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I’m Adam Omary, a psychologist and research fellow at Human Progress. Today I’m joined by Jonathan Alpert, the author of Therapy Nation: How America Got Hooked on Therapy and Why It’s Left Us More Anxious and Divided.

I should begin by mentioning that, although the subject we’re talking about today, psychiatric overdiagnosis and the therapization of culture, is a problem in America, particularly in terms of mental health spending and psychiatric medication, we’re seeing similar trends across the developed world. I’ve termed it the psychological paradox of progress.

However, many people, when they see rising rates of depression and anxiety, might say, “Well, historically there was so much stigma around mental illness, and people were underreporting their mental suffering.” So how much of these rising rates of depression and anxiety might be due to greater awareness?

It may simply be that there’s more awareness, more people are open about their mental health issues, and we have better ways of detecting or diagnosing mental illness, and therefore the rates are higher. That’s one possibility. The other possibility is that we actually are sicker.

There certainly is greater awareness and less stigma than there once was around mental health issues. But my profession, I worry, has contributed to some of the pathology that we’re seeing. I argue in that book that therapists have pathologized ordinary life experiences.

The University of Michigan, for example, has decided to eliminate grades for freshmen in certain programs. Instead of using letter grades, those courses will be pass or fail. And the reason they’re doing that is, they say, because of a mental health crisis created by grades. I think that’s a perfect example of an institution that is pathologizing what I would consider a normal college experience. Sometimes we do poorly in classes, and that’s part of growing up and learning. I see this in a lot of areas in our society.

It is useful to think about the context in which we talk about these ordinary struggles. My colleague here at Human Progress, Chelsea Follett, has a book coming out, The Grim Old Days: An Introduction to Pre-Industrial Life. And she talks about how throughout most of human history, the levels of suffering were much greater than anything most people, certainly anyone with the luxury of being able to listen to a podcast like this, would face.

It’s interesting to frame that from an evolutionary psychology perspective. If we have these innate threat detection systems that are configured to our early environment, we’re gonna have a stress response to what is bad, not in objective terms, because this is fundamentally a subjective measure, but relative to our normal day-to-day baseline. And paradoxically, as much as that baseline has gotten dramatically better, ordinary discomforts, such as getting a bad grade, can really induce this sense of anxiety.

Yeah, and we’re not helping young people or even older people by pathologizing experiences such as getting a bad grade or having a conflict with a colleague or a significant other. Spend five minutes on social media, and you’ll likely see terms such as “PTSD” or “trauma” or “borderline” or “toxic” being thrown around. These terms have just become part of our everyday lexicon; people now label their friends or significant others with these very serious clinical terms. I think that’s creating some fragility and some pathology in our society.

When people self-diagnose or identify with their diagnosis, they sometimes say it’s very validating. It helps them understand and describe their struggles. Sometimes they say it helps them find community, especially online. But as you mentioned, it can also contribute to fragility or a sense of victimhood. As a psychotherapist, how can you tell when a diagnosis is going to help someone versus leave them more anxious?

When a diagnosis is accurate, it can be helpful. But all too often I think the diagnoses are being inaccurately applied. Post-traumatic stress disorder is a really good example. There are certain criteria that need to be met in order to be diagnosed with PTSD. One thing that needs to be evident is the threat of death, having experienced the threat of death or at least having perceived the threat of death. That might describe someone who was in a bad accident, or someone who experienced war.

But what we’re seeing lately is people just labeling themselves or therapists labeling their patients as suffering from PTSD if they had a fight with a boss or a bad housemate. That’s not usually perceived as life-threatening. So that term has been loosened. One danger in that is people who identify as having PTSD might actually become weaker. The other danger is that it waters down the diagnosis, meaning people who are deeply suffering may not get the level of attention they need. That’s very concerning to me.

I tell a story in my book about an accident that I had a few years ago. I was biking and got hit by a car. It was an awful experience, but I can walk, I can bike, and I’m okay now. But after the accident, when I would see a big black SUV, the kind of vehicle that hit me, I would get a little tense and anxious. That’s not clinical PTSD. It wasn’t life-threatening. But a lot of therapists would probably be willing to label it as PTSD.

In principle, there’s no upper limit to your mental health, your social functioning, your career functioning. So could everyone benefit from therapy, or is there a limit?

I think therapy should be used properly. If you’re depressed, if you’re anxious, if you’re having trouble in a relationship or managing your stress, those are probably good reasons to seek professional help. But if you’re just going to a therapist to vent and get stuff off your chest and feel better in the moment, you could vent to a friend and save a whole lot of money. So there should be an actual problem that’s being addressed.

You also say that, aside from therapy or the therapeutic culture sometimes backfiring with respect to mental health, it’s also left us more divided. How is that happening?

Yeah. I see a lot of therapists doing more than they were trained to do. When Donald Trump entered the scene as president, therapists were not maintaining neutrality in their practice.

Therapy should be a safe space for people. Whether you voted for Trump or Biden or Harris, you should feel comfortable and safe speaking to a therapist. All too often, and I’ve heard countless stories about this, people are made to feel ashamed of how they voted. I’ve heard cases where therapists refused to treat someone if they voted for Trump. That’s a violation of ethics.

We should not be discriminating against patients. We should look at the person as an individual. But a lot of graduate schools these days are categorizing people as rich, poor, oppressed, or oppressors. And in my profession, therapists love to put people into these boxes instead of looking at the person as an individual.

There’s a sense that greater awareness of mental health is a good thing. It’s a good thing that people can name their problems and seek out support. But that can also backfire. It can backfire at the level of the individual if they seek out these disordered labels in a way that fuels a sense of victimhood. And there are also perverse financial incentives to keep the patient in treatment for longer.

In the United States, in the last 20 years or so, mental health spending has tripled, and rates of depression and anxiety continue to rise. So could the mental health industry be fueling the mental health crisis? And if so, what do we do about that?

Yeah, there’s the paradox.

I think therapists can start to make some adjustments and changes. I think we can start to make sessions more about outcomes, hold ourselves responsible, and maybe do a proper assessment of the patient. We could set goals early on, in collaboration with the patient, and really understand what they hope to accomplish.

Cognitive behavioral therapy works great with things such as anxiety and depression. It’s also a form of therapy that’s widely studied, and we have good data on it. With cognitive behavioral therapy, we may rate how the patient feels, so there’s some quantifiable information that we can use. That kind of outcome-oriented approach could help make therapy less of a lifestyle and more of a tool.

An interesting set of data we’ve seen worldwide is that, on average, in most countries, suicide rates and self-harm rates have remained flat or decreased across much of the world. But the United States is a bit of an outlier; suicide rates, particularly among young people, have increased in the last several decades.

Why do you think that is?

I’m not entirely sure. Social media might be playing a role by normalizing feeling bad. You can also more easily learn ways to take your own life. We’ve seen some tragic cases of people, especially young people, utilizing AI as a therapist and being terribly misguided. I think connecting with people is key; having a sense of community and feeling comfortable enough to speak to a family member or a teacher or a friend about these struggles could help prevent some of these suicides.

A lot of the hypotheses that you’ve named, whether it’s technology, lack of community, or pathologizing ordinary struggle, we also see across other wealthy developed nations. And mental health trends are similar across the US, UK, Canada, and Australia. And yet again, if you look at the mental health data referenced against the suicide data, they’re inversely correlated across much of the developed world except for the US.

Some people will say it’s because we have more guns or more opiates, but that doesn’t account for the increase in youth suicides. Most are not by firearms, and most of the opiate-related deaths are among middle-aged men rather than teenage girls, among whom we’re seeing a lot of this increase in self-harm.

Yeah, I don’t think we can pin it to one factor. We have a society where there’s a lot of unhappiness. People have lots of grievances about wealthy and successful people. I don’t think that’s helping us to be healthier. I’m not saying this causes suicide, but it does create unhappiness. And we’ve seen this play out in terrible ways. Luigi Mangione has become sort of a poster boy of this grievance culture. And he admitted to killing the CEO of UnitedHealthcare because he had his complaints about the health insurance industry. We’ve seen it play out with the assassination attempts on President Trump, the killing of Charlie Kirk. These people had their gripes with society and took matters into their own hands. People dislike corporations, so they justify stealing from stores. So there’s a lot of unhappiness, a lot of blame, and a general lack of accountability and self-sufficiency that might be contributing to the collective unwell of society. And again, I’m not saying that causes someone to be suicidal, but it certainly isn’t making a person healthier and happier.

On that last point, outside of your book, you’ve also written about the psychological appeals of socialism despite its repeated failures. Is there some emotional logic behind a lot of that political and economic discussion today?

Yeah, I think socialism to some people is very seductive. If you think the government will provide housing and buses and grocery stores and make your life better, you might be looking to the wrong people to improve your life.

There’s a concept in psychology known as locus of control. What that means is, “To what degree do you feel like you have control over your fate, your destiny, and to what degree do you feel like others do?” So one would be an internal locus of control; the other would be external. A lot of people who are embracing socialism have an external locus of control. They feel like their fate is determined by other people. And that’s where you start to see the hate towards wealthy people or billionaires. They feel like certain people are interfering with their success. Instead of looking at what they have control over, such as getting an education or starting a business or getting a better job, they’re just relying on the government.

Much of this seems to relate to Maslow’s hierarchy of needs. You have at the base of the pyramid needs for food and shelter. And above you have needs for belonging and community, then for autonomy, fulfillment, self-actualization. And those more material goods, one can, in principle, imagine the government solving for you. But the further up the pyramid you move, the more those needs can only be met by oneself.

I wonder how much of this paradox of prosperity is driven by the fact that we’ve seen this remarkable progress in material abundance. Most people across most of the world don’t have to focus on their day-to-day survival. So as much as you would expect that we’d be celebrating that, we have a tendency to just price in the good things and focus on what remains to be attended to. And as adaptive as that’s been for survival, it can leave us with this sense of, “Okay, what’s next?” And if what’s next is this monumental task of self-actualization, and if you’re expecting that that’s gonna be solved for you, it is not surprising that in the best time in history to be alive, we’re seeing this paradoxical rise of discontent.

Yeah. And so much can be accomplished if you look at notable figures in our country who went from rags to riches. Dolly Parton just passed away. She grew up dirt poor, one of, I believe, 11 or 12 kids in a small house. She went on to become a global superstar who will be known for centuries, hopefully. She’s a great example of someone who probably didn’t spend her time hating the world and coming up with excuses. We need more people like that, whether it’s in industry and science or academia or athletics or music. We need more people in the world who see challenges not as obstacles, but as opportunities to work harder or reinvent themselves.

But there are some people in this world, in this country, who just need someone to hate. They’re consumed by it. And I try to work with some of those people and get them to shift their thinking. Sometimes I’m successful, other times I’m not. But I do think the people who sit in that hate and misery are not doing well.

Closing advice, Jonathan, for expanding one’s internal locus of control, sense of optimism, and mental health?

Really try to focus on what you actually have control over, and be reasonable and realistic in your expectations.

You don’t go from wanting to run a marathon to actually running 26 miles in a day. You start with a mile and add to that incrementally. And that’s true with most things in life.