Book Review

Therapy's Delusions
The Myth of the Unconscious
and the Exploitation of Today's Walking Worried

by Ethan Watters & Richard Ofshe
published by Scribner, New York, 1999

reviewed by Douglas Smith

      I read this book not primarily because of the promise on the dust cover that the book "reveals how, over the years, talk therapy has masqueraded as a scientific discipline and has cost patients time, money, and their mental well-being" but rather because of the claim, also on the dust cover, that the book "makes the decisive case for the biomedical approach to mental illness."  The book succeeds admirably as a critique of so-called psychotherapy.  However, it fails to present a convincing case for "the biomedical approach to mental illness."
      Most of the book is a criticism of so-called psychotherapy, and most of this criticism is accurate and justified.  For example, the authors, a sociology professor and a journalist, say the following:

"...we will show how talk therapy, in most of its forms, can make little claim to effectively cure major mental illnesses" (p. 14).

"To seek out therapy today is to stick your hand into a grab bag of theories that often utterly contradict each other" (p. 14)

They write of "the undeserved deference and status accorded to psychotherapists as applied scientists" (p. 18).

"...psychoanalysis has long masqueraded as a science" (p. 23 - footnote).

"The sad truth is that there are many mental health healers who have studied hard in the belief that they were receiving a solid understanding of the mind and behavior.  What they often received instead, through no fault of their own, was an education in the psychological equivalent of alchemy" (p. 25).

"...there is no agreement in the profession over what constitutes the state of 'mental health'" (p. 33).

"What the history of the discipline shows is not only that psychodynamic therapy has proven ineffective in treating mental illnesses, but that practitioners have often done their patients great harm" and "To offer someone in need a treatment known to be harmful is unconscionable" (pages 41-42).

"...no one agrees on what psychotherapy is" (p. 129).

"In a review of forty-two studies comparing professional therapists with paraprofessional therapists (such as teachers given the job of counseling students), only one study showed that the trained therapists got better results.  Twenty-nine studies showed no difference between the two groups, and the remaining twelve studies showed that the paraprofessionals actually outperformed the professional therapists" (p. 130).

"A clear and general understanding of therapy's effectiveness would indeed lead to a general collapse of therapeutic authority" (p. 136).

The authors don't dispute the value of what they call "well-intended counseling and advice" and say "counseling services fall largely outside our critique of psychotherapy." But they also say "we will question whether such practice deserves status as a mental health discipline as well as whether it warrants our shared investment through health care dollars [i.e., health care insurance].  We will also question whether such counseling requires special training and certification" (p. 15).  They say: "We believe there is good reason to warn people, in the strongest possible language, away from explanatory theories and treatment methods that claim respect because they are scientific but in reality are built on myth.  Similarly, if we as a society recognize that therapy depends on faith and not proof of its effectiveness, we may want to allocate our collectively gathered health care resources [i.e., health care insurance] elsewhere" (p. 235).

Almost any impartial person who believes in psychotherapy before reading this book won't afterwards.
      Odd as it may seem, on one point I disagree with the authors of this book and agree with the psychodynamic therapists.  That is the existence of the unconscious.  The subtitle of this book is "The Myth of the Unconscious..." A little reflection can demonstrate the existence of the unconscious to almost anyone: Have you ever tried to remember someone's name and been unable to do so?  Have you then - an hour, a day, or a week later - remembered the name without having been reminded of it?  Question: Where was your memory of the name during the time you couldn't remember it?  It must have been in your mind somewhere or you couldn't have remembered it later without being reminded.  The answer is it was in the unconscious part of your mind.  Similarly, important aspects of your thinking can be forgotten, that is, can become unconscious.  For example, if you have a low opinion of yourself, you might not remember the reason being what your parents told you when you were young.  Sometimes you can free yourself of the consequences of such bad experiences simply by remembering (retrieving from your unconscious) why you feel as you do.  For example, if as an adult you see how fallible (or worse) your parents are, you may more easily discount their disparagement when you were a child, but only after you realize where your feelings of inferiority came from.  Where I part company with today's psychotherapists and agree with the authors of Therapy's Delusions is I do not think trained psychotherapists are better than anyone else at helping you with this process.
      After reading a few chapters of the authors' critique of psychotherapy I got impatient and skipped ahead searching for their defense of the biomedical approach to so-called mental illness, and I found much of it is simply wrong.  For example, they say the effectiveness of lithium for mood swings or so-called manic-depression is "beyond doubt" (p. 212).  They overlook the fact that lithium is simply a neurotoxic chemical that interferes with almost all neurological function.  It is not specific for so-called manic-depression and reduces much more mental functioning than just mood swings.  They say "the atrophy of the brain and dilated cerebral ventricles" of so-called schizophrenics shown by magnetic resonance imaging (MRI) proves that schizophrenia is biologically caused (page 213).  They are apparently unaware that this brain damage shown with MRI is caused not by "schizophrenia" but by the drugs with which so-called schizophrenics are treated!
      What little I found that might have some validity appears on a single page:

Careful doctors can test blood and find out, for example, if the patient has higher-than-normal levels of lead, copper, or carbon monoxide.  With sophisticated tests, they can learn whether someone is suffering the long-delayed effects of a typhus exposure, a brain tumor, or a heart problem that is limiting oxygen supply.  Through other means they can detect thyroid problems, sleep disorders, Lyme disease, metabolic defects, and hundreds of possible infections, viruses, and lesions.  All of these things can cause (and are often first noticed because of) changes in behavior and mental processing.  Many of these problems can cause symptoms of depression; others can bring on hyperactivity or psychosis, and still others (like copper buildup) can spark bizarre and antisocial behavior.  Medical science has treatments for all the problems mentioned above and in many cases can effect complete cures.[p. 215]

I suspect even these assertions are questionable, mostly because it is difficult to distinguish a person's psychological reaction to health problems from direct neurological causes.  Generally, biological diseases that affect the brain eliminate rather than cause thinking, emotions, or behavior.  For example, a heart problem causing limited oxygen supply probably won't cause severe unhappiness or depression, as these authors say, but will instead cause a general loss of function, mental and otherwise - unless the patient becomes emotionally depressed because of his awareness of his heart problem.  However, on the very next page the authors of this book correctly say that such bona-fide health problems "are not likely to be recognized by a therapist or even most psychiatrists.  ...  Therapists and most psychiatrists presented with any of the problems mentioned above will likely never know that they are treating a patient with a curable disease that is affecting the brain and therefore behavior" (p. 216 - italics in original).  These authors bemoan "the lack of diagnostic skill on the part of the psychiatrists in the profession" (p. 227).  As part of this criticism of psychiatry, they present an effective and entirely justified critique of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders or DSM.  In particular, they point out that the "diagnostic" categories in the DSM are invalid, because to qualify as a diagnosis, the cause must be identified, and the "diagnoses" in the DSM don't do that.  The "diagnoses" in the DSM are descriptions, not diagnoses.
      I completely agree with the authors of this book where they say "it is time for the mental health professions to begin agreeing on the methods that are effective and to limit their practice to those methods" (p. 236 - italics in original).  The problem is if mental health professionals were to limit their practices to what is truly helpful, just about all of today's biological psychiatry and all psychotherapy other than common-sense counselling would be discontinued, and only a small number of today's mental health professionals could earn a living doing that.