But psychiatry goes a step too far when it claims that people who become emotionally helpless, hopeless, lonely, or agitated are actually _sick_. Szasz claims that they are not sick; they are helpless, hopeless, lonely, or agitated. These are not "illnesses" but, rather, some of the tragic conditions of life. They are _problems of living_. For Szasz--and for therapists like Viktor Frankl and Alfred Adler--psychological problems resemble "moral problems" much more than they do "physical diseases." They involve discouragement, loss of morale, loss of moral courage. They are _states of demoralization_. Now, demoralization is not a _treatable condition_--not, certainly, in the medical sense. You cannot apply treatment from without and expect that the patient will get better. The situation is much more complex than this. The patient--let's shift at this point to calling him or her the _client_--is much more actively involved in the process of psychotherapy than is a _patient_ in medicine. A woman who contracts pneumonia can be cured with antibiotics while she lies in bed watching television or sleeping. But an emotionally troubled woman--who has had a succession of unhappy marriages, who has lost job after job, whose personality is offensive to others, who has a low sense of self-worth, and who has lost a sense of meaning and direction in life--cannot be cured while she lies in bed and is treated with appropriate medication. "Effective treatment" just isn't possible; too much is up to the client herself. Basically, this is why studies of the effectiveness of psychotherapy have generally led to discouraging results. Most psychological conditions (there are exceptions, as we will see) are not, at least at present, _treatable in the medical sense_. To combat them requires of the client a great deal of his or her own effort and even exertion. They require self-discipline, moral courage, faith in oneself--all the things emotional distress tends to undermine. No approach to psychotherapy can itself be medically effective in treating conditions like these. Somehow, the client must reach a point where he can lift himself by the bootstraps. He can be _encouraged_ by the therapist, he can be _reasoned with_, he can be {272} _manipulated in strategic therapeutic ways_, the therapist can exhort him to be rational, but the focus always comes back to the client. Is he or she motivated to learn how to change? Is he or she an "effective learner"--that is, a "good student"? The hundreds of attempts to evaluate the effectiveness of approaches to psychotherapy have, incredibly, left out this essential reference to the clients themselves: What kind of people are they? What encourages _them_? What can act as a source for their motivation, for the strength they have lost? Ironically, the answer to these questions also lies unwittingly in the hands of psychotherapy's harshest critics.