Cultures of Healing: Correcting the Image of American Health Care.

"The first quality we can ask of mental health professionals, then, is greater truthfulness," says Dr. Robert Fancher, a psychoanalyst, in the final chapter of his book. That being the case, I confess to having previously written a less-than-flattering book about psychoanalysis (Freudian Fraud) and to being a biological psychiatrist. I also confess to having indulged in the book reviewer's universal practice of checking the book's index and references for citations to my own pertinent work. Alas, there were none.

Despite this oversight, Dr. Fancher has produced a well-written and interesting book, as far as it goes. He claims that there is, in our society, a "culture of healing" in which "difficulties and miseries get classed as psychopathology when there is a market that will pay professionals to try to get rid of them." This "makes the United States far and away the most therapized country on earth." The reification of the problems of living into psychopathology, one of the hallmarks of contemporary American culture, thereby creates the industry of counseling and psychotherapy, and it is the mechanics of this industry which occupy most of the author's attention.

Counseling and psychotherapy, argues Dr. Fancher, are most often based on one of four cultures of healing: psychoanalysis, behaviorism, cognitive therapy, and biological psychiatry. He devotes a chapter to each, dissecting their assumptions and practices and demonstrating how each is a belief system rather than a scientific undertaking. Counseling and psychotherapy are effective, Fancher argues, not because of the specific theories or practices of any one of these "cultures of healing," but rather because of general factors which underlie all counseling and psychotherapy.

Fancher's failure to pursue these general factors more aggressively is one shortcoming of his book. He briefly describes the seminal work of Dr. Jerome Frank, whose Persuasion and Healing: A Comparative Study of Psychotherapy is the classic study in this field; but he fails to discuss related studies which have enriched this literature in recent years. Counseling and psychotherapy do work, but they work because of factors such as the personal qualities of the therapist and the expectations of the person undertaking therapy, not because of specific psychoanalytic, behaviorist, or cognitive therapy belief systems.

Fancher also devotes considerable discussion to the perpetual behind-the-scenes turf wars which preoccupy psychiatrists, psychologists, and psychiatric social workers. he states explicitly, "I do not accept the claim that psychiatrists are the only people fit to deal with mental health problems," and criticizes psychiatry for "its unflagging efforts throughout the century to prevent other mental health professions from encroaching on its market and social position." Fancher is here writing from personal experience, for he is a philosopher who became a psychoanalyst. And lay analysts, until recently, were bitterly contested in America by medical psychoanalysts, even though they have been accepted in Europe since the beginning of psychoanalysis and were indeed sanctioned by Freud himself.

The weakest section of Cultures of Healing covers biological psychiatry. As a philosopher, Fancher has no apparent biological background or experience, and his lapses are embarrassing. He denies scientific status to anti-psychotic drugs because they were discovered accidentally, but so were many antibiotics and other useful drugs. He says that "biological psychiatry has, at present, drugs to medicate only four classes of complaint: depression, anxiety, schizophrenia, and manic-depression." Many of us would call this an impressive list, given where we were three decades ago. Strangely, Fancher omits obsessive-compulsive disorder, childhood hyperactivity, and some eating disorders, all areas in which biological psychiatry has enjoyed success. He says that in clinical practice "there exist no biological tools for distinguishing between biological psychopathology and similar problems that do not involve biological abnormality," apparently unaware of neurological or neuropsychological testing, magnetic resonance imaging, or measures of brain metabolism.

Fancher's book would have been stronger if he had omitted the chapter on biological psychiatry altogether. Like many psychoanalysts, he confuses problems of "mental health" with legitimate brain diseases which constitute mental illness. We now know that there is no more relationship between "mental health" and mental illness than there is between the Red Cross and the Red Sea; both share an adjectival prefix but belong in completely different object categories.

The biggest disappointment in Cultures of Healing is Fancher's failure to deal with broader aspects of America's affair with therapists. References to books such as Charles Sykes' A Nation of Victims: The Decay of the American Character or Wendy Kaminer's I'm Dysfunctional, You're Dysfunctional are nowhere to be found. Yet both describe important consequences of the culture Fancher claims his book documents. In this culture, the suzerainty of self sanctions the rationalization of one's own happiness, rather than service to others, as the summum bonum. This leads logically to the Woody Allen syndrome, in which 33 years of psychoanalysis only produce rationalizations for having an affair with one's de facto stepdaughter. The American psychotherapy industry, like Woody Allen himself, often becomes a parody of a Woody Allen movie.

It also would have been illuminating if Fancher had included a discussion of the political aspects of America's "culture of healing." There is no group of professionals in the nation--indeed, probably in the world--which votes as predictably and unanimously as do mental health professionals. For example, in the presidential elections of 1960, only 6 percent of psychoanalysts voted for Richard Nixon, and in 1964 only three percent voted for Barry Goldwater. More recently, one wonders what role Middle America's disgust with "dysfunctional families" and "codependency" played in pushing American politics to the right. Did the "culture of healing" contribute to the depreciation of traditional liberalism? Was John Bradshaw the real force behind the rise of Newt Gingrich?

But all this is what might have been in Cultures of Healing, the traditional meanderings of a book reviewer regarding what he wishes the author had written. It should not detract from the fact that there is much of interest and value in the book, especially the advice on finding a therapist. Fancher stresses the desirability of matching the culture of the therapist and the person seeking therapy, because studies have shown that therapy is more likely to be effective when the two have a shared world-view. Another piece of advice is offered in the appendix and perhaps sums up the whole book: "We have seen in this book that what therapists say is usually optional, and therapists say substantially different things. You should not assume that what a prospective therapist says is necessarily true."