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Nevertheless, he adds, "the success of psychotherapy alone must be qualified. It works best with people who are not severely ill." These are patients who fall "within a relatively narrow range of the full spectrum of disorders." Unfortunately, psychotherapy, by which he means talk therapy, doesn't work particularly well with alcoholics, drug abusers, and psychotics.
These are three mighty big categories of potential patients, but Engel tells us that other approaches now exist to serve them. It's true that alcohol and drug-abuse specialists employ talk therapy techniques, but more as an adjunct to a comprehensive package of assistance. For alcoholics, the vast surrogate family of Alcoholics Anonymous, while imperfect, seems to be more effective than pure talk therapy. While therapy may be a useful supplement, drug-abuse patients often need residential treatment to separate them from the culture that reinforces and exploits their condition. People with drug problems must often be completely retooled to face life without their addiction. A diet of group-session rebuke and encouragement seems to be a primary instrument in that process. For patients suffering psychotic illnesses, it's now clinical conventional wisdom that talk therapy is insufficient, certainly until extreme symptoms are diminished.
So all told, psychotherapy works best for distressed people who aren't in the full bloom of an addiction and who aren't delusional. That's a lot of people. Still, while therapy can help many individuals, its inherent limitations mustn't be forgotten.
The central question that underlies Engel's book is a basic one: what, after all, is therapy? Observers have wrestled with this question for decades. The original Freudians viewed therapy as an excursion in an alternative reality of the inner psyche. Like submariners looking for the sunken Titanic, they saw themselves exploring the murk of the unconscious. Their mission was to excavate truths that, once faced and addressed, could transform lives and reduce suffering. Cognitive behavioral therapists—roll-up-your-sleeves pragmatists, to whom Engel is partial—abandoned this obsession with mysteries of the mind. They favor tinkering with patterns of thought that lie closer to the surface of everyday awareness. Clearly influenced by the cognitive perspective, Engel believes that therapy is fundamentally an educational enterprise: it operates by "fixing broken bonds" and readjusting "people to normal social intercourse," and works by "educating rather than analyzing."