CBT, and much of the mental-health culture around it, tends to miss.
McTherapy distortion: defenses are obstacles to authenticity, openness, and growth.
Literary correction: defenses are structures that make the unbearable bearable.
In Chapter 30 of The Age of Innocence, Newland Archer, who is in love with his wife’s cousin, finds himself dwelling on small household mysteries—such as why his wife is late to dinner—“as a means of tying his thoughts fast to reality.” He wonders whether his father-in-law’s “absorption in trifles” has a similar origin: “perhaps even Mr. Welland, long ago, had had escapes and visions, and had conjured up all the hosts of domesticity to defend himself against them.”
Every time I read this passage, my heart stops. Even now, my fingers hover over the keys, reluctant to strip Wharton’s prose for its psychological parts.
A certain kind of therapist would see Newland’s absorption in trifles and urge him to open up, be vulnerable, “speak his truth,” and quit “repressing” his underlying emotions. Perhaps some of that would even be right; as a reader, I am certainly screaming at Newland to follow his heart. But Wharton has much more pathos than that of our contemporary therapist-cheerleader. She understands both why Newland cannot follow his heart and why, afterward, he needs to dull it. His absorption in domestic trifles keeps him from agonizing over the choice he could not make.
Wharton understands that what looks like deadness, distraction, or avoidance from the outside is often preserving life on the inside. Some people must lop off branches, at least for a time, to keep the trunk alive.
This brings us back to Chesterton’s Fence, a point from Part I. CBT therapists can be too quick to see a defense and start tearing it down before understanding what it protects. Yet a defense is often the mind’s way of surviving what it cannot face directly. In Newland’s case, the danger is, at first, the temptation to follow his heart, and then later, the torment of knowing that he didn’t. His absorption in domestic trifles protects him from that knowledge.
The point is not that fences should never come down. It is that you had better know what they are holding back first.1
Common therapeutic distortion: distress is overlocated inside the person.
Literary correction: the situation might be the pathology.
In Bartleby, the Scrivener, Melville presents one of literature’s strangest tragic heroes. Bartleby, hired as a legal scrivener—someone paid to copy legal documents by hand—does not rage against the world or his place within it, as a more conventional hero might. As he slowly withdraws from every aspect of life, and eventually life itself, he does not make a scene. Instead, to more and more things, he simply says: “I would prefer not to.”
As you might imagine, Bartleby’s refusal to work eventually begins to grate on his boss, the story’s narrator. But the boss checks his “nervous resentment” by recalling another office conflict that ended in tragedy:
I remembered the tragedy of the unfortunate Adams and the still more unfortunate Colt in the solitary office of the latter; and how poor Colt, being dreadfully incensed by Adams, and imprudently permitting himself to get wildly excited, was at unawares hurried into his fatal act—an act which certainly no man could possibly deplore more than the actor himself. Often it had occurred to me in my ponderings upon the subject, that had that altercation taken place in the public street, or at a private residence, it would not have terminated as it did. It was the circumstance of being alone in a solitary office, up stairs, of a building entirely unhallowed by humanizing domestic associations—an uncarpeted office, doubtless, of a dusty, haggard sort of appearance;—this it must have been, which greatly helped to enhance the irritable desperation of the hapless Colt.
This is basically situationism before psychology had the word for it. Melville understands that behavior does not emerge from the person alone. It is summoned, shaped, and sometimes deformed by circumstance. How else are we to understand Colt being “unawares” about committing an act that “no man could possibly deplore” more than himself? Indeed, the narrator seems to imply that the situation was almost wholly responsible for the shooting.
In Bartleby, Melville takes this further by giving us a character with no biography or personality, leaving the environment to do all the explanatory work. In the opening paragraph, as he prepares to introduce Bartleby, the narrator tells us, “I believe that no materials exist for a full and satisfactory biography of this man.” The first time Bartleby refuses work, the narrator explains that “had there been any thing ordinarily human about him, doubtless I should have violently dismissed him from the premises. But as it was, I should have as soon thought of turning my pale plaster-of-paris bust of Cicero out of doors.”
Without past or personality, Bartleby functions as a perfect medium for his surroundings—surroundings which, Melville wants us to understand, are deadening. Bartleby copies legal language for a living, pretty much the opposite of writing as expression. He sits behind a “high green folding screen” in his boss’s office, beside a window that “commanded at present no view at all.” He works “mechanically” on whatever “trifling thing” his boss wishes.
Even his refusal, like the rest of him, is without color—gray. He does not say “I won’t,” or “Do it yourself,” or “Go to hell.” Only: “I would prefer not to.” Yet, by the end, this refusal is all Bartleby has.
There is undoubtedly some awareness of situationism in therapy, but it tends to appear in one of two stunted forms. The first is a kind of therapeutic Mad Libs, in which every client’s suffering is traced back to the same handful of large, approved villains: capitalism, racism, patriarchy, neoliberalism, or whatever else happens to be trendy. These words refer to real forces, but when treated as the key to a client’s suffering, they often become a distraction from circumstances that are much more salient and addressable. Even evolutionary mismatch is no exception to this rule.
The second form is more common. Situationism often functions in therapy the way “work-life balance” functions inside companies. The phrase is invoked frequently to make employees feel warm and safe, even when the company has neither the ability nor the interest to make it happen. Likewise, therapists often reassure clients that their suffering is not all their fault, but because therapy still takes place with the individual client in the room, treatment defaults back to the individual anyway. Like a billboard on the highway, the situation is acknowledged and then left behind.
For the most part, the field is trained to investigate the client in one situation: therapy. What do they talk about? What symptoms do they report? How do they carry themselves? What transference do they enact? How do they reason? In and of themselves, these are not bad questions, but they become aloof if not paired with simpler Melvillean ones: What kind of life has this person been placed inside? What room do they sit in every day? What work are they expected to perform? Who do they have to deal with? What arrangement of space, money, status, family, noise, loneliness, and obligation makes up their daily lot?
“The situation” becomes all the more salient when we consider the evolutionarily novel world we all inhabit. I am sure many readers recognize elements of Bartleby’s life in their own: doing fake work, hunched over, under bad lighting, for too many hours, in rooms with no views, while the sun rises and sets.
Melville would not have been surprised by the despair that follows.
Therapeutic distortion: suffering is a problem to solve.
Literary correction: sometimes listening is the intervention.
In James Baldwin’s Sonny’s Blues, the narrator spends much of the story trying, and failing, to understand his younger brother Sonny. Sonny is an addict, a musician, and a source of worry and incomprehension. The narrator loves him, but mostly from a moral high ground. He wants Sonny to be safe, respectable, intelligible—like he is. He wants him to stop being such a problem.
This is the basic temptation of much psychotherapy: to fix the client. What’s the diagnosis? What’s the treatment plan? What distorted thoughts or maladaptive habits are maintaining the symptoms? What skills should be practiced before next session? Why doesn’t the client seem motivated to change?
But Sonny is a stubborn one. He can’t seem to be reasoned, managed, persuaded, corrected, or exhorted into becoming more like his Boy Scout older brother, who is a schoolteacher. He insists on being a musician, which his older brother thinks is “beneath him, somehow.”
The Boy Scout mindset reappears when the narrator talks to his mother about Sonny for the final time. “Don’t you worry,” he tells her. “I won’t let nothing happen to Sonny.”
His mother “smiled as though she were amused at something she saw in [his] face.” Then she said, “You may not be able to stop nothing from happening. But you got to let him know you’s there.”
The narrator does not fully understand this until the final scene, when he stops trying to correct his brother, or live his life for him, and instead listens to him. When he goes to hear Sonny play piano in a nightclub, he finally understands that Sonny’s music is not an escape from his suffering, but a way of shaping it.
Music doesn’t cure Sonny. It does not erase addiction, grief, family history, or the darkness Baldwin has been circling the whole story. But it makes the suffering intelligible, even shareable. It lets other people take part in it. Only an approach hellbent on cure—on solving Sonny’s blues—would be disappointed by this.
Officially, “bearing witness” is so widely endorsed that the phrase has become cliché. Every therapist knows they are supposed to listen to their clients. Every therapeutic orientation gives at least ceremonial respect to empathy, attunement, and “being with.” But much of the time, the field is not actually organized around it.
As Kenneth Fisher says in The Iconoclast’s Notebook:
Training programs in psychotherapy rarely focus upon the immediacies of the process— looking, listening, sensations, feeling, empathy, imagination, intuition, and speech. Instead, what occupies center stage are diagnosis, transference, interpretation, resistance, and personality change. Therapy, therefore, is taken to be, not a many-sided human interaction, but a guided process, an elaborate manipulation.2
The pressures behind this are easy enough to understand. Managed care wants efficiency. Clients want to stop feeling bad. Graduate programs want methods they can teach, supervise, and test. Therapists, after years of training, want their expertise to amount to more than unusually careful listening.3
None of this is mysterious, and much of it is reasonable. But taken together, these pressures pull therapy away from the immediacy Fisher is describing and toward the posture of Sonny’s older brother: being too busy knowing what should happen to hear what is happening.
Baldwin reminds us of something therapists should probably have taped to the wall: sometimes listening is the intervention. Listening does not mean contorting your face into a compassionate tableau, or softening your voice to prove you are “holding space.” It begins and ends with genuine curiosity about what someone else has to say. “The greatest compliment ever paid me,” Thoreau says, “was when one asked what I thought and attended to my answer.”
This is what art often knows better than therapy. It does not rush to solve pain or make it productive. It does not insist that suffering justify itself by becoming growth. It simply attends. In a letter to Alexei Suvorin, Chekhov writes: “You are right in demanding that an artist should take an intelligent attitude to his work, but you confuse two things: solving a problem and stating a problem correctly. It is only the second that is obligatory for the artist.”
The same is true for a therapist. Therapy is “not to solve [the client’s] problems,” Fisher writes, “but to make them colorful and worthwhile.”4
One of my colleagues embodies this better than anyone I know. She laughs, cries, becomes curious, holds her breath, and all but eats popcorn as clients tell her about their week. At the end of session, rather than reaching for homework, dispensing an interpretation, or offering advice, she sighs like an ancient Greek at the theater. Then, standing up and holding the door for the client, she says, “I can’t wait to hear what happens next.”
A clarification before closing.
I’m not saying everyone should do bibliotherapy. I’m not saying every therapist needs to be trained in the classics and literature, although it wouldn’t be the worst idea. And I’m definitely not saying we should give up science and do whatever feels right. The best science we have is still considerable, and therapists who ignore it aren’t being deep; they’re just being irresponsible.
The problem isn’t science. It’s scientism: the misuse of scientific authority when the method is too crude for the object. CBT, along with much of modern therapy, has foreclosed too early on the question of what suffering is, where it comes from, and how best to meet it—not because it found the answer, but because it was pressured to produce one.
Science works beautifully when used for the right job. It is excellent at reducing complexity when reduction is possible. But when reduction is not possible, and we reduce anyway, the important things do not get explained. They just disappear.
To my immense relief, they can still be found in the arts.
It’s normal, when trying to fix an imbalance, to swing too far the other way.
The mental health industry has a long history of being almost hopelessly unscientific, its course charted by charismatic leaders and compelling theories. CBT is the overcorrection. It made therapy more transparent, teachable, measurable, respectable, and science-seeming. But the price of this respectability was premature reduction. A meaningful conversation became something to manualize. Experience became a symptom checklist. The therapeutic relationship became a delivery system for interventions.
More broadly, the strange and shifting experience of living a life—a miracle by any honest account—became something to squeeze into goals, worksheets, symptom scores, treatment plans, and reimbursable units, while its improvement was increasingly likened to going to the gym for the mind.
The problem isn’t only that CBT is overhyped, shallow, and sometimes wrong. The deeper problem is that CBT has helped install a cramped picture of human suffering. It has taught clinicians and the public to see pain as internal, diagnosable, measurable, treatable, and, in many cases, avoidable.
Fortunately, the writers discussed above preserve a larger picture. Wharton understood that defenses form for a reason, which is why we should not dismantle them before we know what they are protecting. Melville understood that actions are shaped by situations in ways treatment manuals simply cannot accommodate. Baldwin understood that people are often helped not when someone finally figures out how to fix them, but when someone stops trying long enough to listen.
My hope for the field is that practitioners learn to use the best science we have, which is still considerable, while also accepting its limits. Beyond those limits lie perception, judgment, imagination, relationship, and art. In this, I am mostly parroting my supervisor, who likes to say: “To become a better therapist, travel, learn new things, have conversations with strangers, and above all—read fiction.”
Our motto might be: science to its limits, art beyond them.
The Contra CBT Series
To be fair, defenses are central to psychodynamic therapy. Freud gave us much of the language, and Anna Freud later systematized many of the common mechanisms. My target here is not psychodynamic therapy, nor any therapist who understands defenses as protective compromises. It is the contemporary therapy culture too eager to treat defenses as obstacles to “living your best life.”
“Why is there so much stuffy, unintelligible prose by the highly educated, including therapists?” Fisher asks. “Hold on, dear reader, here is an explanation—the kind and amount of study these experts have had to do along the way.” (p. 54)
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