There was a book review in this past Sunday’s New York Times called “Still Crazy After All These Years.” The book reviewed is American Therapy: The Rise of Psychotherapy in the United States (great review title, no?). The review seemed to dovetail nicely with Stillman Brown’s recent post about Seasonal Affective Disorder and the discussion that followed.

As the title suggests, the book (and review) describes the quick rise and fall of psychotherapy in the United States. One passage in particular of the review seemed to summarize the issues we got into in the comments section of Stillman Brown’s post:

Engel describes how factors like changes in the structure of health insurance shaped (and often distorted) psychiatric care . .. [he] gestures at, but doesn’t directly address, some of the most interesting questions prompted by the rise of psychotherapy. Is the enormous growth of the field over the last century simply a case of supply surging to meet demand, or does the volume of neurosis fluctuate over the years? Are anxiety and alienation always symptoms to be treated, or are they sometimes appropriate — even healthy — responses to the vicissitudes of late modernity? Is psychotherapy an art or a science, a subcategory of humanism or of biology?
Psychotherapy was undermined both by the rise of psychiatric drugs and, well, by the fact that it didn’t seem to work very well. Or rather, it did often work, but apparently not more than access to comparable sympathetic figures. Beginning in the 1970s, researchers found that “effective psychotherapy seemed to require little more than a willing patient and an intelligent and understanding counselor who met and spoke regularly and in confidence. . . a University of Pennsylvania study found that the most successful therapists—regardless of whether they were Freudians or behaviorists, cognitive therapists or Z-therapists—were honest and empathic and connected quickly and well with other people.”
That was my personal experience. I only saw a therapist for a few months, but I did feel like I benefited at least somewhat. At the same time, he didn’t seem to provide much more than a sympathetic ear. Which is not to dismiss the considerable value of that. But I can’t help but wonder if it can’t be provided at dramatically lower cost.
I mentioned in the comments section to Stillman Brown’s post that “I suspect we are still in the mental health dark ages, and some day people will look at our psychology/psychiatry the way we now view Roman medical theories of yellow and black bile and phlegm and so on.” I don’t have any dramatic alternative proposals or insights, and I certainly wasn’t advising anyone not to avail themselves of what help is available if they need it. Rather, I was just stating the facts as I see them, which is that what we seem to have going for us right now is:
1) Counseling. Certainly there are acquired skills that allow therapists to be more effective. But it seems to be that the most important factors are intangible (like the therapist giving a shit), and therefore hard to teach and certify. And, as I mentioned, it seems that it costs way too much considering how inconclusive the data is regarding its effectiveness.
2) Drugs. I would be all for them if they worked well, but it seems that we still understand brain chemistry so poorly that not many actually do. I also suspect that it will continue to be exceeding hard to establish when they are appropriate and when they aren’t. And unfortunately, the overwhelming systemic pressure is for our society to answer that question with, “always.”
3) Mindfulness. Not a cure all, certainly, but usually a help.
4) Making our society itself more sane and humane in myriad ways. This one is tricky, sometimes confusing, and often elusive. But we’re working on it.
If any progress is made in the next decades helping people in serious mental and emotional distress, I think it will necessarily involve three or four of these components, at least in most cases.