An Insubstantial Book for a Weighty Problem

I have been looking forward to reading Abigail Shrier’s new book Bad Therapy for a while. I’ve personally dealt with mental illness for a long time. I’m a family physician whose primary professional focus for the past several years has been delivering mental health care to people who previously had no access to it. I’m a parent trying to raise my kids in a cultural milieu that’s… well, a bit crazy. I’ve been observing cultural currents about concepts from psychiatry making inroads into the church for a while. So I was intrigued by a book promising to explain how and why “therapy culture” is making kids these days more fragile and less capable of dealing with the world, so I bought it the week it came out.

I’m disappointed to report that Bad Therapy isn’t a great book. It describes real problems that parents, teachers, health professionals, and pastors in America ought to be paying attention to. It marshals a significant host of experts to counter certain prevailing trends. However, it does so in a way that is sloppy, uneven, and (at points) downright annoying to read. As someone who agrees with the general gist of Shrier’s arguments, I wish there was a better spokesperson for her ideas.

Substantial Problems, Insubstantial Writing

Shrier’s most important argument regards iatrogenesis, the concept that a therapeutic intervention can cause unintended harm. Sometimes that harm outweighs the benefit that the intervention was meant to bring about. In the medical world, we often think of the example of an antibiotic for a sinus infection might cause a severe allergic reaction requiring an ICU admission. If that antibiotic wasn’t needed in the first place (for example, for a cold caused by a virus that can’t be treated with antibiotics), then giving the medicine is giving people harm without a chance of any benefit.

Psychotherapy for people who don’t need it also runs the risk of iatrogenic harm, and subjecting children to psychotherapy who are just going through the normal ups and downs of life is like performing surgery on a patient with a cold just to make sure it’s just a virus and not cancer. The harms of psychotherapy primarily arise from excessive introspection, magnification of negative feelings, and the response of authority figures to any expression of psychological distress with attention and care that children will instinctively respond to by expressing… more distress. It’s a compelling argument, and there’s plenty of research to suggest it’s a genuine harm that psychotherapy and other emotionally-focused interventions can cause.

Closely related is a broader cultural shift towards what has been termed an “external locus of control.” Good studies have shown (and common sense will tell you) that people who believe themselves to be agents of their own destiny capable of making choices that will make their lives better (called an “internal locus of control”) will do better on a wide variety of measures than people who believe themselves to be helpless victims of external forces. (Here’s a great essay looking at the ways in which certain political beliefs lend themselves to “reverse cognitive-behavioral therapy” and encourage an unhealthy external locus of control.) Talking to therapists, teachers, and young people themselves, Shrier finds plenty of evidence that this tendency, especially when adults are asked to make accommodations for kids who experience distress with routine activities, is making kids more fearful and less capable of dealing with the real world.

However, when Shrier sets her sights on bigger and broader targets she is less convincing. She is deeply suspicious of the deployment of social-emotional learning principles in schools, and mostly uses extreme examples for a concept that is undoubtedly applied unevenly (and probably worse in California than anywhere else, where she spends the most time investigating,) She is rightfully concerned about how school counselors and psychologists are permitted to circumvent parental authority, but she also does not describe how she would design a different system that would allow children who are in an unsafe home to get help. She reprints several mental health surveys that feature rather invasive questions that could possibly make teens more likely to considers things like suicide more normative, but she also doesn’t tell us how often these surveys are given or what percentage of the youth population fills them out. (For 2021, it was less than 20,000 questionnaires in 152 schools in the largest CDC study.)

The concept of trauma has become ubiquitous in the West, and Shrier brings it in for a much-needed skewering. She makes the important and necessary clarification that Adverse Childhood Events (ACEs) can predict poor health among adults on a population-wide basis, but that doesn’t mean that people who experience chronic pain or other illnesses can blame their symptoms on childhood trauma. However, she perseverates on this idea, trying to disprove a link between trauma and bodily symptoms as she chases the white whale of Bessel van der Kolk’s The Body Keeps the Score. Any doctor can tell you that stress or other negative emotions can produce symptoms of pain, racing heartbeat, or even more dramatic symptoms—so to try to deny that trauma, especially severe trauma, might have downstream consequences is ludicrous. She also doesn't note that even van der Kolk has dismissed some of the broader appropriations of his book.

The chapter on medication is perhaps most frustrating. Medicalization of otherwise commonplace struggles is a real issue, and the American tendency to overdiagnose mental illness and then throw drugs at any emotional problem deserves serious examination. However, Shrier throws journalistic rigor out the window as she fails to cite a single study about the efficacy of medication for ADHD, depression, or anxiety. She hints throughout the book that the American public and many professionals do not distinguish between transient, ubiquitous feelings of depression and anxiety and disabling or deadly psychiatric diagnoses like major depressive disorder or generalized anxiety disorder. However, Shrier commits the same error when she writes about how depression and anxiety can be good, which is true of the ubiquitous feelings but not so much of the more rigorously defined disorders. There’s a huge opportunity here to talk about reshaping school and home in order to treat these illnesses without medications, but Shrier passes that up for more acerbic observations.

The lack of precision throughout the book will be grating to any serious reader. Shrier is at her best when she's carefully laying out the evidence that iatrogenic harm from psychotherapy is possible and that a general cultural shift among young people to an external locus of control is bad for their well-being. When she's taking on the empathy debate or mocking parents for not setting stricter boundaries with their children based on what she found lurking on various Facebook groups, she's far less convincing. The incessant use of the first person plural switched between genuine confession of behaviors she herself has engaged in, sarcasm, overgeneralization and hyperbole. By the end of the book I couldn't tell which was which.

Overstatements abound. “There is hardly a parent in the West today who will inculcate obedience as the highest virtue.” (I am not sure she wants obedience to be the highest virtue, either, but if she spent any time in conservative Christian communities she could probably find a few families working that way.) She claims (with no data besides what she's heard and read) that parents who believe themselves to be appropriately “authoritative” truly aren't. “Everyone nursing a private agenda for the next generation knows we [parents] are the obstacle.” There’s more than a hint of a conspiratorial tone throughout.

Less important but more revealing of the author’s lack of editorial restraint, the tone of the book veers between journalistic inquiry and gleeful mockery. Shrier has an irritating habit of turning to the reader with a wink to emphasize how stupid her subjects are, like she's the narrator in an early-2000’s sitcom. “Where is the Enigma cryptology team when we need it?” she snarks after one mother confesses that her methods of parenting might be the problem. She goes on to say of the “gentle parenting” philosophy: “So does it work? The short answer is no. The longer answer is noooooooooooo.” I'd expect this kind of rhetoric in a Fortnite Discord chat, not a serious book for adults.

Teasing Out the Real Issues

Lots of recent books, from Matthew Crawford’s The World Beyond Your Head to Freddie deBoer’s The Cult of Smart, seem to feel obligated to include a chapter about liberalism from the Enlightenment on. These often strike me as a bit gratuitous, but this time the absence of such an analysis was notable. Shrier doesn’t seem interested in either the broader cultural trends that have created a felt need for therapy or the breakdown of relationships and institutional structures that used to provide the sorts of advice and insights that people now look to therapy to provide.

Similarly, there's no discussion of the nature of excessive therapeutization as a spiritual crisis. Shrier's own religious commitments are unclear, but reductions in churchgoing (or churches themselves making a therapeutic turn) have clearly produced a crisis of authority that mental health professionals have rushed in to address. As Bonnie Kristian also noted, the book’s final advice to do things your own way with your own kids is pretty vacuous. If this is the alternative, no wonder people are going with the sacrosanct advice of psychologists.

There's also no real history of parenting ideas to be found. Aside from a few references to research from the 1970’s, there's very little discussion of psychological advice or therapy culture prior to the current generation of parents—denying us critical context for our current moment. Consider Alistair Macintyre, writing in 1983 in After Virtue: “The idioms of therapy have invaded all too successfully such spheres as those of education and of religion. The types of theory involved in and invoked to justify such therapeutic modes do of course vary widely; but the mode itself is of far greater social significance than the theories which matter so much to its protagonists.” Philip Rieff published Triumph of the Therapeutic in 1966, before Shrier was even born. Freudian theories about repression are well over a century old. If anything was going wrong before Gen X was born, Shrier seems uninterested in it.

Bad Therapy speaks in vague generalities about how parents used to act in the past and compares the spankings of yesteryear favorably to contemporary therapy-esque parenting, but there's no specificity to any of those claims. This is especially frustrating when she talks about children who cut themselves off from their parents, many of whom are presumably Shrier’s peers and some of whom surely received the sort of parenting she prefers.

The targets of this book are overwhelmingly upper-crust Americans with the time and energy to apply all sorts of trendy parenting techniques, but there’s no serious treatment of other families. Even as Shrier acknowledges that there are children who have suffered severe abuse, neglect, or trauma that do need a therapeutic approach, she seems to ignore the fact that the average school system will be dealing with lots of children whose parents don't read gentle parenting books—or any books at all.

When I worked in America and saw pediatric patients, much of what I observed from parents was a muddle of genuine affection, lackadaisical permissiveness, harsh physical or verbal discipline, and a desire for children to succeed with varying degrees of intuition about how to help. The average teacher, doctor, or school counselor who doesn't work in a very wealthy school is probably going to encounter lots of children whose home life is chaotic and whose parents do need guidance from professionals because they are disconnected from a family system or religious institution that would normally provide this guidance. These children may or may not meet criteria for a psychiatric illness and it is not always clear if the current therapeutic model will benefit them. But the current therapeutic model is in many ways a response to the products of these chaotic homes, and any analysis of mental health in young people that elides this reality is going to be insufficient.

Bad Therapy isn't the book we need. But the questions raised by Shrier are important, even more so because few other people are questioning therapy culture in an accessible and pointed way. Others need to pick up these critiques and investigate them with more rigor and charity, especially in non-elite contexts. I fear that Shrier's sloppy and often vindictive style will fall flat with the people who most need to hear her message. Worse, I’m concerned that if we don't produce a more thorough approach to questions of mental health, we will have nothing of substance to say and slip into an endless parade of reflexive mockery ourselves.