Therapy in the Machine World

On "Pharmakon" and the Need for Discernment

The Madhouse by Francisco Goya (1819)

Many things in life may fall under the concept of pharmakon, which essentially means that one thing can be a cure, but at certain doses, also be a poison. It’s not always clear at first what might fall under this categorization, but in the past few years, I’ve been feeling increasingly that therapy might not be as neutral as it seems. Many people, including myself, have benefited considerably from therapy. But regardless, to uncritically evaluate therapy as something that is incapable of doing any harm seems short-sighted, particularly in our ever-changing socio-cultural landscape. In order for therapy to do the most good, it’s important to allow ourselves to be aware of alarming trends and pay attention to feelings that tell us “something is not quite right.”

Over my life, mental healthcare has become normalized, and my generation has had access to more tools than any other generation before us. I often feel tremendously grateful that I’m able to work through my issues through so many means — books, YouTube, actual human therapists, podcasts, and so many other things that have made a real difference in my self-concept, authenticity, and my process of individuation. These are all good things. But at what point does the “cure” become a “poison”?

I’m not the first to point out the widespread use of pop psychology “therapy speak,” and how deploying this language can eliminate nuance, undermine our perceptions, and lead to the over-pathologization of human behavior. Additionally, we’ve seen a rise in “self-ID” and over-identification with diagnoses, which can have a limiting effect on people struggling with mental health. As someone interested in psychology, these more taboo and complicated problems often catch my eye.

This past week I stumbled across this video from Breaking Points, which describes how BetterHelp may be causing more harm than good due to its incentive structure, which encourages therapists to work insane hours to increase their hourly rate through the platform. Anyone who is a therapist, has gone to therapy, or who knows a therapist knows that sustained, active attention within a session is of supreme importance. This model that BetterHelp has deployed encourages therapists to be distracted and not fully present with their clients. There has also been some scandalous information coming out that suggests their hiring process lacks rigor, leading to unqualified therapists being accepted onto the platform, unbeknownst to users.

Additionally, the rise of platforms like BetterHelp has led to a normalization of text-based therapy. I’ll get into why this is troubling, but first, we need to turn our gaze to a critical component within all forms of therapy.

Your Therapist is Not Your Friend (They Can’t Be)

This is not an indictment on therapy whatsoever, but it’s just a fact that therapy is a transactional relationship. Your therapist may care for you deeply, and likewise you may care for them, but the moment you stop paying for sessions, the relationship ends. I know this from personal experience. This is rather different than the majority of relationships we have in real life, which do not rely on a monetary economy, but rather a gift economy. In The Master and His Emissary, Iain McGilchrist writes that “before the development of currency, there is an emphasis on reciprocity” specifically imprecise reciprocity, whereas monetary exchanges are precise (an hour of your therapists time equals x). In the case of therapy, often the exchange is related to attention. You’re paying someone to pay attention to you and help you understand your problems, and in the best case, your payment translates into critical assistance in building skills to cope with life’s difficulties. In relationships, the reciprocity required between one action or service (or a shoulder to cry on) to the “gift” fulfilled is not immediate, and it may ultimately be unequal. Our needs in relationships are contextual and unique, yet we all know that “repayment” is an important aspect of maintaining relationships.

The therapist, therefore, should never be considered to be a substitute for real-life relationships, because our real-life relationships aren’t predicated on a financial transaction. They’re predicated on time spent, care expended, and intimacy shared. Furthermore, just like physical therapy or other similar medical interventions, the goal of therapy should be to get “better,” move through our crises, and no longer need the treatment. Therapists should give us, their clients, the tools to flourish and cope with the vicissitudes of life on our own and with community members that are real stakeholders in our lives.

The problem is, real relationships are not at all like therapeutic relationships. In real life, we push each others’ buttons. We challenge one another. We make mistakes, and we hurt each others feelings. In my personal experience, a therapeutic relationship is very divergent from a real relationship, beyond it being very one-sided and non-reciprocal emotionally. Therapists don’t always challenge you on your bullshit the way a good friend would. They don’t always call you out for your inconsistencies like a parent would. And they don’t always pick up on the ways you’re not living up to your own values the way a partner would. Our real, flesh-and-blood relations have an investment in us, in our growth, and in our well-being in a way that a therapist never could. They are literally barred by codes of ethics from truly being part of your intimate community, and in some cases, it’s actually illegal for them to do so. They cannot be our friends, no matter how much we might want them to be.

In Abigail Shrier’s new book, Bad Therapy: Why the Kids Aren’t Growing Up, she describes an alarming phenomenon.