Abigail Shrier's Bad Therapy: Mental Health Care

The thrilling conclusion

I.

Abigail Shrier’s writing about therapy in her book Bad Therapy is like looking through a funhouse mirror that wildly distorts all my views into a form that is both stupid and evil.

II.

Sometimes “therapy” refers to discrete, evidence-based programs: cognitive behavioral therapy for insomnia, phobia, or panic attacks; exposure and response prevention for OCD; sensate focus for sex therapy; the Gottman method or emotionally focused therapy for couples’ therapy; dialectical behavioral therapy for emotional dysregulation. These programs are hard to find, and if you don’t put specific effort into finding them you won’t. Psychology Today’s therapist finder doesn’t cut it; you need to go on the website of whomever trains people to do the program and find someone certified in it.

Most of the time, when you find a therapist, the service you’re getting is an hour a week of talking to a kind, sympathetic, wise person who has seen many problems like yours before and might have some good advice.

Abigail Shrier repeatedly makes this criticism of therapy: that many therapists are nothing more than a “really expensive friend.” I agree, and potential therapy clients should be more aware of this fact.

Where I disagree with Shrier is that I think there is absolutely nothing wrong with most therapists being expensive friends. Many, many people—including many, many people with diagnosable mental illnesses—have problems best solvable by a kind, sympathetic, wise person listening to them and giving them advice. The Dodo bird verdict—that every therapy is as good as every other therapy—is controversial. But it’s uncontroversial that much of the benefit of therapy comes from the therapist-client relationship, and even a crappy therapy can work if the client and therapist are a good fit. Here are some ways that the therapist-client relationship can help:

• You have a really obvious problem (“the reason you’re depressed is that you spend eighteen hours a day doomscrolling, watching TV you don’t like, and masturbating”) and you need someone to tell you the obvious solution in a way that you’ll actually listen to.

• You don’t believe anything will ever improve and you need someone who believes in your ability to make changes in your life.

• You are mean to yourself and you need someone to say kind things to you until you can say “well, I think I’m stupid and worthless, but my therapist would think…”

• You need someone to give you permission to do the thing you want and need to do but feel guilty about doing (“yes, you can dump your terrible boyfriend”).

• You need a set time to think about your life problems or you never will.

• You need a rubber duck to sit there and go “mm” while you explain your problems to yourself until you find the solution.

• You need someone to praise you for doing very hard things, even if they wouldn’t be hard for anyone else.

• You want someone with common sense to help you figure out which things you believe are reasonable and which are crazy.

• You have a hard time taking steps to improve your life, but you will if you have to explain to someone next week exactly why you didn’t ask for a raise.

You might say that these services are supposed to be provided by your friends. Usually they are! Any good therapist wants to eventually transition you away from therapy and towards support by people who love you. But sometimes you’re too lonely or your problems are too big, and then therapy helps.

In the past, “kind, wise person listens to you” was a service offered by religious leaders and community elders. As society became more secular and atomized, we started paying for people to provide it. And therapy actually has a number of advantages over friends, community elders or religious leaders:

• You can get therapy even if you don’t have friends or a community.

• You can get therapy even if your friends are all too busy or burned out to give you as much help as you need.

• Because therapy is confidential, you can talk to your therapist without worrying that you’ll be a subject of gossip or that it might harm your career.

• Therapists have seen more diversity of humanity, and thus are less likely to freak out about your horrible childhood or weird sex thing.¹

• You can easily and without social drama fire your therapist if you hate them or their advice sucks.

• Your therapist isn’t connected to your group of friends, and so provides an unbiased outside perspective.

• Your therapist doesn’t require reciprocal emotion work from you, which is good for people who are already burned out and overloaded.

• Therapists who violate ethical codes usually lose their licenses.

All too often, we think of therapy as something you can get the same way you take a pill. But every therapist/client dyad is different. If you’re seeking therapy, it’s crucial to find a therapist you like and trust. Seeing a therapist you don’t like and trust is like taking a sugar pill in the hope that the dye and fillers will cure you. Therapists do not have access to any special magical wisdom that is unknown to self-help book writers, life coaches, inspirational speakers, priests, imams, Internet rationality experts, or your grandma.²³ For most people, the benefits of therapy are about the relationship.

III.

People have a naive faith that there is some magic way of treating mental illness that has no bad side effects. Pills! Pills are suspicious. We know pills can hurt people. But what about meditation? Exercise? My favorite supplement? Therapy? Surely no one has ever been hurt by therapy!

In reality, anything with the power to help also has the power to hurt. Supplements have side effects, just as conventional medicine does. Meditation can cause everything from derealization to anhedonia to delusional beliefs. Even exercise can lead to physical injury.

And therapy, too, can hurt people. Shrier cites a study that shows that about a fifth of CBT patients experience severe or very severe side effects—usually distress, worse symptoms, or difficult family relationships. And that study was based on therapist report. How many people experienced a severe side effect from therapy and then just stopped going?

The problem with therapy is that many therapists are not very good. Most mentally ill people have dozens of stories. I had a therapist who decided that the only reason I’d think people disliked me was social anxiety, and spent months making me redo CBT worksheets until I got the correct answer that people who like me often look pained and annoyed when I talk to them. I had a therapist who concluded my effective altruism was a cognitive distortion and set a therapeutic goal of getting me to be content volunteering at a homeless shelter instead. I had a therapist ask me about best possible outcome I could imagine from therapy, and when I tentatively said that I’d like to go to grad school told me that I was too mentally ill to have a hope of that and I should pick a best possible outcome that’s more realistic. I had a therapist tell me I couldn’t possibly have borderline personality disorder because borderlines have soulless dead eyes, and then fire me as a client two months later because sometimes I was desperate for her approval and sometimes I hated her and how could she have possibly predicted that I might do that.

Abigail Shrier, too, has a list of the ways therapists can harm patients. I agree with many of her complaints. Sometimes, it’s the specific techniques that are the problem: for example, psychological debriefing after a traumatic event has no effect in the short run and may make trauma symptoms worse in the long run. Other times, a client copes well with her problems outside of therapy but unhelpfully ruminates on them in therapy, which makes her upset and perhaps worse at improving her life. And some therapists (consciously or unconsciously) encourage clients to be dependent on them, so the clients never wind up actually leaving therapy and the the therapist has a steady income.

Most of all, you can’t train someone in wisdom or license someone as compassionate. Many, perhaps most, therapists are kind, dedicated, thoughtful people who genuinely improve their clients’ lives. But therapists are people. All people have blind spots, and some people just give terrible advice.

IV.

I have extensively criticized Shrier’s approach to mental health throughout this series, and I won’t go into it again. But a large percentage of her complaints about therapists are that therapists say you should be nice to your kids, and should occasionally talk to people about your feelings, and should try to be happy instead of being a real man who endures a life of quiet misery and then gratefully dies of a heart attack at fifty-five.

More subtly, it never occurs to Shrier that advice might be good for some people and bad for other people.

For example, she talks about how diagnoses can make people think that they’re broken, that they can never change, or that they’re doomed to be miserable forever. This does happen. But it never occurs to her that diagnoses can make people think “oh, I’m not flawed or fundamentally broken, I’m just different”; can give people hope because if other people recovered so can they; can connect people to community; or can validate that they were actually trying as hard as they could, no matter how much other people called them lazy.

She criticizes therapists who encourage parental estrangement or divorce:

I don’t care how annoying she is, you don’t cancel Mom just because her needling gets under your skin. (You hang up on her, wait five minutes, call back, act as if nothing happened, and casually ask her to pick up your sons from soccer practice.)

When parents confront the adult children who’ve cut them off, Coleman tells me, the most typical explanation they give is: “ ‘Well, my therapist said, you emotionally abused me or you’re emotionally incestuous. Or you have a narcissistic personality disorder.’ The parents, of course, respond defensively, and that just feels like proof positive to the adult child.”…

Family estrangement is a major iatrogenic risk of therapy not only because it typically produces so much desperate, chronic distraught to the cut-off parents. It also strips the adult child of a major source of stability and support—and for generations after. Estrangement means grandchildren raised without the benefit of loving grandparents who pick them up from school or temper their parents’ foul moods. Worse, it leaves those grandkids with the impression that they descend from terrible people. People so twisted and irredeemable, Mom won’t let them in the house. Even the homeless guy outside Walgreens gets a wave and a dollar every once and a while. But the people I come from? They must have done something unforgivable.

Children learn that all relationships are expendable—even within the parent-child dyad. Mom cut off her own parents. There’s just no good reason to believe she wouldn’t do the same to me if I did something to upset her, too.

Later, she writes:

This may explain why therapists sometimes inadvertently encourage a client to divorce by making relationship-undermining statements and portraying the absent spouse unfavorably.[10] It’s not that these therapists are necessarily callous; they may simply be empathic.

Therapists readily empathize with the paying clients in front of them over those who have no opportunity to testify in their own defense. How natural to suggest cooling off the relationship with Mom, dispatching a “friendship breakup” text, or hatching the “amicable divorce.” It’s awfully hard to think about a child you’ve never met—say, the little girl whose life is about to be sliced in two—when her tearful mom is perched on your couch.

Citation 10 links to this study, which finds:

Specifically, the therapist suggesting that the spouse was unlikely to change was reported by 64% of participants; suggesting that the spouse had a personality disorder or other mental health diagnosis (without an individual assessment) was reported by 55% of the participants; suggesting that the marriage was beyond repair by 57%; indicating that divorce/separation was the best option by 55%; suggesting negative motives in the spouse by 62%; and suggesting that the marriage was a bad match from the beginning by 59% of clients.

What Abigail Shrier entirely ignores is the possibility that the parents did emotionally abuse with their child, that the parent/child relationship was emotionally incestuous, that divorce was the best option, that a spouse did have negative motives, or that a spouse wasn’t ever going to change.⁴

Of course, many therapists do say that a loving but flawed parent is actually emotionally abusive and you should cut them off, or that self-respect means divorcing a partner who cheats on you without even seeing if the marriage is repairable, or similar. But sometimes parents are awful people and marriages are very bad. Sometimes letting your parent pick your child up from school means subjecting her to mockery of her appearance, interests, friends, and most cherished beliefs, directed with perfect aim at her deepest insecurities and weakest points. Sometimes cutting off your parent teaches your child not that all relationships are expendable but that you shouldn’t be a self-sacrificing doormat when people are cruel to you. Sometimes staying married means exposing your child to someone who beats her. Sometimes ending a marriage fills a child with relief and gratitude because their home is no longer a place of eggshell-walking tension occasionally lightened up by screamed insults.

For someone who talks about groomers, Shrier is oddly cavalier about preserving relationships with family members who are walking piles of red flags. Think about how many cases there are of “oh, well, everyone knew that Grandpa was creepy and inappropriate, but we never thought he would—”

In short, familial estrangement is sometimes bad advice and sometimes fantastic advice. You can’t say “in some cases this advice is bad, therefore there’s no reason for therapists to ever give it.”

Perhaps Shrier’s most appalling lack of nuance is about psychiatric medications. She writes:

But possibly the grimmest risk of antidepressants, antianxiety meds, and stimulants is the primary effect of the drugs themselves: placing a young person in a medicated state while he’s still getting used to the feel and fit of his own skin. Making him feel less like himself, blocking him from ever feeling the thrill of unmediated cognitive sharpness, the sting of righteous fury, an animal urge to spot an opportunity—a romance, a position, a place on the team—and leap for it. Compelling him to play remote spectator in his own life.

Many adults, accustomed to popping a Xanax to get through a rough patch, are tempted to extend that same accommodation to their suffering teen. But the impact of starting a child on psychotropic medication is incomparably different. Every experience of a child’s life—so many “firsts”—will now be mediated by this chemical chaperone: every triumph, every pang of desire and remorse. When you start a child on meds, you risk numbing him to life at the very moment he’s learning to calibrate risks and handle life’s ups and downs. When you anesthetize a child to the vicissitudes of success and failure and love and loss and disappointment when he’s meeting these for the first time, you’re depriving him of the emotional musculature he’ll need as an adult. Once on meds, he’s likely to believe that he can’t handle life at full strength—and thanks to an adolescence spent on them, he may even be right.

I am hesitant about giving children psychiatric medications. Children have limited awareness of their own feelings, limited self-advocacy skills, and limited power. It’s very easy to assume that a medication must be great for your child because she’s doing well in school and obeying the rules and she’s easy to parent. But a child may have a difficult time noticing and articulating a complicated side effect, like cognitive issues or emotional blunting or “not feeling like myself.” A child might prefer to go off a medication because it causes nausea, but the parent might ignore her preference because the parent can’t feel the nausea and can see the grades. A teenager may feel unable to communicate sexual side effects to her parents—if her parents even take sexual side effects seriously (“you shouldn’t be having sex anyway!”). I’m predisposed to like arguments against giving psychiatric medications to kids.

But come on.

Emotional blunting is not a universal side effect of antidepressants, antianxiety medications, or stimulants. It is extremely common for depression to make someone feel numb and like a spectator in their own life, and conversely for antidepressants to vastly increase depressed people’s cognitive sharpness, righteous fury, and animal urge to leap for opportunities. Honestly, stimulants make everyone more cognitively sharp, angry, and animalistically opportunistic, so this argument implies that we should be handing out a Ritalin prescription to everyone first day of freshman year.

But it’s not really about emotional blunting, is it. It’s about Shrier’s intuition that unmedicated emotions are real and medicated emotions are fake and if you have your first crush while also being on SSRIs you have been robbed of the experience of having a pure, authentic, natural crush unmediated by chemistry. But all emotions are real, and all emotions are chemically mediated. Often, antidepressants give people the experience of a pure, authentic, natural crush, as experienced by people whose serotonin is homegrown rather than storebought.⁵

And the doom-mongering is completely unjustified. I know people whose adolescences were stolen by inappropriate prescription of psychiatric medications. The harm done is real, and those years will never come back. They are still capable of handling life at full strength. If anything, they are more capable of handling what life throws at them: they know that life goes on, that nothing is forever, that they can endure. Hey, it’s post-traumatic growth! That thing Abigail Shrier keeps talking about! Fascinating how it slips her mind whenever it’s inconvenient for her argument.

And if a teenager receives psychiatric medications that actually help them, it usually makes them more able to cope without medications as an adult. Yearning for the sweet release of death tends to distract from all the academic, social, and emotional skills we’d like teens to learn. Teens can learn Algebra II and advocating for themselves with authority figures and how to ask their crushes out, or they can learn how to walk into any room and name twenty ways to self-harm without getting caught. While the latter is a fun parlor trick, I think they’ll be better off with the first one.

Giving children and teens psychiatric medications is risky. It is the right decision for some people. Shrier completely ignores this nuance.

V.

Shrier criticizes therapy as a kind of excessive monitoring of children’s lives. Children need age-appropriate privacy, freedom from parental supervision, and the ability to make mistakes. It’s far better for a teenager to have the opportunity to do drugs and to have sex than for them never to have the chance to have a long conversation with another teen without adult snooping. She acerbically writes:

A few moms told me, in roundabout verbiage, that they had hired a therapist to surveil their surly teen’s thoughts and feelings. The therapist doesn’t tell me what my daughter says exactly, the moms assured me, but she sort of lets me know everything’s okay. And occasionally, I gathered, the therapist relayed to Mom specific information gleaned from the little prisoner of war.

And yet, when therapists grant children some measure of privacy and autonomy from their parents, Shrier throws a fit. How dare teenagers be legally permitted to get mental health care without parental permission? How dare school counselors keep information secret from a child’s parents when in their clinical judgment the child would benefit? How dare school counselors informally meet with kids to talk about their LGBT+ status or grades or life stresses even if the parents haven’t specifically said they can do so? How dare counselors give teens the addresses of LGBTQ youth shelters without first consulting Abigail Shrier to see whether she thinks the teens’ parents are loving or not?

Well, you see, this is called “freedom” and “privacy,” and like you said elsewhere in the book children benefit from having it.

I would just parent my child in such a way that he doesn’t want to move to a homeless shelter instead of living with me. Skill issue.

VI.

I criticized Abigail Shrier’s blindness to her own privilege before, and her discussion of therapy really makes it stick out.

Shrier has a trenchant analysis of how distorted the therapy market is. Providing therapy to severely mentally ill people sucks. It’s depressing to hear how much our lives suck, we keep blowing up at you in therapy, most advice backfires, we don’t keep appointments, you might get sued if one of us commits suicide, and most of us are completely broke so you don’t even get paid well for it. On the other hand, sane people just want to vent about their marital problems or their shit jobs or their artist’s block or their climate anxiety, which you already do for your friends for free, and they show up on time and can afford $200 a session. So most therapists have a caseload that consists of people on a spectrum from “normal life problems” to “moderate depression or ADHD.”

At no point does Shrier say anything suggesting that this might be bad for severely mentally ill people.

Look, I agree that it’s bad when therapists make their sane clients emotionally dependent on them to keep their incomes high, or if the worried well wind up more unhappy because they ruminate about their problems once a week. But I think it is a bigger problem that it is difficult to impossible for a severely mentally ill person to find a therapist who has any experience with severely mentally ill people, given that we are much more miserable and hurt people around us more, and that in theory the entire purpose of this system is to help us specifically.

At no point, in fact, does Shrier even gesture at any of the harm done by the therapists to severely mentally ill people. Nothing about involuntary institutionalization, restraint, seclusion, or forced medication. Nothing about the pathologization of harmless or even normal behavior because the person doing it has a label like “personality disorder” or “psychosis” or “autism.” Nothing about the bigotry therapists routinely display towards people with cluster B personality disorders. Nothing about the routine denial of severely mentally ill people’s religious freedom: therapists who assume low-status religious beliefs mean psychosis; mental hospitals that require everyone to pray; therapists who pressure their clients into secularized versions of Hindu movement or Buddhist meditation practices; atheist alcoholics who must submit their life to their Higher Power or go to prison. Nothing about therapists assuming that anything about their patient’s experiences they don’t approve of is a symptom of the patient’s mental illness and changing it an appropriate therapeutic goal—which is gaslighting, the actual technical meaning of the word ‘gaslighting’ and not the synonym for lying, and it is even worse if you actually are insane and the person doing it to you is someone you trust to help.

Because… to Shrier, we don’t exist, we don’t matter, we aren’t real. And you can write a wholeass book about the problems with therapy that doesn’t even acknowledge the people bad therapy hurts most.

1. Yes, they do still freak out sometimes.

2. If your grandma sucks, substitute in someone else’s more competent grandma.

3. You know what CBT for phobia is? It’s “if you do the scary thing, it will be less scary.” Groundbreaking, I know.

4. I’m leaving out the diagnoses because it’s unethical and inappropriate for a therapist to diagnose someone they haven’t examined.

5. Yeah yeah the serotonin theory of depression is fake.