Bookmarks, the Art of the Practical: The Triumphs and Limits of Psychotherapy

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Bookmarks By Richard Handler

The Art of the Practical 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. …