American Therapy: The Rise of Psychotherapy in the United States
Those of us who are nearing retirement from work as a psychotherapist have been privileged to witness extraordinary changes over the course of our careers. Few therapists I know have clung solely to their original training. In the effort to relieve our clients’ emotional pain, we’ve attended workshops and conferences that address populations (adolescents, geriatrics, children, refugees, etc.), disorders (anything and everything from the DSM) and techniques (group therapy, alternative therapies, new therapies, spins on old therapies). We’ve collectively spent millions of dollars and millions of hours developing ourselves and honing our skills.
We’ve changed the way we practice in response to innovations in treatment, client expectations, the availability of better medications, and the limitations of managed care. We have become more sophisticated and complex in our understanding of people’s distress and better at designing treatment plans that address the unique needs of the individual. The end result is that the American therapist of today is usually eclectic in orientation and practice.
It’s a uniquely American trait to always be on the alert for the new and improved. Some ideas disappeared almost as fast as they came on the scene. (Has anyone been to an EST weekend lately?) Others, like a refined awareness of the effects of trauma or a deeper appreciation for the long-term effects of addiction, have become part of our shared assumptions about what can overwhelm people’s ability to cope. Staying current with emerging research and adapting accordingly is only responsible.
In American Therapy: The Rise of Psychotherapy in the United States, Jonathan Engel traces this evolution of American mental health care in a highly readable tour de force. For senior therapists, it is a trip down memory lane, from graduate school to the present. For our younger colleagues, it is a summary of what has gone before that puts present-day discourse in and about the field into meaningful context. Engel reviews the contributions of notable personalities, theories, and techniques, while at the same time tracing the evolution of the three main professions of the field: psychiatry, psychology and social work.
Despite the dominance of Freud’s theories in American thinking, the actual practice of therapy has evolved in response to the need for treatment to be accessible, affordable, and practical. During and following World War II, the need for practitioners was nothing short of desperate. Surprisingly, induction centers found that a substantial number of people who wanted to enlist were not fit for the service. Returning traumatized soldiers and their families needed immediate relief, not long-term self-discovery. Traditional psychoanalysis could not meet the need, both because of the small number of qualified psychiatrists and because of its structure and expense. Still, as psychiatry struggled to meet the need, the general public became more aware of the possibility that talking out one’s problems under the guidance of someone with some kind of specialized training might be helpful.
In response to growing public acceptance and demand for the “talking cure,” other professions turned to the problem. Psychologists began to move away from their original focus on quantification and research to the practice of therapy. They rejected psychiatry’s dependence on Freud and looked to outcome research to guide their work. Meanwhile, the social workers who initially focused on the social ills of poverty, illiteracy and poor health began to expand their practice so that they too began to work on their clients’ interpersonal and personal problems.
Thus, while the roots of psychiatry, psychology, and social work were decidedly different, the focus of their actual work with clients began to look much the same. Competition for legitimacy and for patients forced the professions to work to define themselves and to define what they actually did in session. Longterm analysis, the province of a few psychiatrists, gave way to shorter, more targeted therapies performed by the psychologists and social workers. The medically trained psychiatrists turned more and more to psychopharmacology.
Engel divides the multiple approaches to therapeutic work into three groups: psychodynamic, humanistic, and cognitive and behavioral, each reflecting the decade in which it became popular. The conservatism of the 1950s (analysis, both long and not quite so long term) gave way to the idealism of the ’60s (the emergence of Rogerian work) to the narcissism of the ’70s (encounter groups, and such techniques as gestalt and primal scream) to the angst of the ’90s and the increasing necessity for short, effective treatment (cognitive behavioral techniques such as DBT and EMDR and escalating use of psychopharmacology).
Out of what could have been a tower of (psycho)babble has instead come the understanding that to be an effective therapist, one needs to be able to draw on the best of all of it. Further, study after study has confronted us with the reality that what distinguishes the effective therapist, more than training, philosophy, theory, or specific technique, are the qualities of warmth, empathy and rapport between the therapist and patient.
My only quibble with Engel’s attempt to at least touch on the most important chapters in our history is that he entirely leaves out the surge of couple and family therapy that grabbed our attention in the 1980s. Systemic, strategic, and structural family therapy were all efforts to understand the client in the context of the relationship with the people most important in his or her life. Although the techniques ultimately became too unwieldy (read: unbillable) for private practice, learning to think systemically was a seismic change that informs how many of us treat individual clients to this day.
It is clear that therapy does work. Engel’s review of the research literature shows that 2/3 of patients who engage in therapy do report feeling better. This is better than the 1/3 of patients who report feeling better without the benefit of therapy. Some therapies work better than others, with the current edge belonging to cognitive behavioral models. Some clinicians are more talented than others in establishing the empathy that seems to make the most difference.
I expected that the book would be ponderous and was instead impressed with Engel’s ability to interweave the themes of history, personalities, and therapies. Loosely using chronology as a structure, Engel brings together descriptions of each emerging therapy in historical context, the evolution of the several mental health professions, and discussion of the impact of managed care and politics on the developing field. He doesn’t shrink from discussion of class and its impact on people’s mental health or their access to services. Nor does he hesitate to reveal the flaws in both people and theories where deserved or to comment on the infighting among professions. It’s an ambitious book that gives both the seasoned therapist and the young student a better understanding of where we’ve been.
American Therapy: The Rise of Psychotherapy in the United States
By Jonathan Engel
New York: Gotham Books, October 2008
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Hartwell-Walker, M. (2013). American Therapy: The Rise of Psychotherapy in the United States. Psych Central. Retrieved on February 8, 2016, from http://psychcentral.com/lib/american-therapy-the-rise-of-psychotherapy-in-the-united-states/