Mental(izing) Health
Newsletter, #53
Therapy is often misrepresented in the media, annoyingly so. This trend has been exacerbated by the cacophony of social media, by telehealth ventures in search of profit, and by journalists who jump on the latest bandwagon about mental healthcare, citing research selectively and mounting one-sided arguments. Mental health professionals have been slow to figure out whether and how to respond to such misrepresentations. It can feel like we are risking our professionalism to be in the defensive position of justifying our work; yet, as I will argue in this newsletter, it is also perilous to ignore the shifting, and sometimes negative, ways in which we are viewed publicly.
Have you heard about the series Overanalyzed: How We Fell Out of Love with Therapy from the Cut, part of New York Magazine (https://www.thecut.com/tags/overanalyzed/)? One of the most recent articles in the series by Melissa Dahl, Maybe You Shouldn’t Talk to Someone (https://www.thecut.com/article/everyone-quitting-therapy.html), a rejoinder to Lori Gottlieb’s book, Maybe You Should Talk to Someone, the latter of which intersperses her work as a clinician and her recognition, prompted by a friend, that she needs to return to therapy after a breakup.[i] Gottlieb’s book is a defense of long-term psychotherapy in that her initial reason for seeking help opens a window into larger, existential issues about her life, and with the aid of a wise therapist, comes to a sense of greater agency in choosing to write the book we are reading, rather than the book that she had been conflicted about writing.
Dahl’s saga is witty and impertinent: therapy helped her, she informs us, until she was “in the mood for a less examined life.” Later, Socrates! This state of mind, I believe, is widespread and is not necessarily idiosyncratic. Dahl confides that she told her therapist she was ending therapy for financial reasons, but this was not the whole truth. She was experiencing the work as repetitive, rehashing the same three issues: her tendency to make plans that she didn’t want to do, her worries about writing her second book, and her increasing anxiety at her job. Dahl expresses frustration that her therapist continued to give her the same advice. Something clearly was awry here: the patient was not able to convey her negative feelings honestly and the therapist was allegedly freely dispensing advice, not really tuning into the patient, and unable to inspire the patient to implement change. Dahl does not reveal whether she tried to take steps to address the three issues.
Throughout the piece, Dahl encounters people who report frustration and fury with therapy. Carrie found herself searching to discuss problems, which increased her negativity. Rebecca realized that therapy was a crutch, leading her to complain to her therapist, rather than to her husband or son. Elaine stopped therapy, and when her father died, looked to friends for support, which turned out to be especially rewarding. The Substack writer, P.E. Moskowitz, quits therapy because it was making him less able to tackle his wish to become more ambitious.[ii]
Where is Dahl heading with this argument? She cites research that challenges the assumption that expressing, rather than suppressing thoughts, is desirable (https://www.science.org/doi/10.1126/sciadv.adh5292). This research, conducted during the pandemic, gave the instruction to “just stop thinking” about negative thoughts, and reaches the conclusion that the experimental group ended up with less anxiety and depression than the control group. There is much to tease apart here, as suppression can be a useful strategy in certain circumstances, and clearly has a cultural valence as well. It is limiting, however, to focus on cognition, without contending with emotions (and the large literature on emotion regulation), especially in the context of imagining the application of such a basic instruction in clinical work. It might alleviate distress for some patients, but I am dubious that patients with many kinds of psychopathology—think personality disorders or OCD, for example— would benefit from the utterance of such a top-down pronouncement.
Beyond suppression, Dahl would like us to consider the merits of alternatives to therapy like yoga and physical exercise. She cites a study that, according to her, claims that physical exercise is more effective than CBT or SSRIs; however, a glance at the study suggests otherwise: the authors wish to suggest only that physical exercise can complement therapy. In the authors’ own words: “These forms of exercise could be considered alongside psychotherapy and antidepressants as core treatments for depression” (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10870815/).
It would be hard to disagree with one of Dahl’s main assertions: that there are “bad therapists” out there. In another article from the Overanalyzed series, patients reflect on leaving therapy, based upon factors of negligence and incompetence—like a therapist who wrongly inferred that the patient was having an affair with her boss and then blamed her when she pointed out his mistake; like a therapist who fell asleep in a session, like a therapist who came over and hugged a patient in a way that was uncomfortable for her, like a therapist who asked the patient for an internship for her daughter; and like the therapist whose response to the patient wanting to leave therapy was to threaten to tell the authorities about something that happened with the patient’s children (https://www.thecut.com/article/how-to-break-up-with-your-therapist.html). These stories are disturbing to hear, and naturally, it might well make people skeptical about therapy.
It seems that there is something in the air about the danger of bad therapy. It was the title of a 2020 film with a nightmare therapist. It also happens to be the title of a new book by the journalist Abigail Shrier, Bad Therapy: Why the Kids Aren’t Growing Up.[iii] Her main concern is that the rising generation is fearful and reluctant to be independent, and she attributes this to the dominant influence of therapy in our culture. I intend to focus mainly on what Shier claims about therapy, which is elusive, rather than her overarching argument about kids today.
Shrier’s title is ambiguous, signaling a rhetoric approach that promises provocation more than an investment in weighing both sides of issues. Shrier is explicit about claiming that therapy can be harmful. Moreover, she specifies numerous ways this is the case—for example, that it spurs people to be pay too much attention to their feelings, that it encourages rumination, that it produces preoccupation with diagnosis and medication, and is too tolerant of dependency.
On the face of it, these seem like examples of therapy that is ineffectual, and not representative of all therapy. Yet, Shrier certainly nods in the direction of condemning all therapy. She alludes to her own experience, which she found helpful to some degree but becomes disenchanted in realizing that her therapist became “a really expensive friend, one who agreed with me about almost everything and liked to talk smack about people we (sort of) knew in common” (p. 4). Shrier then drives home the pessimistic conclusion that “Every experience I’ve had with therapy has fallen along a continuum from enlightening to unsettling” (p. 5). She goes on to question the value of therapy with children and is particularly scathing about the value of play therapy.
It is disappointing but revealing that Shrier fudges and fails to delineate the line between therapy that is beneficial and harmful. In the context of discussing trauma in children, she wonders if our society ought to be sponsoring such “therapist-led (and ersatz therapist-led)” efforts (p. 132). Note how, regardless of the apparent difference here she chooses to lump them together, with no differentiation. Shrier is vague here, in part, because her larger intention is to indict the educational system for the way it disseminates therapeutic culture. She reviles social and emotional learning, does not like restorative justice practices, and is dismissive about using the impact of ACEs to obscure our capacity for resilience. Shrier appreciates how therapists’ beliefs and practices are watered down and can be misapplied in educational settings. However, she also avers that “Therapists nevertheless grabbed the reins of the culture and breathed life into a specter that haunts us still: “childhood trauma” (p. 111).
Although I share some of Shrier’s concerns about trauma treatment, it is strange that she does not pause to consider that therapists urge our attention to trauma because they are seeing more trauma in the patients they are encountering. Shrier mentions some factors that are exacerbating the crisis, worrying about smartphones but not the pandemic. She does not mention other factors, like racism or how our divided our society has become. As I see it, most therapists are trying to warn our society about what they are observing; they are not pretending to be all-knowing or to dictate solutions.
Shrier’s take on therapy is largely based on CBT. Perhaps that is why she is inclined to define therapy as operating from a stance of expertise. It is ironic that Shrier proclaims that therapy depends upon a relationship, not just skills, as she thereby lands in the position that psychodynamic therapists have long advocated. In general, she does not accord space for considering contemporary forms of psychodynamic therapy.[iv] She alludes to having an experience in psychoanalysis but does not say much about it or try to distinguish it from other approaches. In discussing trauma, she suggests that psychodynamic clinicians are following in van der Kolk’s footsteps, which is misleading, not to mention mistaken in that Judith Herman’s work has been an influence on van der Kolk from the beginning.
I want to mention an example, which is indicative of Shrier’s scholarship. In urging our attention to that “therapy is no benign folk remedy,” she states that it can “deliver unintended harm and does so in up to 20 per cent of patients” (p. 8). The source for this claim turns out to be a study by German researchers whose focus is on CBT only (https://web-p-ebscohost-com.ccny-proxy1.libr.ccny.cuny.edu/ehost/pdfviewer/pdfviewer?vid=3&sid=ab3c40bd-b6a8-498a-9077-c7527a80820d%40redis).[v] Nothing could justify Shrier’s overgeneralization..
The study itself happens to be quite interesting, as it underscores the disparity in perception between therapists and patients, where therapists were unaware of their patients’ dissatisfaction. In the discussion section, the authors wonder if this might have to do with that therapists are biased toward positive feelings and thus miss their patients’ negative feelings. This apparent vulnerability might apply more to CBT therapists than to psychodynamic therapists, the latter of whom are likely to be more curious about negative feelings, although we should be cautious not to infer anything beyond the subjects in the study.
Taking stock, neither Dahl nor Shrier strive to offer balanced accounts that make room for therapists who do good work and for patients who see their lives as transformed by therapy. Their accounts dovetail and are illuminating to some degree in emphasizing that therapy that can be ineffective or iatrogenic. Although both of heir perspectives are a bit cynical, they differ in that Dahl is amusing, whereas Shrier is more serious, but full of bile. Shrier is drawn to an array of contrarian psychologists like Jordan Peterson. She reports on interviewing Peterson remotely, as he consumes “thick pieces of rib eye with knife and fork” (p. 150) and expresses the view that “There’s no difference between thinking about yourself and being depressed and anxious. They are the same thing” (p. 152). This stands out as a new low in refusing to acknowledge healthy exploration of one’s internal life that is independent of therapy.
To be fair, Shrier’s target is therapeutic culture, an extension of the work of Christopher Lasch and Philip Rieff. Dahl draws our attention to how therapy can be oppressive—more obligatory than gratifying. Shrier experienced therapy as gratifying, but as lacking a critical edge. Her primary concern is that therapeutic culture has interfered with kids’ development.[vi]
My biggest concern about these messages about therapy is that they might serve to strop someone who is contemplating seeking our help. Shrier is explicit about discouraging therapy, grudgingly recommending that it should be a last resort (p. 246). Such messages are dangerous and should be vigorously protested by mental health professionals. Our first line of defense is research. However, we need to be prepared to fight back rapidly when needed, lest the anti-therapy voices gather momentum, and even worse, merge with the authoritarian forces that are swirling just above our heads.
[i] L. Gottlieb (2019). Maybe You Should Talk to Someone. New York: Harper.
[ii] Moskowitz’ newsletter can be found at:
[iii] A. Shrier (2024). Bad Therapy: Why The Kids Aren’t Growing Up. New York: Sentinel (Penguin Random House).
[iv] Shrier is also not well-informed about psychiatry, suggesting that the field has turned away from doing therapy (p. 13), citing a source from 2011, whereas in recent years (and in the post- mental-disorders-are-brain disorders era), training programs have reinvigorated efforts to teach the practice of therapy.
[v] In Germany, being a CBT therapist has a legal status. The therapists in this study had an average of about 5 years professional experience, so they were not very experienced.
[vi] Shrier’s understanding of childhood would not be universally accepted: “the purpose of childhood is to allow kids to take risks” (p. 241).