Bad Therapy:
Why the Kids Aren’t Growing Up
by abigail shrier
sentinel, 320 pages, $30
Is there such a thing as good therapy? Not for kids, argues Abigail Shrier. Sure, “play therapy” for the littlest tykes probably does no more harm (and no more good) than a very expensive babysitter. But when the talk therapy developed for adults is administered to children and teenagers, “no harm” is the best case. Iatrogenic effects include demoralization, rumination, alienation, overdiagnosis, hypochondriasis, and overmedication. All this, for just a “fifty-minute hour” per week.
Shrier argues that therapy is to blame for America’s youth mental health crisis, by which she means the large and expanding cohort of “the worriers; the fearful; the lonely, lost, and sad.” The trends are bad and long-running. Between 1950 and 1988, the rate of adolescent suicides quadrupled. Between 1990 and 2007, the number of mentally ill kids rose 3,500 percent. In the past decade or so, one is tempted to say that mental illness has become fashionable. Diagnoses proliferate, some venerable, some novel, some evidently severe, some seemingly fanciful. Ever more teens present anxiety, depression, dissociation, gender dysphoria (the subject of Shrier’s previous book), eating disorders, self-harm behaviors, hair-pulling compulsions, and tics. To make her thesis go, Shrier relies on an expansive definition of “therapy”: the practice itself, the application of therapeutic concepts to parenting and school discipline, and the suffusion of therapeutic concepts throughout American culture. It’s a salutary polemic, if not airtight.
Forty-two percent of American kids today have a mental health diagnosis, and almost 40 percent have received therapy. They typically enter feeling overmatched by schoolwork, friends, and dating, and complaining of anxiety, insecurity, loneliness—teenagerness, in a word. One of Shrier’s interviewees likens the decision to start therapy on such a basis to a surgeon’s saying that the kid looks normal, “but let’s open him up and see what we find.” Any medical intervention carries risk: the nicked artery, the infection, the allergic reaction. The risks are weighed against expected benefits: the knitted bone, the cessation of pain, the remission of cancer. In the case of psychotherapy, the benefits may be rather vague. Indeed, Shrier argues that many kids get worse while in therapy: demoralized (the patient regards herself as a problem, one her parents can’t solve), ruminative (commanded by the therapist to dwell on disappointments and dissatisfactions), alienated (encouraged by the therapist to judge friends and family guilty or inadequate). By “recasting personality variation as . . . dysfunction,” therapists “train kids to regard themselves as disordered.” The diagnosis (ADHD, anxiety, autism—and that’s just the letter A), however ill-fitting or intrinsically bogus, becomes central to the kid’s identity, a tag on social media. Medication brings advertised side effects (loss of affect, mental acuity, and libido; weight gain; suicidal ideation), plus the failure of the kid to encounter the unmediated world. Shrier’s interviewees opine that this stuff is way too strong for developing brains. Far from a solution to the youth mental health crisis, the widespread resort to therapy starts to look like its major cause.
Whence its popularity? The pervasiveness of therapeutic concepts in American culture—individualism, self-realization, personal happiness—goes back centuries. One contemporary guise is the obsession with uncovering traumas, by confabulating memories if necessary. Shrier decries the sage status of Bessel van der Kolk, the psychiatrist who revived the discredited theory of recovered memory in the form of “body memories” with his 2014 book The Body Keeps the Score (holding steady on the New York Times paperback nonfiction list, as of this writing, for the 270th week). Van der Kolk’s sentimental rhetoric of psychic and somatic wholeness, his science-y charts and jargon, are so much gilding on the patently silly thesis that unpleasant memories are repressed from consciousness and preserved in muscle. I might as plausibly boast that I can do pushups with my hippocampus. Shrier nails van der Kolk as a charlatan whose northern European accent suggests “someone ambiguously serious about matters of the mind.” Just remember, you read it here first (“By Our Wounds We Are Healed,” October 2021).
We also observe a contemporary stress on the happiness and validation of children. Shrier describes the “therapeutic” parenting style that now seems dominant—more or less Dr. Spock on Adderall. It entails that kids understand and consent to rules, rather than submit to discipline. They must receive “consequences,” not punishments. Their feelings must always be consulted. They should “enjoy themselves” at school, at soccer practice, in piano lessons, at the dentist. The “ideal childhood mean[s] no pain, no discomfort, no fights, no failure.”
This is folly. In one of the best moments from the book’s many interviews, a German psychiatrist named Michael Linden points out that no life brims with “happiness,” moment to moment. Indeed, Shrier can list a bunch of worries and frustrations besetting her as she speaks to him over Zoom. This quantum of stress is normal; it doesn’t mean she is clinically anxious or depressed. So with kids, with the caveat that they may become stunted if “supported” too much too soon.
Therapy has wrecked pedagogy and school discipline, which now seeks to “diagnose and accommodate, not punish or reward.” Endless “accommodations” are afforded to kids who are poor test-takers or who struggle with deadlines. Classrooms are outfitted with fidget toys, suspensions and expulsions are condemned by the Department of Education, and teachers implement restorative justice and social-emotional learning. The result, in schools across America, has been a decline in academic outcomes and an increase in rudeness, unruliness, bullying, tantrums, and violent outbursts—the permission of “physical harm in the name of emotional well-being.”
So what good is therapy—for anyone? We exempt from this inquiry cognitive behavioral therapy and related methods, which train obsessives to suck it up. We are concerned, rather, with “conversations about feelings and personal problems styled as medicine” (Shrier’s definition, as the profession does not afford a clearer one). Therapy’s presumption that raking the coals with a mental health professional will make just about anyone happier may be not much truer for adults than for kids. Therapy poses some of the same iatrogenic hazards to adults as to kids, though adults are capable (Shrier stipulates, and one hopes) of recognizing, rejecting, even terminating unhelpful counsel. Shrier recalls benefits she has reaped: Her first therapist, whom she retained after moving to California for a boyfriend, was like a gal pal who always listened, always took her side, and helped her achieve a better understanding of her psyche. Against these gains are weighed certain pitfalls, not excluding the therapist’s sheer presumption. (She urged Shrier to postpone her wedding so that they could do some more work together!) Shrier appears to have moved on from therapy by now and to regard its benefits as, in her case, perfectly nice but not clinically necessary.
Is one good of therapy its reputation as a pursuit of leisured bourgeois people? Since the invention of nervous disorders in the late eighteenth century, vague psychological fragility has been associated with social prestige. Fainting couches are elegant, Freudian couches hardly less so. Shrier discusses the destigmatization of the now common childhood diagnoses: autism, ADHD, and so on. I would add that these diagnoses have all become positively prestigious, in an insurance-abetted trickle-down from the more exclusive pursuit of classical Freudian analysis. Perhaps the decision to start a kid in therapy is often an act of status-signaling.
Economic reality compounds social reality. As Shrier observes, the fragile teenager makes an easy and lucrative patient: She has mundane problems and is covered by her parents’ bountiful insurance plan. Chatting with her in a sunny office beats the hell out of administering subcutaneous antipsychotics in a hospital ward. Shrier is not detained by the fact that the fragile teenager is a member of a socioeconomic class. Socioeconomic terms are absent from Shrier’s analysis, except in this striking quote from a professor of clinical psychology: “One big problem with the field of academic psychology is that it has become limited to the privileged and the wealthy,” with the result that all adversity is construed as crippling trauma. When the worst thing that ever happened to you was getting picked last for dodgeball, getting picked last for dodgeball seems like the worst thing that can ever happen. (For a therapist to correct this misperception would not be “affirming.”)
I wonder whether, like psychology itself, Shrier’s thesis of therapy as the leading cause of teen distemper isn’t too strongly colored by the experiences of the middle and upper classes. No doubt kids in affluent households are indeed affected by therapy and its conceits, for they are exposed to both—whereas it is not clear that kids of the lower classes enroll in therapy in meaningful numbers, or that therapeutic conceits are in the air they breathe. Their insurance, if they have it, probably doesn’t cover therapy sessions, and their parents probably haven’t been obsessed with giving them a frictionless existence. On an expansive conception, “therapy” reaches lower-class kids through its encroachment into school (in)discipline. I wonder, though, whether even this problem is quite as pervasive as Shrier suggests. What if it were broken down geographically? Cozy corners may have replaced the principal’s office in our inner cities, but I reserve a certain doubt whether they have done so in meth country.
Longstanding trends such as divorce, fatherlessness, and unchurching might suggest themselves as environmental causes of poor mental health among the young. Shrier, though admitting that these trends coincide with the decline in youth mental health measures from decades back, dismisses causation—not by disproving it, but by comparing these conservative bugbears to the progressive bugbears of climate change, structural racism, and economic inequality. We can agree that progressives sound like idiots when they propose that kids’ mental health is worsening because after all who isn’t pathologically exercised over the polar ice caps? Shrier demonstrates, through anecdote and data, that even kids from progressive households don’t powerfully care about this stuff. Their parents and therapists project progressive doomerism onto them.
Shrier does not subject the mental health effects of the collapse of the American family to comparable analysis; she merely places the thesis under suspicion for its political salience. But the American family is awfully close to home. Do not kids get down about their own absent fathers and strung out brothers, more than about the headline “Oceans projected to warm two degrees by 2050”? By “kids,” in this scenario, we disproportionately mean kids of the lower classes.
I wonder, too, about smartphones. Shrier can hardly be accused of downplaying the toll of smartphones on youth mental health, as she sounded the alarm in her last book and sounds it again here: “addictive, sleep-depriving, and pathology-inducing.” And yet smartphones can’t be the problem, Shrier argues, since the decline began decades before they massively accelerated it by mainlining social media into kids’ limbic systems; the real problem is the therapeutic mindset that prevents adults from separating kids from the misery machines. Fair, I suppose, but it seems odd to classify such an acute and contemporary malignancy as a subset of a more nebulous one. Late in the book, Shrier says that if school counselors were serious about improving students’ mental health, they would urge a ban on smartphones during class. Here she positions smartphones as “the most ubiquitous and most persuasive” of the various forces “luring teens into a vicious cycle of negative self-focus.” Worse than . . . therapy?
Perils of the unified theory. That’s a quibble. Final point: One of Shrier’s frustrations during her interview with Michael Linden is that it’s early morning in California and she’s hoping not to wake her three kids while Zooming with Germany. She is open about the hard truth that kids generate stress. Accordingly, at the close of the book, she corrects the consumerist “decision to have children” (implying calculated expenditure in the expectation of happiness) with a vocational model: Either “your whole being inclines” to child-rearing, costs be damned, or forget it. But surely the vocational model is itself unthinkable outside a consumerist context, in which we command instruments of choice and can ask which lifestyle will be fulfilling. And it is dependent on affective scripts. Shrier offers compensations for put-upon parents, among them the “knee-buckling” love for a newborn. Alas, newborns overwhelmingly mean tedium, exhaustion, and noise, unless you’re lucky enough to get the kind that sleeps for twenty hours out of twenty-four. If your knees buckle, it probably won’t be for abundance of any tender emotion.
I insist because it’s hard to disentangle the obsession with kids’ feelings from the obsession with parents’ feelings. The relentless questioning whether kids are “enjoying themselves” is hardly separable from the question whether parents are enjoying their children, exhibiting the correct sentiments: Am I patient enough, gentle enough, attentive enough? Do I love enough? Toughening up our kids may begin with admitting that we can love them without always liking them all that much.
Julia Yost is senior editor at First Things.
Image by Upsilon Andromedae licensed via Creative Commons. Image cropped.
