The Triumphs and Limits of Psychotherapy

American Therapy: The Rise of Psychotherapy in the United States
Jonathan Engel
Gotham Books. 351 pp. ISBN 978-1-592-4038-06

Jonathan Engel begins his history of therapy in the United States with an anecdote. His purpose is to highlight the refusal of American therapy “consumers” to be bullied by the weighty-sounding pronouncements of psychoanalytic theory. He tells of an analyst who offered a young woman his “first grand insight into her condition” after three months of listening to her dreams and free associations. What was her response? “Who are you to tell me that I have penis envy?” she sniffed, getting up from his couch, never to return.

The story of American therapy, according to Engel, is the triumph of American pragmatism over the intellectual mystique of Freud’s theories. From the perspective of today’s marketplace, it may be hard to accept that until 1980, psychoanalysis dominated most departments of psychiatry in the nation’s medical schools. It was then that a growing awareness of the practical limitations of psychoanalysis took over: analysis took too long, was too expensive, and despite its snobbish, top-dog position in the field, had failed to produce a body of empirical studies to show that it worked better than anything else.

On the back cover, the publishers extol Engel’s book as the “first comprehensive history of American psychotherapy from Freud to Zoloft.” It’s hardly that, but it does offer a decent outline of the major developments in the field in the 20th century. Engel, like a good stand-up historian, has
an ear for the witty jab and the telling judgment. For instance, he quotes Thomas Gutheil of Harvard Medical School, who pithily sums up Freud’s contribution: “First, there’s a whole lot more to folks than meets the eye, and second, keep your mouth shut and learn something.”

From Engel’s bird’s-eye view, what conclusions can be drawn from our culture’s love affair with psychotherapy? “Psychotherapy works,” says Engel. “For all the doubts expressed by skeptics over the decades, none can credibly discount the evidence emerging from numerous studies that patients emerge from therapy feeling better. A consistent two-thirds of patients improve after six months of therapy.” Engel tells us that it doesn’t matter which technique is practiced: patients and clients appear to improve after being helped by practitioners of “every educational background and using every type of therapeutic approach.”

Nevertheless, he adds, “the success of psychotherapy alone must be qualified. It works best with people who are not severely ill.” These are patients who fall “within a relatively narrow range of the full spectrum of disorders.” Unfortunately, psychotherapy, by which he means talk therapy, doesn’t work particularly well with alcoholics, drug abusers, and psychotics.

These are three mighty big categories of potential patients, but Engel tells us that other approaches now exist to serve them. It’s true that alcohol and drug-abuse specialists employ talk therapy techniques, but more as an adjunct to a comprehensive package of assistance. For alcoholics, the vast surrogate family of Alcoholics Anonymous, while imperfect, seems to be more effective than pure talk therapy. While therapy may be a useful supplement, drug-abuse patients often need residential treatment to separate them from the culture that reinforces and exploits their condition. People with drug problems must often be completely retooled to face life without their addiction. A diet of group-session rebuke and encouragement seems to be a primary instrument in that process. For patients suffering psychotic illnesses, it’s now clinical conventional wisdom that talk therapy is insufficient, certainly until extreme symptoms are diminished.

So all told, psychotherapy works best for distressed people who aren’t in the full bloom of an addiction and who aren’t delusional. That’s a lot of people. Still, while therapy can help many individuals, its inherent limitations mustn’t be forgotten.

The central question that underlies Engel’s book is a basic one: what, after all, is therapy? Observers have wrestled with this question for decades. The original Freudians viewed therapy as an excursion in an alternative reality of the inner psyche. Like submariners looking for the sunken Titanic, they saw themselves exploring the murk of the unconscious. Their mission was to excavate truths that, once faced and addressed, could transform lives and reduce suffering. Cognitive behavioral therapists—roll-up-your-sleeves pragmatists, to whom Engel is partial—abandoned this obsession with mysteries of the mind. They favor tinkering with patterns of thought that lie closer to the surface of everyday awareness. Clearly influenced by the cognitive perspective, Engel believes that therapy is fundamentally an educational enterprise: it operates by “fixing broken bonds” and readjusting “people to normal social intercourse,” and works by “educating rather than analyzing.”

Engel doesn’t think highly of what he considers the unrealistic and overblown goal of inner transformation, and he scoffs at New Age notions of spiritual healing. He has harsh things to say about the “kooky therapies” of the ’60s: he believes they brought dishonor and focused public skepticism on the entire field. He distrusts those who claim they can help patients change their identities as if they were shopping for clothing brands or disposable shavers.

For Engel, therapy is ultimately an exercise in learning and gradual self-improvement. He tells us that “psychotherapy works best when it leverages a patient’s desire to participate more productively in the world around him, when the patient is genuinely committed to the difficult process of acquiring new, healthy skills.” He even paraphrases Viktor Frankl, the psychiatrist and concentration-camp survivor who said, according to Engel, that the “common trait of all emotionally healthy people is a desire to get to work.” To Frankl, even in the midst of a Nazi hell, those who had the best chance of surviving seemed to be those who could make themselves the most useful to others. This is also what Engel values: people who engage with life, even under the most trying circumstances.

What Engel is talking about is close to what the psychologist and writer Daniel Goleman means by “emotional intelligence.” For other therapists and clients, it may be just a new way of saying “For goodness’ sake, grow up, please!” In the end, that means “Be true to your responsibilities, delay immediate gratification, and settle into a longer view.” For many patients, however, the new skills and altered beliefs necessary to change the direction of a life may be hard to learn in 12 or 20 managed-care therapy sessions. That sort of emotional education may take longer than we like it. (Believe me: I’m still working on it.) We may need constant reminders, homework, and emotional tune-ups to make and maintain real progress.

Ultimately, Engel sees therapy as being about learning to keep a sense of perspective and remaining engaged in a raucous world. That’s an underlying therapeutic philosophy that a Freudian might find too utilitarian and shallow, but that Engel, the American pragmatist, heartily endorses.