Ever since the Puritans landed in Massachusetts ready to build their “City on a Hill,” American soil has been the most fertile in the world for new idealistic movements. In his book, “American Therapy,” Jonathan Engel argues that the birth of psychotherapy is “a classic American tale of discovery, entrepreneurship and self-promotion.” The analyst émigrés who brought Sigmund Freud’s psychoanalysis from Europe received little honor in their home countries. They were as marginal in 20th century Europe as Winthrop’s Puritans’ had been in the 17th. But Americans greeted the talking cure with enthusiasm, disregarding its lack of scientific rigor. “Americans, those eternally optimistic people who seem constantly to reinvent themselves,” Engel writes, “have long looked to therapy as a conduit to new lives and improved selves.”
After World War II, when the Veteran’s Administration was overrun with tens of thousands of cases of what we now call post-traumatic stress disorder, money was poured into minting new mental health professionals. By 1950, the number of psychiatric residencies quintupled and by 1960, America had more psychiatrists, psychologists and social workers than the rest of the world combined.
This host of new healers, being so very American, tried every new idea they could think of, from primal scream therapy to Prozac. In our zeal for personal transformation, Americans were bound stumble onto something worthwhile, even if only by trial and error. Engel’s thesis is that the field that began with exuberant enthusiasm for Freud’s unproven and later discredited ideas ultimately led to the triumph of biological psychiatry and the more effective cognitive behavioral psychotherapeutic approaches of today. Research and clinical experience proved that “medicine worked,” often dramatically and quickly. As more pragmatic short term therapies were introduced, it was found that “psychotherapy works,” too. “Cognitive therapy advanced as psychoanalysis declined,” writes Engel, and nowadays, “few serious mental health professionals turn to [Freud’s] works for guidance.”
The problem with this notion is that Engel needs to squeeze the facts to fit the narrative. While he declares psychoanalysis to be essentially “dead,” such rumors are slightly exaggerated. Though greatly diminished, it is still a force in the field. By contrast, Engel is a little too rosy in his views of the biological psychiatry revolution. In praising Prozac’s “extraordinary efficacy, coupled with its lack of side effects,” he is more sweepingly positive than even the drug’s maker Eli Lilly would dare to be.
Almost every one of the patients in my practice is on medicine, where 20 years ago almost none of them were, which speaks to the power of this revolution, but almost all of them have some problems with side effects. Some studies suggest that up to 50% of patients on drugs like Prozac have sexual side effects of varying severity, and these drugs can also induce agitation and in some cases mania. Engel later acknowledges, but only in passing, that the new anti-depressant wonder drugs, “tend to diminish sexual response and in some patients caused restlessness and insomnia.” Every practicing psychiatrist knows there’s no free lunch. We are always weighing the relative benefit of a drug’s therapeutic effects against its side effects, and half the art of psychiatry is mastering this balancing act as best you can.
Engel has another problem with his book, one faced by anyone who has written about the history of an idea. Stories about people are compelling, and yet while the book acknowledges many contributors to the field, it lacks any major characters whose own dramatic personal stories might pull us through. Instead, it reads like an excellent survey course. Engel might have done better to include more case histories or therapy transcripts to involve us in the patient’s stories. Though clearly written and admirably free of jargon, Engel keeps things on a fairly theoretical level. For the average American reader, who is frantically pursuing their own happiness through personal transformation as they understand it, that may take too much patience.
John Gartner is the author of “In Search of Bill Clinton: A Psychological Biography.”
American Therapy
The Rise of Psychotherapy in the United States
Jonathan Engel
Gotham