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American Therapy: The Rise of Psychotherapy in the United States

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I rarely "bash" books when I review them but this is one time I feel obligated to. "American Therapy" is without a doubt the most poorly written and weakly researched account of... well... it is so poorly written it is hard to say exactly what it is supposed to be about. If it is supposed to be a history of therapy in America it falls woefully short. If it is supposed to give the reader a sense of the state-of-the-art of therapy it totally fails. As far as I can tell it is a propaganda piece for the pharmaceutical industry but, I am getting ahead of myself. Let me start with the author's so-called "research."

This book is riddled with more errors than the charter for the "Flat Earth Society." Engel frequently eschews peer-reviewed sources and relies heavily on popular sources like "Time" and "Newsweek" which can hardly be said to have a grasp of the history of psychotherapy let alone how therapy works. The book clearly had no "fact check" or peer-review process as the author goes on and on about the research done by behavior therapists and totally misses the fact that Carl Rogers (who Engel dismisses as "one of a number of humanistic psychologists") pioneered psychotherapy research and was the first one to record sessions, publish transcripts and analyze transcripts of entire therapy relationships from start to finish.

Engel seems unaware that Rogers is credited with "virtually founding the professional counseling movement and made professional counseling accessible to diverse helping professions" (Howard Kirschenbaum, "The Life and Work of Carl Rogers," p. 581). But to be fair, Engel doesn't even seem to know that a counseling profession exists with licenses in every state and a national organization of 47,000 members. He never once mentions it despite giving considerable space to the rise of social work and psychology.

Engel doesn't seem to be aware of Rogers' psychotherapy research and lazily criticizes a quote taken out of context from one of Rogers' books glibly concluding the discussion with "It is left to the reader to make sense of that!" (p. 78). The author also mistakenly claims Rogers wanted to "elevate the individual at the expense of society" (p. 81). Only someone relying on secondary sources could come to this erroneous conclusion.

Rogers' devoted decades of work to social causes and trying to understand how the individual fits into society, not how the individual should transcend or ignore society. Finally in a misguided nod to Rogers' research Engel states "While Rogers did evaluate his clients for the success or failure of their treatment, the evaluations could not be exploited to further refine the counseling technique" (p. 82). I guess Engel never bothered to read Eugene Gendlin, publications from the Association for the Development of the Person-Centered Approach, The World Association for Person-Centered Experiential Psychotherapy and Counseling or the journal The Person Centered Journal. But again, these works don't show up in "Newsweek" so I guess Engel missed them.

Engel's coverage of other topics is equally weak. One example is his foray into the impact of meditation on the therapy movements. Rather than citing the classic initial study by Wallace (in the journal "Science") he settles for a summary article in "Science Digest." His treatment of encounter groups is not much better. Again, rather than crediting Rogers with the ethical development of the medium he focuses on popular accounts of unethical uses of encounter groups. He gives coverage to recovered memory therapy and not once sites the groundbreaking work of psychologist Elizabeth Loftus whose research did much to discredit recovered memory therapy (see. p.181).

OTHER EXAMPLES:

The author uses outdated references for modern constructs. In discussing what works in therapy (what we call common factors research) Engel cites Jerome Frank in the 1974 rather than Hubble, Duncan and Miller in the 21st Century ("The Heart and Soul of Change," 2001).

The author seems confused regarding Abraham Maslow's actual work. Engel writes as if Maslow were a therapist where in fact Maslow's training was largely in comparative (animal) psychology. The author seems confused as to why Freud abandoned hypnosis leaving out Freud's concern that when it worked is seemed a little too mystical. Engel dismisses Thomas Szasz as a "paranoid kook" (p. 186) without seeming to understand the substance of his arguments against nosological labels or the context of those arguments. Engel gives the appearance of thinking that the psychologist prescription privileges in U.S. states and territories began in the 70s rather than the 80s (p. 237).

Engel has a whole chapter on supposed "Narcotics" (using Drug Enforcement labels rather than the proper pharmacological labels) and concludes "drug addicts did benefit from speaking about their personal histories and working through psychic traumas but, in addition, they usually needed doses of military boot camp, methadone, personal responsibility and a healthy fear of God" (p. 217). Apparently he has not read any treatment literature published after 1980 as he neglects Suboxone, brain imaging, and other developments in addictions studies.

Perhaps most inexcusable is his constant reference to mythic "chemical imbalances,"his conjecture that there are "...biological and organic bases..." (187) to mental disorders and his assertion of the "growing evidence of the physiological and biochemical bases of mental illness" (p. 219). To state these as hypotheses would be fine but he states them as conclusions and then does not cite one study to back up the assertions - not one!

He writes about "neurochemical imbalances" (p. 227) but never bothers to cite a study telling us which "chemicals" are imbalanced (of course no such study exists but the author would have you believe otherwise). Engel seems to prefer the illusion of certainty to honest exploration and inflicts his own brand of cocky "word magic" (creating illusions of certainty with words) throughout the book leading up to his finale "medication worked" on page 250. Worked when? For what conditions? For which clients? Engel doesn't say.

After reading that "the age of magic pills had dawned, in which the biochemical roots of many psychiatric disorders could be targeted with highly specific molecules" (p. 251) I assumed Engel must somehow be on the payroll of a pharmaceutical company. How else can you account for these and similar statements? He preaches about how Prozac had a "lack of side effects" (p. 243). Lack of side-effects? How about the over 70% of people who experience sexual dysfunction and weight gain? He goes on to glorify SSRI antidepressants and is apparently unaware that in the 21st century a meta-analysis of antidepressant studies in the FDA database showed that antidepressants were only better than placebo 50% of the time - so that means most people have a 50/50 chance of getting relief from antidepressants.

[See Khan, A., Leventhal, R. M., Khan, S. R., & Brown, W. A. (2002). Severity of depression and response to antidepressants and placebo: An analysis of the Food and Drug Administration database. Journal of Clinical Psychopharmacology, 22, 40-45. ]

Engel seems ignorant of the fact that his constant allusions to "biochemical roots" of psychiatric disorders is at odds with the American Psychiatric Association's Task Force for revising DSM. In A Research Agenda for DSM-V published in 2002 (six years before Engel's "book" was released) authors state "...the field of psychiatry has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder" (p. 33). Again, if you're relying on Time and Newsweek for your information like Engel appears to be, then all you can do is parrot the myths perpetrated by the pharmaceutical industry (which takes out two-pages ads in Time for psychotropic medication).

This book is a crime against scholarship that should never have been released. The author claims to have gotten a Ph.D. from Yale but if this is evidence of Ivy League training, send your kids to state universities.

This book is a once-over lightly summary of a few aspects of the development of psychotherapy in the U. S. The author is a historian, and his lack of understanding of psychology and psychotherapy is apparent. He beats up Freud again, as if that were needed, and emphasizes the kooks and quacks in the history of therapy such as L. Ron Hubbard, Werner Erhard, and Arthur Janov. A review of their nutty ideas can be entertaining to people who have never heard of them, but why focus on them? The author criticizes Carl Rogers as naive and "humanistic" but likes Albert Ellis and Aaron Beck. He calls Thomas Szasz, one of the most respected and influential psychiatrists, a "kook." The author loves AA and claims it works, and is apparently unaware that since AA is anonymous (duh) there is almost no research supporting its effectiveness. He is so gushing about AA that one wonders if he is an alcoholic who just enjoys going to his meetings. Why the author felt it was necessary to inject his personal opinions into what should have been an objective history is unclear. The book is sloppily written, with misattributions, inaccurate information, and missing references. On page 173 he refers to Hans Strupp, who was a psychoanalytic researcher, as a "humanistic therapist" and on page 234 he refers to the same man as Hans Krupp. Didn't anyone proofread the manuscript? With so many errors and outright false information, anyone who looks to this book for accurate history will be disappointed.

Poorly researched and full of commonplaces and cliches, this book insults the intelligence of anyone who has taken more than an introductory course in psychology. In the introduction he goes as far as to claim that psychotherapy is a uniquely American phenomenon, because of course Freud was a false prophet and every school of psychotherapy that still subscribes to some basic psychoanalytic tradition, (as do most in Europe and South America) is a waste of time and more importantly money.
Engel's ambivalence towards psychotherapy could be an interesting topic for his own analysis. His painfully superficial and biased account of psychoanalysis is dangerously misleading and irresponsible. Engel goes out of his way to ignore the fascinating and exciting new research in neuroscience that suggests the validity of some of the most important psychoanalytic concepts. It turns out that we have all this brand new scientifically sound evidence that suggests that the evil Dr. Freud was actually on to something.I recommend "The biology of freedom" for those interested in an intelligent discussion of this topic.
He fails to explain how self-help groups such as AA are different from psychotherapy and to recognize that all evidence of their effectiveness is based on the same "unscientific" methods traditionally used to justify psychoanalysis, namely anecdotal evidence.
In the next chapter, goes on to say that all forms of therapy work just about as well, that's a little confusing if you consider his obvious preference for American cognitive orientation.
I would sell this book back if a new copy wasn't already available for less than half the listing price!

Engel begins by telling readers that one-on-one doctor-patient psychoanalysis and psychiatry make up a very small portion of American mental health care. Social workers, priests, pastoral counselors, self-help gurus, and support groups (eg. AA) must also be included. WWII greatly altered America's understanding and perception of mental illness when thousands of draftees (about 12%) were found mentally unfit, many other broke down from traumatic stress (about 1 million), and alcoholism rates rose significantly after the war (consumption increased about 30%).

Engel contends that psychoanalysis (eg. Freud and interpretation of dreams) does not work. A 1950s study by the American Psychoanalytic Association showed only one in six ultimately were cured; most other studies indicate a nearly 90% remission rate for neurotic patients over five years, with remission rates for those in analysis somewhat lower.

On the other hand, Engel believes that psychotherapy (empathetic help in managing one's life) does work - multiple studies over the past half-century have demonstrated that about two-thirds of recipients improve within 6 months. Success rates seem independent of the type of therapy used, though the qualities of the therapist (especially empathy, honesty, and the ability to connect quickly) are more important. Engel also concedes that the exact mechanism by which therapy works has not been identified.

Further clouding the issue is the fact that about one-third of all patients achieve spontaneous remission, the conclusion that most mental disorders have a chemical or physiological basis, and that psychotherapy has proven only modestly successful with alcohol or drug abuse.

Psychotherapy has lately been challenged by a series of miracle drugs. Research, however, shows that most patients improve more thoroughly when treated with a combination of medication and therapy.

This book provides a unique perspective for anyone studying psychotherapy in college. It fills in the blanks and provides the dark side of the human beings that transformed the profession.

A new book about psychotherapy gives good press to psychodrama, the action method developed by Jacob L. and Zerka Moreno.

This is a good thing, since the method, originally developed in the 1920s, has often been relegated to the back of the shelf. Way back. Even experienced mental health professionals and others don't know that Dr. Moreno, a European-born physician, coined the phrase "group psychotherapy" and was a true pioneer in the fields of mental health, marriage counseling, alternative creative arts therapies and other topics that we take for granted today.

The book is "American Therapy: The Rise of Psychotherapy in the United States" by Jonathan Engel and contains well-written passage about sociometry, the science of relationships, which was also developed by Moreno. There's particular mention of his work at a New York facility for female juvenile delinquents - as they were called in the early days - and how he rearranged their assigned rooms to create more cooperation and less turmoil after evaluating their relationships.

Most of the focus of the book leans to Sigmund Freud, who we consider the originator of modern mental health treatment, and how his ideas spread to the United States, before heading off in new and more practical directions to treat emotional pain. Moreno was one of Freud's first challengers, at around 1912 when he was a young medical student in Vienna. Although Moreno died in 1974, the worlds of psychodrama and sociometry are very much alive not only in the mental health but many other fields, thanks to the efforts of his widow, Zerka, who is in her nineties and still working, and many others.

True, author Engel makes some misstatements in other parts of the book, including the incorrect surname of a Vanderbilt University researcher who in 1979 conducted a study that raised questions about the role of specialized training in effective psychotherapy. He was Hans Strupp, not Krupp, and the incorrect reference to three eminent U.S. doctors who were early promoters of Freudian theory. Adolf Meyer and Harry Stack Sullivan were psychiatrists, and James Jackson Putnam was a neurologist; they were not "psychologists."

Recommended.

As a lay person who has passing knowledge in the fields of psychology and psychiatry, American Therapy was a superb read. Engel writes lucidly with numerous examples both from scholarly literature and from periodical literature - magazines and newspapers - tracing the development of psychotherapy. It was interesting to read how the profession evolved from the realm of psychiatrists to social workers, educational psychologists and clinical psychologists. This book explains the methods of analysis and the history and methods of twelve-step programs such as Alcoholics Anonymous.

After I read the book, I could see why a psychoanalyst or psychotherapist might feel uncomfortable or even pessimistic about the profession with Engel's comments about the limits of psychotherapy. He makes the balanced case that neither drugs alone nor years and years of analysis may help a patient. Engel affirms with a tone of optimism that psychotherapists stand (or sit!) in a unique position to help patients to overcome the emotional or psychological obstacles they are facing in their lives. Like his recent book on AIDS (The Epidemic), he tells a good historical story that is relevant and deeply considered.

Mr. Engel's ability to relate the history of a topic that is abstract to most is admirable. Engel effortlessly moves from one psycho-therapeutic movement to another in his thorough account of how Americans have viewed, treated, and acted towards mental illness over the past 100 years.

Having read many objective accounts of narcotics (including Opium: A History, Cannabis: A History, Psychedelics Encyclopedia, Tobacco: A Cultural History of How an Exotic Plant Seduced Civilization, Shroom: A Cultural History of the Magic Mushroom, and Cocaine: An Unauthorized Biography), Mr. Engel's chapter on narcotics seemed overly dismissive and ignorant of many factors.

This inconsistency aside, American Therapy is a great read for anyone wanting to gain a working knowledge of the historical approaches to psychotherapy in America.