Bad Therapy E-Book

Abigail Shrier

• Herausgeber: Swift Press
• Kategorie: Geisteswissenschaft
• Sprache: Englisch
• Veröffentlichungsjahr: 2024

Seitenzahl: 455

Beschreibung

From the author of Irreversible Damage, an investigation into how mental health overdiagnosis is harming, not helping, children 'A pacy, no-holds barred attack on mental health professionals and parenting experts ...thought-provoking' Financial Times 'A message that parents, teachers, mental health professionals and policymakers need to hear' New Statesman In virtually every way that can be measured, Gen Z's mental health is worse than that of previous generations. Youth suicide rates are climbing, antidepressant prescriptions for children are common, and the proliferation of mental health diagnoses has not helped the staggering number of kids who are lonely, lost, sad and fearful of growing up. What's gone wrong? In Bad Therapy, bestselling investigative journalist Abigail Shrier argues that the problem isn't the kids – it's the mental health experts. Drawing on hundreds of interviews with child psychologists, parents, teachers and young people themselves, Shrier explores the ways the mental health industry has transformed the way we teach, treat, discipline and even talk to our kids. She reveals that most of the therapeutic approaches have serious side effects and few proven benefits: for instance, talk therapy can induce rumination, trapping children in cycles of anxiety and depression; while 'gentle parenting' can encourage emotional turbulence – even violence – in children as they lash out, desperate for an adult to be in charge. Mental health care can be lifesaving when properly applied to children with severe needs, but for the typical child, the cure can be worse than the disease. Bad Therapy is a must-read for anyone questioning why our efforts to support our kids have backfired – and what it will take for parents to lead a turnaround.

Leseprobe

Bad Therapy

To my mother and fatherandZach. Always Zach.

Sometimes love is not enoughand the road gets toughI don’t know why

—Lana Del Rey

Contents

Author’s Note

Introduction: We Just Wanted Happy Kids

Part I

Healers Can Harm

Chapter 1     Iatrogenesis

Chapter 2     A Crisis in the Era of Therapy

Chapter 3     Bad Therapy

Part II

Therapy Goes Airborne

Chapter 4     Social-Emotional Meddling

Chapter 5     The Schools Are Filled with Shadows

Chapter 6     Trauma Kings

Chapter 7     Hunting, Fishing, Mining:Mental Health Survey Mischief

Chapter 8     Full of Empathy and Mean as Hell

Chapter 9     The Road Paved by Gentle Parents

Chapter 10   Spare the Rod, Drug the Child

Part III

Maybe There’s NothingWrong with Our Kids

Chapter 11   This Will Be Our Final Session

Chapter 12   Spoons Out

Acknowledgments

Notes

Select Bibliography

Author’s Note

Talk of a “youth mental health crisis” often conflates two distinct groups of young people. One suffers from profound mental illness. Disorders that, at their untreated worst, preclude productive work or stable relationships and exile the afflicted from the locus of normal life. Theirs is a crisis of neglect and undertreatment. These precious kids require medication and the care of psychiatrists. They are not the subject of this book.

This book is about a second, far larger cohort: the worriers; the fearful; the lonely, lost, and sad. College coeds who can’t apply for a job without three or ten calls to Mom. We tend not to call their problem “mental illness,” but nor would we say they are thriving. They go looking for diagnoses to explain the way they feel. They think they’ve found “it,” but the “it” is always shifting.

We shower these kids with meds, therapy, mental health and “wellness” resources, even prophylactically. We rush to remedy a misdiagnosed condition with the wrong sort of cure.

Introduction:We Just Wanted Happy Kids

My son returned home from sleepaway camp this summer with a stomachache. When it didn’t quickly abate, I took him to a pediatric urgent care clinic, where a doctor ruled out appendicitis. “Probably just dehydration,” came the verdict. But before the doctor cleared us to go home, he asked us to wait for the nurse, who had a few questions.

In bustled a large man in black scrubs wielding a clipboard. “Would you mind giving us some privacy so that I can do our mental health screening?” he said. After a beat, I realized that the privacy the man wanted with my son was from me.

I asked to see his questionnaire, which turned out to be issued by the National Institute of Mental Health, a federal government agency. Here is the complete, unedited list of questions the nurse had planned to put to my twelve-year-old in private:

1.   In the past few weeks, have you wished you were dead?

2.   In the past few weeks, have you felt that you or your family would be better off if you were dead?

3.   In the past week, have you been having thoughts about killing yourself?

4.   Have you ever tried to kill yourself? If yes, how? When?

5.   Are you having thoughts of killing yourself right now? If yes, please describe.1

When the nurse asked me to leave the room, he wasn’t going off script. He was following a literal one. The “Script for Nursing Staff” directs nurses to inform parents: “We ask these questions in private, so I am going to ask you to step out of the room for a few minutes. If we have any concerns about your child’s safety, we will let you know.”2

Driving my son home from the clinic, I was haunted by the following possibility: What if I had been just a little more trusting? Children often try to please adults by producing whatever answers the grown-ups seem to want. What if my son, alone in the room with that large man, had given him the “yes” the questions appeared to prompt? Would the staff have prevented me from taking my son home?

And a child who was entertaining dark thoughts? Was this really the best way to help him? Separate him from his parents and present him with a series of escalating questions about killing himself?

I hadn’t signed my son up for therapy. I hadn’t taken him for a neuropsychological evaluation. I had taken him to the pediatrician for a stomachache. There was no indication, no reason to even suspect, that my son had any mental illness. And the nurse didn’t wait for one. He knew he didn’t have to.

We parents have become so frantic, hypervigilant, and borderline obsessive about our kids’ mental health that we routinely allow all manner of mental health expert to evict us from the room. (“We will let you know.”) We’ve been relying on them for decades to tell us how to raise well-adjusted kids. Maybe we were overcompensating for the fact that our own parents had assumed the opposite: that psychologists were the last people you should consult on how to raise normal kids.

When we were little, my brother and I were spanked. Our feelings were seldom consulted when consequential decisions about our lives were made—where we would attend school, whether we would show up at synagogue for major holidays, what sort of clothes fit the place and occasion. If we didn’t particularly relish the food set out for dinner, no alternate menu was forthcoming. If we lacked some critical right of self-expression—some essential exploration of a repressed identity—it never occurred to either of us. It would be years before anyone in my generation would regard these perfectly average markers of an eighties childhood as vectors of emotional injury.

But as millions of women and men my age entered adulthood, we commenced therapy.3 We explored our childhoods and learned to see our parents as emotionally stunted.4 Emotionally stunted parents expected too much, listened too little, and failed to discover their kids’ hidden pain. Emotionally stunted parents inflicted emotional injury.

We never doubted that we wanted kids of our own. We vowed that our child-rearing would reflect a greater psychological awareness. We resolved to listen better, inquire more, monitor our kids’ moods, accommodate their opinions when making a family decision, and, whenever possible, anticipate our kids’ distress. We would cherish our relationship with our kids. Tear down the barrier of authority past generations had erected between parent and child and instead see our children as teammates, mentees, buddies.

More than anything, we wanted to raise “happy kids.” We looked to the wellness experts for help. We devoured their bestselling parenting books, which established the methods by which we would educate, correct, and even speak to our own children.

Guided by these experts, we adopted a therapeutic approach to parenting. We learned to offer our kids the reasons behind every rule and request. We never, ever spanked. We perfected the “time-out” and provided thorough explanation for any punishment (which we then rebranded as a “consequence” to remove any associated shame and make us feel less authoritarian). Successful parenting became a function with a single coefficient: our kids’ happiness at any given instant. An ideal childhood meant no pain, no discomfort, no fights, no failure—and absolutely no hint of “trauma.”

But the more closely we tracked our kids’ feelings, the more difficult it became for us to ride out their momentary displeasure. The more closely we examined our kids, the more glaring their deviations from an endless array of benchmarks—academic, speech, social and emotional. Each now felt like catastrophe.

We rushed our kids back to the mental health professionals who had guided our parenting, this time for testing, diagnosis, counseling, and medication. We needed our kids and everyone around them to know: our kids weren’t shy, they had “social anxiety disorder” or “social phobia.” They weren’t poorly behaved, they had “oppositional defiant disorder.” They weren’t disruptive students, they had “ADHD.” It wasn’t our fault, and it wasn’t theirs. We would attack and finally eliminate the stigma surrounding these diagnoses. Rates at which our children received them soared.

In the course of writing my last book, Irreversible Damage, and for years after its publication, I spoke to hundreds of American parents. And during that time, I became acutely aware of just how much therapy kids were getting from actual therapists and their proxies in schools. How completely parents were relying on therapists and therapeutic methods to fix their kids. And how expert diagnoses often altered kids’ perceptions of themselves.

Schools, especially, jumped at the opportunity to adopt a therapeutic approach to education and announced themselves our “partners” in child rearing. School mental health staffs expanded: more psychologists, more counselors, more social workers. The new regime would diagnose and accommodate, not punish or reward. It directed kids in routinized habits of monitoring and sharing their bad feelings. It trained teachers to understand “trauma” as the root of student misbehavior and academic underperformance.

These efforts didn’t aim to produce the highest-achieving young people. But millions of us bought in, believing they would cultivate the happiest, most well-adjusted kids. Instead, with unprecedented help from mental health experts, we have raised the loneliest, most anxious, depressed, pessimistic, helpless, and fearful generation on record. Why?

How did the first generation to raise kids without spanking produce the first generation to declare they never wanted kids of their own?5 How did kids raised so gently come to believe that they had experienced debilitating childhood trauma? How did kids who received far more psychotherapy than any previous generation plunge into a bottomless well of despair?6

The source of their problem is not reducible to Instagram or Snapchat. Bosses and teachers report—and young people agree—that members of the rising generation are utterly underprepared to accomplish basic tasks we expect all adults to dispatch: ask for a raise; show up for work during a period of national political strife; show up for work at all;7 fulfill obligations they undertake without requiring extensive breaks to attend to their “mental health.”

It’s not unheard of for boys of sixteen or seventeen to put off getting a driver’s license on the grounds that driving is “scary.”8 Or for college juniors to invite Mom along to their twenty-first birthday celebrations. They are leery of the risks and freedoms that are all but synonymous with growing up.

These kids are lonely. They settle into emotional pain for reasons that seem, even to their parents, a little mysterious. Parents seek answers from mental health experts, and when our kids inevitably receive a diagnosis, they grasp it with pride and relief: a whole life, reduced to a single point.

No industry refuses the prospect of exponential growth, and mental health experts are no exception. By feeding normal kids with normal problems into an unending pipeline, the mental health industry is minting patients faster than it can cure them.

These mental health interventions on behalf of our kids have largely backfired. Recasting personality variation as a chiaroscuro of dysfunction, the mental health experts trained kids to regard themselves as disordered. The experts operate from the assumption that everyone requires therapy and that everyone is at least a little “broken.”

They speak of “resilience” but what they mean is “accepting your trauma.” They dream of “destigmatizing mental illness” and sprinkle diagnostic labels like so much pixie dust. They talk of “wellness” while presiding over the downward spiral of the most unwell generation in recent history.

With the charisma of cult leaders, therapeutic experts convinced millions of parents to see their children as challenged. They infused parenting with self-consciousness and fevered insecurity. They conscripted teachers into a therapeutic order of education, which meant treating every child as emotionally damaged. They pushed pediatricians to ask kids as young as eight—who had presented with nothing more than a stomachache—whether they felt their parents might be better off without them.9 In the face of experts’ implacable self-assurance, schools were eager; pediatricians, willing; and parents, unresisting.

Maybe it’s time we offered a little resistance.

HealersCan Harm

The best of doctors are destined for hell.

—The Mishnah

Chapter 1

•

Iatrogenesis

In 2006, I packed up everything I owned and moved from Washington, DC, to Los Angeles to be closer to my then boyfriend. I had only ever visited California once, a few months earlier, when I had flown out to meet his parents. Outside of my boyfriend and his family, every single person who could identify my body in the event of an untimely demise lived on the East Coast.

Then twenty-eight and having recently graduated from law school, I faced the unpleasantness of having become a lawyer. I was restless. My boyfriend had a business in Los Angeles. If I wanted things to work out with him, I needed to move.

But I also knew it was entirely possible that in this new life—his life—I would go crazy. My best friend, Vanessa, lived in DC. We’d both been hired by law firms, which meant long hours and an impossible time difference, as far as calls were concerned. I needed someone to listen to my worries and misgivings on my schedule. I needed a stand-in Vanessa, available every Thursday at six p.m. And for the first time in my life, I could afford one. I hired a therapist.

Every week, for a “fifty-minute hour,” my therapist lent me her full attention. If I bored her with my repetition, she never complained. She was a pro. She never made me feel self-absorbed, even when I was. She let me vent. She let me cry. I often left her office feeling that some festering splinter of interpersonal interaction had been eased to the surface and plucked.

She helped me realize that I wasn’t so bad. Most things were someone else’s fault. Actually, many of the people around me were worse than I’d realized! Together, we diagnosed them freely. Who knew so many of my close relatives had narcissistic personality disorder? I found this solar plexus–level comforting. In quick order, my therapist became a really expensive friend, one who agreed with me about almost everything and liked to talk smack about people we (sort of) knew in common.

I had a great year. My boyfriend proposed marriage. I accepted. And then, a month before we were due to get married, my therapist dropped a bomb: “I’m not sure you two are ready to get married. We may need to do a little more work.”

I felt the demoralizing shock of having walked into a plate-glass door.

My therapist was a formidable woman. She had at least fifteen years on me, a doctorate in psychology, and an apparently strong marriage of long duration. She dropped casual references to never missing Pilates. I once caught her at her spotless desk before our session, eating a protein bar she had carefully unwrapped, and marveled at her obvious self-mastery, the dignity she managed to bring to our silly modes of consumption. Maybe I should have been thrown into crisis by her pronouncement, but for whatever reason, I wasn’t. For all her training, she was still human and fallible. I had already moved across the country by myself, set up a new life, and by then I knew: I didn’t agree with her assessment, and I didn’t need her permission, either. I left her a voicemail expressing my gratitude for her help. But, I said, I would be taking some time off.

A few years later, happily married, I resumed therapy with her. Then I tried therapy with a psychoanalyst for a year or so. Every experience I’ve had with therapy has fallen along a continuum from enlightening to unsettling. Occasionally, it rose to the level of “fun.” Learning a little more about the workings of my own mind was at times helpful and often gratifying.

When I agreed with my therapist, I told her so. When I didn’t, we talked about that. And when I felt I needed to move on, I did. Which is to say: I was an adult in therapy. I had swum life’s choppy waters long enough to have gained some self-knowledge, some self-regard, and a sense of the accuracy of my own perceptions. I could pipe up with: “I think I gave you the wrong impression.” Or, “Maybe we’re placing a little too much blame on my mom?” Or even, “I’ve decided to terminate therapy.”

Children and adolescents are not typically equipped to say these things. The power imbalance between child and therapist is too great. Children’s and adolescents’ sense of self is still developing. They cannot correct the interpretations or recommendations of a therapist. They cannot push back on a therapist’s view of their families or of themselves because they have no Archimedean point; too little of life has gathered under their feet.

Nevertheless, parents my age have been signing up their kids and teens for therapy in astonishing numbers, even prophylactically. I talked to moms who hired therapists to help their kids adjust to preschool or to process the death of a beloved cat. One mom told me she put a therapist “on retainer” as soon as her two daughters reached middle school. “So they would have someone to talk to about all the things I never wanted to talk about with my mom.”

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.

If the notion of “therapy” here seems vague, that’s largely to do with the experts. The American Academy of Child and Adolescent Psychiatry offers a tautology in place of a definition. What is “psychotherapy”? “A form of psychiatric treatment that involves therapeutic conversations and interactions between a therapist and a child or family.”1 The American Psychological Association offers a similarly circular definition of psychotherapy: “any psychological service provided by a trained professional.”2

What’s a “clock”? A device for measuring time. What’s “time”? Something measured by a clock. Any conversation a therapist has with a patient counts as “therapy.” But you get the idea: conversations about feelings and personal problems styled as medicine.

Parents often assume that therapy with a well-meaning professional can only help a child or adolescent’s emotional development. Big mistake. Like any intervention with the potential to help, therapy can harm.

Iatrogenesis: When the Healer Makes Things Worse

Any time a patient arrives at a doctor’s office, she exposes herself to risk.3 Some risks arise through physician incompetence. A patient goes in to have a kidney removed, and the doctor extracts the wrong one. (“Wrong-site surgery” happens more often than you might think.4) Or negligence: the surgeon loses track of a stray clamp or sponge in the patient’s abdomen, then sews her up.

Or he “nicks” an organ. Or the operation proceeds swimmingly, but the patient develops an opportunistic infection at the surgical site. Or an allergic reaction to the anesthesia. Or bedsores, from lying in recovery too long. Or everything goes according to plan, but the entire treatment was based on a misapprehension of the problem.

“Iatrogenesis” is the word for all of it. From the Greek, iatrogenesis literally means “originating with the healer” and refers to the phenomenon of a healer harming a patient in the course of treatment. Most often, it is not malpractice, though it can be. Much of iatrogenesis occurs not because a doctor is malicious or incompetent but because treatment exposes a patient to exogenous risks.

Iatrogenesis is everywhere—because all interventions carry risk. When a sick patient submits to treatment, the risks are typically worth it. When a well patient does, the risks often outweigh the potential for further improvement.

And here, what I’m calling an “intervention” is any sort of advice or corrective you would typically give only to someone with a deficiency or incapacity. So, telling kids to “eat vegetables” or “get plenty of sleep” or “spend time with friends” may be advice, but it isn’t an intervention. We all need to do those things.

With interventions, a good rule of thumb is: Don’t go in for an X-ray if you don’t need one. Don’t expose yourself to the germs of an ER just to say hello to your doctor friend. And—just maybe—don’t send your kid off to therapy unless she absolutely requires it. Everyone knows the first two; it’s the last one that may surprise you.

Psychotherapy Needs a Warning Label

For decades, the standard therapy proffered to victims of disaster—terrorist attack, combat,5 severe burn injury—was the “psychological debriefing.”6 A therapist would invite victims of a tragedy into a group session in which participants were encouraged to “process” their negative emotions, learned to recognize the symptoms of post-traumatic stress disorder (PTSD), and discouraged from discontinuing therapy. Study after study has shown that this bare-bones process is sufficient to make PTSD symptoms worse.7

Well-meaning therapists often act as though talking through your problems with a professional is good for everyone. That isn’t so.8 Nor is it the case that as long as the therapist is following protocols, and has good intentions, the patient is bound to get better.

Any intervention potent enough to cure is also powerful enough to hurt. Therapy is no benign folk remedy. It can provide relief. It can also deliver unintended harm and does so in up to 20 percent of patients.9

Therapy can lead a client to understand herself as sick and rearrange her self-understanding around a diagnosis.10 Therapy can encourage family estrangement—coming to realize that it’s all Mom’s fault and you never want to see her again. Therapy can exacerbate marital stress, compromise a patient’s resilience, render a patient more traumatized, more depressed, and undermine her self-efficacy so she’s less able to turn her life around.11 Therapy may lead a patient by degrees—sunk into a leather sofa, well-placed tissue box close at hand—to become overly dependent on her therapist.12

This is true even for adults, who in general are much less easily led by other adults. These iatrogenic effects pose at least as great a risk, and likely much more, to children.

Police officers who responded to a plane crash and then underwent debriefing sessions exhibited more disaster-related hyperarousal symptoms eighteen months later than those who did not receive the treatment.13 Burn victims exhibited more anxiety after therapy than those left untreated.14 Breast cancer patients have left peer support groups feeling worse about their condition than those who opted out.15 And counseling sessions for normal bereavement often make it harder, not easier, for mourners to recover from loss.16 Some people who say they “just don’t want to talk about it” know better than the experts what will help them: spending time with family; exercising; putting one foot in front of the other; gradually adjusting to the loss.17

When it comes to our psyches, we’re a lot more bespoke than mental health professionals often acknowledge or allow. And Tuesdays at four p.m. may not be when we’re ready to confront our woes with a hired expert. Reminiscing with a friend, cracking a joke with your spouse you wouldn’t dare make with anyone else, helping your cousin box up her apartment—without talking about your problems—often aids recovery far more than sitting around in a room full of sad people. Therapy can hijack our normal processes of resilience, interrupting our psyche’s ability to heal itself, in its own way, at its own time.

Think of it this way: group therapy for those who experienced loss or disaster forces the coping to hang out with the sad. This may make the relatively resilient sadder and prompt the sad to stew. The most dejected steer the ship to Planet Misery, with everyone else trapped inside.

Individual therapy can intensify bad feelings, too. Psychiatrist Samantha Boardman wrote candidly about a patient who quit therapy after a few weeks of treatment. “All we do is talk about the bad stuff in my life,” the patient told Boardman. “I sit in your office and complain for 45 minutes straight. Even if I am having a good day, coming here makes me think about all the negative things.”18 Reading that, I remembered saving up emotional injuries to report to my therapist so that we would have something to talk about at our session—injuries I might have just let go.

Interestingly, even when patients’ symptoms are made objectively worse by therapy, they tend to assume the therapy has helped.19 We rely largely on how “purged” we feel when we leave a therapist’s office to justify our sense that the therapy is working. We rarely track objective markers, for example, the state of our career or relationships, before reaching a conclusion. Sometimes when our lives do improve, it’s not because the therapy worked but because the motivation that led us to start therapy also led us to make other positive changes: spend more time with friends and family, reconnect with people we haven’t heard from in a while, volunteer, eat better, exercise.

An embarrassing number of psychological interventions have little proven efficacy.20 They have nonetheless been applied with great élan to children and adolescents.

D.A.R.E. to Say “Yes” to Drugs

Picture it: 1992. Blue eyeliner, Doc Martens, and acid-washed jeans shot out at the knees. Into your high school assembly room tromps a uniformed officer in clodhoppers, keys jangling at the edge of a stiff black belt, armed with a jeremiad about the dangers of drugs.

This was the decades-long D.A.R.E. campaign, designed to raise awareness that drugs could ruin your life.21 Utilizing therapeutic techniques designed by Carl Rogers, one of the most influential psychotherapists of the twentieth century, D.A.R.E. counselors led students in a kind of group therapy. They entered schools and prompted kids to talk about their personal problems, confess their drug use, and role-play refusing drugs from each other.22

Turns out, you can lead a teen to D.A.R.E., but it might make him wink. The program flopped like Vanilla Ice in his parachute pants, humiliating everyone involved. Not only was the campaign entirely ineffective, but follow-up studies revealed that D.A.R.E. may have actually increased substance and alcohol use among teens.23 Kewpie-faced Kirk Cameron pleaded, “You don’t have to try ’em to be cool,” but we sniffed a traitor, shilling for the Man. Kirk promised there were other avenues to cool, but teens who heard this message apparently figured drugs were quicker and more straightforward than most.24 Participating in group therapy to discuss a problem you didn’t already have? That may be sufficient to introduce it.

Wanting to Help Is Not the Same as Helping

Therapists almost always want to help, but sometimes they simply don’t. And while some therapies have shown success in circumscribed areas—like cognitive behavioral therapy has in treating phobias—those who study the efficacy of therapies often point out that the results across treatment types are not terribly impressive.25

Mental health experts have a long, florid track record of plying patients with ghastly treatments, introducing novel problems into the patient pool they claim to heal. Fortunately, they’ve abandoned many of the grisliest purported treatments: insulin-induced comas, deliberate infliction of malaria, and of course frontal lobotomies—all employed, not in the Medieval Period, but in the last century.26 Therapists induced an epidemic of the phony ailment neurasthenia at the start of the twentieth century. A century later, they were still ginning up ailments: recovered memory syndrome and multiple personality disorder.27 Therapists fell for the fraud of widespread satanic ritual abuse, too.28

In the last decade, therapists promoted the gender dysphoria craze, which led to a 4,000 percent increase in diagnoses for teen girls.29 A growing army of young women who regret their medical transitions, “detransitioners,” tell strikingly similar stories. Very often, when they trace their lives back to the junction where things sped dramatically off course, there stood a shrink playing railway signalman, flipping the switch.30

This shouldn’t surprise us. The human brain is perhaps the world’s most complex and least understood organic structure. Fixing the problems of the human mind is incomparably more difficult than setting a broken bone. We can’t expect therapists to fail less often than medical doctors. But we can expect more transparency and humility than practitioners typically bring to discussions of therapy’s limitations.

“In psychotherapy, psychologists help people of all ages live happier, healthier, and more productive lives,” declares the American Psychological Association.31

There is, alas, no proof that they accomplish any of that in aggregate. Wanting to help is just not the same as helping.

Therapists Are a Little Touchy about Iatrogenesis

Iatrogenesis isn’t news to medical doctors who are professionally obligated32 to admit their treatments may produce adverse effects.33 But when I asked therapists point blank whether therapy carried risks, most minimized and many outright denied this.34 They wanted both to promote therapy as an effective remedy for mental illness and to deny that it carries significant risks.

Why don’t therapists typically admit that their methods can cause iatrogenic harm?

A group of researchers considered the question and concluded that, unlike the doctor, the “psychotherapist is the ‘producer’ of treatment,” and is “therefore responsible, if not liable, for all negative effects.”35 The therapist often doesn’t want to acknowledge that the medicine isn’t working—because she is the medicine. The admission is a little personal.

Shrinks are badly incentivized where iatrogenesis is concerned. A doctor may decide that a patient would no longer benefit from thyroid medication, discontinue it, and keep the patient. A therapist gets paid by the dose. Once she decides you don’t need therapy, she loses a customer.

Actually, it’s worse than that: it’s in therapists’ interest to treat the least sick for the longest period of time. Ask any therapist what it’s like to treat a bipolar or schizophrenic patient. Answer: extraordinarily difficult. (Many refuse to treat such patients for this reason.) But sit with a teenager once a week who has social anxiety? The family pays on time, the teen’s problems are small, nobody’s getting violent during your session. It’s little wonder why, having acquired such a patient, a therapist may be reluctant to surrender her.

Most therapists have no idea who has been made worse by their therapy because they make no effort to track side effects. The profession does not require it. Medical doctors (psychiatrists), who once dominated therapeutic practice, generally stopped offering psychotherapy in recent decades.36 The medical authority they lent to therapy fell to those without medical training.

And since the field of psychology lacks clear guidelines on what qualifies as a therapeutic “harm,”37 it’s unclear how therapists would track damage done by therapy, even if they wanted to. As one group of researchers put it: “a divorce can be both positive and negative, and crying in therapy can reflect a painful experience and therapeutic event.”38

When iatrogenic risks go untallied, the harms pile up, threatening the well far more than the sick. It isn’t hard to see why: Suffer a gunshot wound, and your risk of picking up an opportunistic infection in the operating room is outweighed by the lifesaving treatment you require. Suffer a scratch, and you have nothing to gain from surgery—nothing but risk.

What would we expect to find if we steeped a generally healthy population in a tea of unnecessary mental health treatments? Unprecedented iatrogenic effects. With that in mind, please meet the rising generation.

Chapter 2

•

A Crisis in the Era of Therapy

At sixteen, Nora1 sits at the giggly edge of womanhood. Her hair, a cascade of dense brown curls. Her smile, all gums and braces, enlivens whenever she mentions her friends. She is always, always connected to them, she tells me—on Snapchat, all day long, even during class. At her large private high school in Southern California, she sings in the school choir, is a cast member of every play, and is a top student.

On a mild April afternoon, we sit on Adirondack chairs in her mother and stepfather’s backyard patio. Nora tosses her hair and recrosses her legs, bare in a flouncy skirt, testing the air with the notion that we are two adults—she, the cuter, more up-to-date model.

“I always have a friend who’s going through something super serious,” she tells me. “I don’t know why it’s always that way.”

That sounds normal enough for high school girls, so I ask: What are they going through? Anxiety, depression, she ticks off. Trouble with parents. Lots of self-harm.

Like what?

Scratching, cutting, anorexia, she rattles off. “Taking away basic needs. Like, one of my friends will be in the shower and turn it up too hot or too cold.”

Okay. What else?

“Trichotillomania.”

“Excuse me?”

“Pulling out your hair. That’s a big one.”

Also known as “hair-pulling disorder,” this is the urge to pull out hair from the scalp, eyelashes, and eyebrows, emanating from an uncontrollable need to self-soothe. Dissociative identity disorder, gender dysphoria, autism spectrum disorder, and Tourette’s belong on her list of once-rare disorders that are, among this rising generation, suddenly not so rare at all.

Nora is casually au fait with dozens of mental disorders, almost as if she keeps the Diagnostic and Statistical Manual of Mental Disorders by her bedside. (She doesn’t.)

Given how poorly so many seem to be faring, one might be inclined to suggest that these teens could really use some therapy. Actually, “a large majority” of Nora’s friends are already in therapy—many have been for years, she tells me. Several are on psychiatric medication.

Does it seem to be helping?

“I’d say for some, yes. Others?” Nora shrugs. “My friend, I’m not going to say her name—since COVID-19 started, she just got a lot of anxiety. She’s been on medication for a few years now. She sees a therapist, and I have to say, she just seems to be getting worse.” Nora thinks it over. “She honestly seemed better before medication.”

I ask Nora what seems to be troubling her friends. Nora reiterates that they’re going through “really hard things,” but when I ask her what, she is vague: strained relationships with peers, breakups, disagreements with parents.

By the time I meet Nora, I’ve interviewed enough adolescents to know that she isn’t avoiding the question. Teenage communication today is more constant, largely digital, and, even among teen girls, far more superficial than it was a generation ago. Less baring of souls, more trading of memes. Even to their best friends, they communicate only this: that they are going through something bad and serious, something that will require their friends’ sympathy and indulgence.

Some of her friends complain their parents are “emotionally abusive,” but when I ask Nora why their therapists haven’t called Child Services, she seems unperturbed. Yes, she assumes they’re sort of exaggerating. To preserve the friendship, you suspend disbelief.

There’s something else. Nora drops her chin, embarrassed by what she’s about to confess: “I’ve noticed with a lot of people who’ll use their mental issues—it’s almost like a conversation piece. It’s almost like a trend.”

I reassure her that she’s at least the twelfth adolescent to tell me this. She exhales.

What’s it like to have so many friends suffering with anxiety disorders and depression? Actually, she tells me, those who don’t have a diagnosis feel left out. “You’re expected to have these mental issues. And these things that are being normalized—these things are not normal,” she says. “I’m surrounded by it, so I think that in some ways, it has become our new normal. How is it possible, with all that around me, for it not also to be inflicted on me—for me not to be depressed about it?”

I ask her why it’s depressing to have friends who are struggling. “I know three people who were committed to mental facilities long-term—one who committed suicide,” she says. All of them, high school students.

Nora is faring a lot better than most of her peers and many of the young people I interviewed: she has a group of friends, a steady boyfriend, excels at school, and is planning for her future. She is on no psychiatric medication, and is not in therapy.

But she also casually bundles two sets of friends, as if they are one: those whose mental illness is so profound that it requires psychiatric commitment, and those who are seeking explanations for their unhappiness and discovering diagnoses. Like so many young people I talked to, she regards high school friends with “exam anxiety” or “social phobia” as existing on merely one end of a psychological continuum that terminates with the woman who shows up naked to Target.

They Need Therapy, You Say?

The mental health establishment has successfully sold a generation on the idea that vast numbers of them are sick. Less than half of Gen Zers believes their mental health is “good.”2 They do not believe mental health is something that arises typically, in the normal course of a balanced life, but like a boxwood tree, requires constant tending by the gardener you hire to prune it.

The rising generation has received more therapy than any prior generation. Nearly 40 percent of the rising generation has received treatment from a mental health professional—compared with 26 percent of Gen Xers.3

Forty-two percent of the rising generation currently has a mental health diagnosis, rendering “normal” increasingly abnormal.4 One in six US children aged two to eight years old has a diagnosed mental, behavioral, or developmental disorder.5 More than 10 percent of American kids have an ADHD diagnosis6—double the expected prevalence rate based on population surveys in other countries.7 Nearly 10 percent of kids now have a diagnosed anxiety disorder.8 Teens today so profoundly identify with these diagnoses, they display them in social media profiles, alongside a picture and family name.

And if you ask mental health experts if young people, in aggregate, have undiagnosed mental health problems, they invariably answer in the affirmative. Meaning, according to experts, not having a mental health problem is increasingly anomalous.

We have plied members of the rising generation with more antianxiety and antidepressant medication than any prior. We’ve afforded them more mental health accommodations in school9 and in sports.10 They face less stigma11 for receiving mental health treatments, and so much more emotional sensitivity12 from adults in their lives.

From the time they first lurched across the living room rug on unsteady legs, parents treated them to therapeutic parenting. (“I see you’re having some big feelings. How would you like to express that, Adam? Would you like to stomp your feet? Or grit your teeth?”) Their teachers employed therapeutic methods of pedagogy (“Tell me about your drawing, Madison. What does it represent to you?”) and read them books about how to process their feelings.

A decade ago, a writer for Slate noted that instead of using moral language to describe misbehavior, educated parents had begun employing therapeutic language.13 A-list adolescent heroes from Huck Finn to Dylan McKay suddenly struck us as undiagnosed sufferers of “oppositional defiant disorder” or “conduct disorder.” Agency slunk out the back door.

Suddenly, every shy kid had “social anxiety,” or “generalized anxiety disorder.” Every weird or awkward teen was “on the spectrum” or, at least, “spectrumy.” Loners had “depression.” Clumsy kids had “dyspraxia.”

Parents ceased to chide “picky eaters” and instead diagnosed and accommodated the “food avoidant.” (Formal diagnosis: “avoidant restrictive food intake disorder,” or ARFID.) If a kid whined about an itchy tag at the back of his shirt or complained that hallway noise kept him from getting restful sleep, his parents didn’t tell him to ignore it; they bought tag-free clothing of soft Pima cotton and appointed his room with a soft-sound machine to address his “sensory processing issues.” No chiding kids for messy handwriting (that was “dysgraphia”). No telling kids with the blues that it takes time to adjust to a new town or new school (they have “relocation depression”14). No reassuring them that it’s normal to miss their friends over the summer (“summer anxiety”15).

We’ve all been swimming in therapeutic concepts so long we no longer note the presence of the water. It seems perfectly reasonable to talk about a child’s “trauma” from the death of a pet or the routine humiliation of being picked last for a sports team.

In the course of a single month, three zeitgeist-epitomizing stories hit the news: The American Academy of Pediatrics, in 2022, reversed perhaps a century of standard protocol and declared that kids with active headlice should no longer be sent home from school; better to scatter bloodthirsty vermin across the entire student body than that anyone bear the emotional stigma of having been sent home.16 The Washington Post’s “mental health professional” informed readers that having your name mispronounced is damaging to the psyche.17 And New York University fired a storied organic chemistry professor, author of the field’s premier textbook, because holding premed students to the same standards (and grading scale) he’d employed for decades suddenly failed to make student well-being a priority.18

“Student Wellness Centers” have sprouted at our most prestigious universities. Our best athletes withdraw from competition to attend to their mental health; and young Hollywood starlets, Prince Harry, and a slew of Grammy winners proclaim the “work” they are doing in therapy against a continuous struggle with anxiety and depression. “Wellness” and “trauma” form the contrapuntal soundtrack against which the rising generation came of age.

Seventy-five years of rapid expansion in mental health treatment and services has landed us here, marveling at the unprecedented psychological frailty of American youth.

The Treatment-Prevalence Paradox

It began with the soldiers returning home from the Second World War.19 On a scale previously unimagined, GIs had seen—and meted out—death and suffering. Many returned home shaky—some, shattered.

Congress greenlit a dramatic expansion in preventive therapeutic services.20 No longer content to treat the ill, therapists became determined to support the healthy.21 Between 1946 and 1960, membership in the American Psychological Association quadrupled.22 Then, from 1970 to 1995, the number of mental health professionals quadrupled again.23 In the United States since 1986, nearly every decade has seen a doubling of expenditure on mental health over the one before.24

There’s a paradox embedded in this tale of exponential expansion. More widely available treatment ought to abate the rate (and severity) of disease.

Take breast cancer, pitiless killer of over forty thousand American women each year. As early detection and treatment for breast cancer improved since 1989, rates of death from breast cancer plummeted. Or maternal mortality: as antibiotics became more readily available, rates of maternal death in childbirth collapsed. Better and more widely available dental care has meant fewer toothless Americans. And as we developed immunizations and cures for childhood illness, child mortality rates nose-dived.

And yet as treatments for anxiety and depression have become more sophisticated and more readily available, adolescent anxiety and depression have ballooned.

I’m not the only one to have found something fishy in the fact that more treatment has not resulted in less depression. A group of academic researchers recently noticed the same. They published a peer-reviewed paper titled “More Treatment but No Less Depression: The Treatment-Prevalence Paradox.”25 The authors note that treatment for major depression has become much more widely available (and, in their view, improved) since the 1980s worldwide. And yet in not a single Western country has this treatment made a dent in the incidence of major depressive disorder. Many countries saw an increase.

“The increased availability of effective treatments should shorten depressive episodes, reduce relapses, and curtail recurrences. Combined, these treatment advances unequivocally should result in lower point-prevalence estimates of depression,” they write. “Have these reductions occurred? The empirical answer clearly is NO.”26

I checked with several of the paper’s authors. Two confirmed that the same might be said for anxiety. As treatment has become more widely available and dispersed, point-prevalence rates should go down.27 They have not. And while the authors admit that there was likely more depression in the past than we realized, they argue that there is at least as much, and probably more, depression now.28

After generations of increased intervention, that shouldn’t be the case. More access to antibiotics should spell fewer deaths from infection. And more generally available therapy should spell less depression.29

Instead, adolescent mental health has been in steady decline since the 1950s.30 Between 1990 and 2007 (before any teens had smartphones), the number of mentally ill children rose thirty-five-fold.31 And while overdiagnosis or the expansion of definitions of mental illness may partially account for this rapid change, it is hard to dismiss or contextualize away the startling rise in teen suicide: “Between 1950 and 1988, the proportion of adolescents aged between fifteen and nineteen who killed themselves quadrupled,” The New Yorker reported.32 Mental illness became the leading cause of disability in children.

Yes, the coincidence of these two trends—deteriorating mental health in an era of vastly expanded awareness, detection, diagnosis, and treatment of psychological disorders—may be just that: coincidence. It does not unveil a causal arrow. But it is peculiar. At the very least, it may provide a clue that many of the treatments and many of the helpers aren’t actually helping.

Therapists will insist that I’ve got things wrong end up. They are the lifeguards, not the sharks; it’s simply that the rising generation has been swimming in shark-infested water, meeting more formidable challenges than any prior generation.

Karla Vermeulen, an associate professor of psychology at the State University of New York at New Paltz, told me that explicitly in our interview. And she says so in her book, where she writes: “No past American generation has faced the cumulative load of multiple simultaneous stressors today’s emerging adults grew up with”33 (emphasis is hers).

Therapists are helping young people, they insist. Young people today simply face more formidable challenges than did their predecessors. Therapists typically point to three: smartphones, COVID-19 lockdowns, and climate change.34

Is It the Smartphone, Dummy?

Tic disorders, gender dysphoria, anorexia, dissociative identity disorder, trichotillomania, cutting: the parade of horribles induced by smartphones could fill a psychiatric manual of its own. If smartphones were a boy who wanted to see your daughter, a generation ago, parents would have taken one look at him and said: No way am I letting that kid in the door. The smartphone and the rise of social media offer a compelling candidate for an environmental cause of poor adolescent mental health.35

Eight years have slipped by since Twenge and Haidt36 (and four years since yours truly37) first warned the public of the dangers of social media and smartphones to teens.38 That ought to have provided our eager mental health experts with an obvious mandate: treat social media like cigarettes. Call to restrict smartphones from middle school and high school campuses. Urge companies to place a black-box warning on social media, if they were really feeling feisty.

They didn’t. None of the psychological organizations—not the American Psychiatric Association, the American Psychological Association, the National Association for School Psychologists, or the American School Counselor Association—issued any such call to arms. In the last decade, as the average age of a child getting a first smartphone dropped to age ten,39 these organizations had little to say about it.

They’ve been preoccupied with their own style and method of intervention. Because any parent can take away a phone, but only a psychologist can diagnose a child or refer for medication. The most important thing they could have done to help improve kids’ mental health was something that didn’t require their expertise.

In truth, the entire society has dropped the ball when it comes to kids and smartphones. Why have parents continued to supply these devices in ever greater numbers to younger and younger kids? Flip phones are useful in emergency; GPS devices and digital cameras are of higher quality and cheaper than ever before. Why do parents continue to gift $1,000 phones to kids knowing full well that they are linked to a rise in depression, anxiety, and self-harm? The most conscientious of parents at best require their kids to dock them in the kitchen and cease their scrolling at bedtime. That’s what counts as restricting a device that has been convincingly linked to shortened attention span, insomnia, severe anxiety, and depression.

When I asked parents why they would hand their children a device that puts kids at risk for a wide array of mental disorders, they invariably give one answer: That’s how they make plans with friends. I don’t want them to be the only one who doesn’t have one. Therapists typically discourage parents ever from taking away a teen’s smartphone, on the grounds that doing so will only sabotage the parent-child relationship.40

And while we’re asking questions, why did public middle and high schools, en masse, abandon all efforts to police their use even during class time?

I spoke to one head of a private high school where students keep their phones with them all day long, even in class (now standard protocol at most high schools). It siphons their attention while they’re trying to learn, I said. It keeps them from getting to know each other. They don’t talk or make friends in the same way as they might if there were no phones present. And then there’s all the ways that social media sabotages their emotional well-being. Why would you allow this?

He nodded amiably until it was his turn to speak. “It keeps them calm,” he said.

Nobody has made any serious effort to block teens’ smartphone use—not parents, not teachers, and definitely not mental health experts—because smartphones have become one more mental health accommodation we disburse to the young. We know it isn’t good for them. We know the long-term consequences run from dark to dire. We know the devices are addictive, sleep-depriving, and pathology-inducing. But for right now, they provide unbeatable palliative care—soothing as any blankie.

If mental health experts wanted to do what was best for adolescents, advising parents against giving young teens smartphones would be a nobrainer. They would say, as a doctor might: There’s no point in bringing your kid here if you’re going to let him keep smoking. They hold themselves out as guardians of youth mental health; they ought to offer the most radical advice when it comes to smartphones and our young.

Instead, mental health experts rush in the opposite direction, embracing smartphone use, dismissing smartphones’ impact on adolescent depression as exaggerated;41 offering seminars to teens and their parents on “responsible social media use,” which is a little like drug counselors lecturing on the appropriate uses of ecstasy. Mental health experts arrive at schools to warn parents and teens of the “risks” of social media, always careful to weigh these against the many wonderful benefits, and then conclude: Have at it!

And for a generation that already struggles with in-person interaction, mental health experts now offer the ultimate morphine drip: therapy, embedded in the smartphone. Some have done away with both voice and video interactions, offering therapy by text message.

If you want to improve a kid’s mental health, locking up her smart-phone might be a start. At a minimum, smartphones take a teen further from the world of in-person friends and activity likely to bolster her sense of well-being. They are undoubtedly responsible for exacerbating a variety of social contagions, from tic disorders to gender dysphoria. But banish the smartphone and fix a generation? I’m not so sure.42

Youth mental health has been in decline, after all, for the last five or six decades.43 And then there’s parents’ powerful reluctance to take away our kids’ smartphones. What accounts for this fecklessness, in the face of the obvious threat they pose? The very fact that we’ve been so long aware of their dangers and done absolutely nothing to curtail their ubiquity in adolescent hands requires its own explanation. That we persist in handing these devices to young teens and tweens is itself a symptom of a larger problem.

Didn’t Enjoy Your Solitary Confinement?

COVID-19 lockdowns sent numberless kids into punishing isolation. If our mental health experts anticipated the predictable mental health catastrophe of forcing kids into social solitude for over a year, they largely kept the insight to themselves. Not a single one of their major national professional organizations even opposed the lockdowns’ continuing into a second consecutive school year in the fall of 2020, when a further deepening of kids’ isolation might have been averted.44

The mental health organizations are not shy about wading into public policy discussion: The American Psychological Association has railed against America’s history of systemic racism. “Our nation is in the midst of a racism pandemic,” said the APA’s CEO in his June 2020 congressional testimony, advocating changes to police tactics.45

In this vein, the APA has touted the mental health benefits of affirmative action,46 and, in a splashy press release, announced its readiness “to help society respond to climate change.”47 But against the pressing and pervasive threat of forced social isolation? Crickets.

How could the experts have missed a mental health calamity so obvious and foreseeable?

Parents protested; they were largely ignored. The mental health–expert complex, with all its institutional heft, declined to offer so much as a public warning to policymakers about the impact on kids.48 Perhaps they didn’t know the lockdowns would be devastating to the young people they were uniquely responsible to help. Whatever the reason for this colossal failure, there’s something perverse in their subsequent attempt to use the pandemic lockdowns to wave away the treatment-prevalence paradox, or—worse—to argue for their greater role in public policy development and the lives of American kids.

In truth, before the novel coronavirus had escaped China’s borders in 2019, nearly a third of Americans between the ages of eighteen and thirty-five said they were experiencing a mental illness.49 Hospital admissions for nonfatal self-harm were up 62 percent over the previous decade,50 with nearly 20 percent of girls ages twelve to seventeen reporting having had a major depressive episode in the previous year. Child suicide rates rose 150 percent over the previous decade.51

“Climate Anxiety”

Karla Vermeulen wears her hair in a cool pixie cut cropped close to the scalp. The lenses of her square plastic glasses are the size and shape of two Post-its. At the base of her neck, a string of beaded earthenware completes the picture of a no-nonsense researcher. Indeed, Vermeulen outranks almost any American as a credentialed expert in adolescent mental health.