Blame the Therapists?

Over the past 30 years, there has been a marked rise in the proportion of children and teens diagnosed with psychiatric disorders. Why? As a family doctor (MD) and PhD psychologist, I have been writing about this topic for more than 20 years, based primarily on my first-hand experience in the office, and secondarily on my visits to more than 500 schools over the past 23 years. In my first book Why Gender Matters (Doubleday, 2005), I called attention to what I called “the medicalization of misbehavior.” The teacher who once might have told a parent “Your son is rude” is now more likely to say “I’m thinking your son may have Oppositional Defiant Disorder, have you thought of having him evaluated?” In my more recent book, The Collapse of Parenting (Basic Books, 2016), I argued that American popular culture has become a culture of disrespect, a culture in which many kids think it’s cute and funny to be defiant and uncooperative. I shared the connections I have observed between a culture of disrespect, the resulting collapse of parental authority, and the growing cohort of kids who are anxious, depressed, and disengaged. These two mechanisms—the medicalization of misbehavior and the culture of disrespect—feed on each other synergistically.

In her latest book Bad Therapy: why the kids aren’t growing up, journalist Abigail Shrier, formerly an opinion columnist for the Wall Street Journal, offers a different explanation for the rise in psychiatric disorders among children and teens. In Shrier’s view, the upsurge in psychiatric diagnosis is due primarily to therapists practicing “bad therapy.” Shrier considers most of modern psychotherapy to be “bad therapy”—hence the title—and “bad therapy encourages hyperfocus on one’s emotional states, which in turn makes symptoms worse” (p. 64). Even if your child doesn’t see a therapist, your child is still subject to bad therapy, in her view.

“Far from confinement to the psychoanalyst’s couch,” Shrier writes, “bad therapy is today practiced on almost every kid—by therapists and just as often by nontherapists. The epicenter of bad therapy in your children’s life is, most likely, their school” (p. 65). 

Shrier then asserts that most teachers are now amateur psychotherapists. The only scholarly paper she cites in support of that remarkable assertion is a study I published more than 20 years ago, reporting a survey I did of physicians in and near Washington DC, in which I asked: “Who first suggests the diagnosis of attention deficit hyperactivity disorder (ADHD)?” The respondents to my survey reported that teachers were the most likely to be the first to suggest the diagnosis. But it’s a big leap to jump from that finding of mine to the claim that teachers are actually acting as therapists in the classroom. In support of that assertion, Shrier reports on a conference for public school teachers in Anaheim, California, which she attended. Teachers at the conference were instructed in “trauma-informed education,” learning to treat every child as a survivor of trauma. Shrier puts great weight on this conference, and on a few anecdotes from the classroom, to buttress her claim that teachers everywhere, not just in California, are now bringing “bad therapy” into the classroom. She writes: 

A recent California bill, likely to pass, allocated $50 million for the hiring of additional squadrons of social workers and mental health professionals in public schools. Meaning, however much in-school therapy kids have already received, they likely will soon be getting much more. (p 73) 

Actually, that bill—California Assembly Bill 912—was vetoed by Governor Gavin Newsom on October 8 2023, almost five months before publication of Shrier’s book. Note her claim that “however much in-school therapy kids have already received, they likely will soon be getting much more.” Her claim should have been “however much in-school therapy California kids have already received, California kids likely will soon be getting much more.” The bulk of the examples Shrier provides of teachers pushing kids to talk about their feelings come from California, where Shrier has lived for the past two decades. I counted 25 mentions of  California in her book. Shrier makes little effort to determine whether these interventions are commonly practiced in most other states. 

In the very first line of her book, Shrier asserts that 

Talk of a ‘youth mental health crisis’ often conflates two distinct groups of young people. One suffers from profound mental illness. . . 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. 

The foundational premise of Shrier’s book is that these two groups are easily distinguished. The “worriers; the fearful; the lonely, lost, and sad” do not, in Shrier’s opinion, benefit from psychotherapy at all. Instead, she asserts that modern psychotherapy makes this “far larger cohort” worse rather than better. Shrier’s preferred intervention is to “shake it off”. She writes that encouraging kids to just walk it off, shake it off does “a helluva job playing triage nurse to kids’ minor heartaches and injuries, proving to kids that the hurt or fear or possibility of failure need not overwhelm them” and provides “its own kind of tough love and emotional nourishment” (p. 168). Snap out of it. Don’t talk about your problems. She continues:

How do you know whether to put your thirteen-year-old in therapy? Simple: don’t take your kid to a shrink unless you’ve exhausted all other options. . . In all but the most serious cases, your child is much better off without them. . . Adolescents who are suffering with anxiety and depression are obviously not being helped by the current and pervasive mental health treatments. 

Reading Shrier’s book, I couldn’t stop thinking about Madison Holleran. As a high school student, Madison was a sports phenom, leading the high school girls’ soccer team to two consecutive state championships. She also won the New Jersey state championship in the girls’ 800-meter. She was smart and successful, a top student as well as a top athlete. She enrolled at the University of Pennsylvania, but in her first semester at Penn she soon came to feel overwhelmed by the challenging coursework and the demands of being on the track team. She told a friend “I never thought it was possible to sink so low, so fast.” She met with her track coach to talk about quitting the team. He offered her generous accommodations: she would no longer have to attend every practice or even most practices; she would no longer have to go to meets; she could cut way back. But don’t quit, he encouraged her. He noted that she was doing well academically, and that she was one of the fastest girls on the team. 

Five days after meeting with the coach, Madison Holleran committed suicide by jumping off the top floor of a parking garage. She had no previous psychiatric history. She had never seen a therapist or been on any psychiatric medication. After her death, her parents gave Madison’s phone, unlocked, and her computer, to reporter Kate Fagan. Fagan then spent months reviewing every text message, every Instagram post, interviewing every friend, every roommate, every teammate, to try to understand: why? Why would this beautiful, popular, bright, talented girl kill herself? 

I would like to ask Shrier: What guidance would you provide to determine whether a girl or boy is at risk of suicide? Bad Therapy provides no guidance in answer to this question. Madison Holleran was doing well in school. She had many friends; in fact, she was popular. There was no evidence that she suffered from any mental illness prior to her suicide. If her parents had read Shrier’s book, they might not have considered therapy for Madison, when in fact a careful reading of Fagan’s book, What Made Maddy Run, shows that Madison would have needed intensive therapy, medication, and possibly inpatient treatment to prevent her suicide. 

Perhaps I should acknowledge that, as a practicing physician, I am reading Shrier’s book with a perspective quite different from hers. She is a former opinion columnist for the Wall Street Journal. A columnist doesn’t have to worry about being sued for malpractice. As a clinician, I operate in a different world. Suppose a parent consults me about a child who is “lonely, lost, and sad.” Let’s suppose I advise mom to encourage the child to walk it off, to tell her child not to think about her problems so much—which is what Shrier would advise. Let’s suppose that Mom follows my advice. One week later the child commits suicide. I would be liable. My action met the four requirements for malpractice: 1) I had a duty of care, as a physician; 2) my advice constituted a dereliction of duty; 3) something bad happened; 4) my dereliction of duty was plausibly the proximate cause of the bad thing that happened. As a journalist, Shrier has no duty of care. She can write anything she darn well pleases. 

The most dangerous assumption of Shrier’s book is that it’s easy to distinguish between kids who truly have serious problems and kids who don’t. This assumption is false. That’s the lesson of Madison Holleran’s suicide. On the contrary: as a family doctor, I can tell you that this distinction is one of the highest-stakes calls I have to make. When a parent asks, “Do you think we need to be concerned? Should we seek professional help?” you’d better be absolutely sure you know what you’re talking about before you tell the parent, as Shrier would seem to have us say in almost all cases, “No, your child is better off without professional help.” 

In my view, Shrier’s book is a well-written editorial, building on her 2018 opinion piece for the Wall Street Journal titled “Shake It Off” and expanded to book length. And yes, her book has been boosted to the top of the bestseller lists, helped along by renowned authorities such as Elon Musk and Joe Rogan and even Jordan Peterson. But as much as I wanted to like this book, I am concerned that Bad Therapy is likely to confuse and mislead parents whose kids really need professional help and who would benefit from receiving it. 

Leonard Sax MD PhD is a practicing family physician and the author of four books for parents, including The Collapse of Parenting, which was a New York Times bestseller. More information is at www.leonardsax.com.