Bad Therapy, Worse Outcomes

A Review of Abigail Shrier's Bad Therapy with R.W. Richey

Pain of mind is worse than pain of body. —Publilius Syrus

Who looks outside, dreams; who looks inside, awakes. —Carl Jung

A wise man will be master of his mind, a fool will be its slave. —Publilius Syrus

Above: Trauma is an amoeba with no defined form; it ebbs and flows, waxes and wanes.

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It’s no secret that the state of America’s mental health is poor. Were the attempts to combat this crisis a cheese, they would be Swiss: widespread, tasteless, and full of holes.

Put simply, mental health treatment is broken.

Therapy is expensive, inconvenient, and often unavailable when needed most. Many therapists (i.e. credentialed conversationalists) neither follow uniform, best practices (about which there is no rigorous, credible consensus) nor apply those few evidence-based, research-backed methodologies (e.g. Cognitive Behavioral Therapy).

Worse still, if you think about it, therapists face perverse financial incentives to retain clients instead of ameliorating them. After all, recurring revenue trumps one-off cash infusions.

It's no wonder that despite the surge in mental health awareness and treatment, mental health metrics are getting worse, not better. The below picture from Mental Health America is worth a thousand words:

It’s clear that we need a new way forward. Less obvious is which direction that ought to be.

Increasingly, I think Americans need to spend fewer hours splayed on a therapist’s couch and more in a mental gym of sorts. I recently stumbled upon Pensive—an evidence-based personal trainer for your mind. The jury’s still out, but I think research-backed exercises at a fraction of therapy’s cost represent a step in the right direction.

Keen to separate the crisis’ symptoms from its cause, I recently read Abigail Shrier's eye-opening Bad Therapy: Why the Kids Aren't Growing Up alongside my good friend Ross Richey.

A self-made man and devoted father, Ross contains multitudes. He is a writer’s writer and a thinker’s thinker; never ceasing to amaze me with the breadth and depth of his intellect. I mean, the man devours audiobooks at 3x speed…

We read it (I did so much, much more slowly) and discussed it at length. As it turns out, Shrier’s book is just the tip of the iceberg. Ross wrote a truly exceptional review that plunges to the heart of the matter and extracts nuance, insight, and reflection that only a father-cum-philosopher-cum-theologian can do.

Though worth a read in full, below is a terrific excerpt:

Bad Therapy doesn’t disappoint. In fact, it has already attracted even more controversy—as well as its share of plaudits. As such, it’s entirely possible that you have already formed an opinion on this book and its topic.

Whatever your opinion, favorable or not, the subject of trauma, therapy, and tots is much more complicated than it appears, some of this complexity is well-covered by Shrier, some of it is not, thus this review. 

We need to begin with one very important observation, something that cannot be overlooked in this discussion by either Shrier or her critics:

Despite a vast increase in preventative resources, American mental health has not gotten any better, and by many measures it has gotten worse.

Shrier lays out the following statistics:

Between 1946 and 1960, membership in the American Psychological Association quadrupled.¹ Then, from 1970 to 1995, the number of mental health professionals quadrupled again.² In the United States since 1986, nearly every decade has seen a doubling of expenditure on mental health over the one before.³

…And yet as treatments for anxiety and depression have become more sophisticated and more readily available, adolescent anxiety and depression have ballooned.

I’m not the only one to have found something fishy in the fact that more treatment has not resulted in less depression. A group of academic researchers recently noticed the same. They published a peer-reviewed paper titled “More Treatment but No Less Depression: The Treatment-Prevalence Paradox.”⁴ The authors note that treatment for major depression has become much more widely available (and, in their view, improved) since the 1980s worldwide. And yet in not a single Western country has this treatment made a dent in the incidence of major depressive disorder. Many countries saw an increase.

The increased availability of effective treatments should shorten depressive episodes, reduce relapses, and curtail recurrences. Combined, these treatment advances unequivocally should result in lower point-prevalence estimates of depression,” they write. “Have these reductions occurred? The empirical answer clearly is NO.”⁵

I checked with several of the paper’s authors. Two confirmed that the same might be said for anxiety. As treatment has become more widely available and dispersed, point-prevalence rates should go down.⁶ They have not. And while the authors admit that there was likely more depression in the past than we realized, they argue that there is at least as much, and probably more, depression now.⁷ [Emphasis mine.]

Why is this? We don’t see this happening with other diseases. Dedicating additional resources towards cancer and heart disease, for example, has improved outcomes, not worsened them. 

Why is mental health so resistant to improvement? Shrier believes it’s because these resources have been misallocated, the methodologies employed by these additional resources are misguided, and in too many cases they're actively harmful. 

Put simply: we’re doing it wrong. The way in which we’re doing it wrong, however, is more complicated, and there are nuances and implications that even Shrier doesn’t completely grapple with, but in part that’s what I intend to do.

Read on here:

Bad Therapy vs. Resilience

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Per my about page, White Noise is a work of experimentation. I view it as a sort of thinking aloud, a stress testing of my nascent ideas. Through it, I hope to sharpen my opinions against the whetstone of other people’s feedback, commentary, and input.

If you want to discuss any of the ideas or musings mentioned above or have any books, papers, or links that you think would be interesting to share on a future edition of White Noise, please reach out to me by replying to this email or following me on Twitter X.

With sincere gratitude,

Tom