Twenty-one years ago, The Myth of Neurosis, a short polemic by a maverick British doctor, triggered an outburst of furious name-calling by the American psychiatric establishment. Its author, Dr Garth Wood, a London psychiatrist not long out of medical school, had attacked the prevailing orthodoxy of expensive psychoanalysis for the worried wealthy and doling out tranquillisers to the anxious poor.

In his investigation of psychotherapy, Wood tried to “expose a clandestine conspiracy to extend the boundaries of mental illness”. He said we’d been sold the lie that a “person suffering from an excess of life’s problems needs ‘expert’ medical and psychotherapeutic intervention. Such a view is dangerous nonsense”. Wood said psychiatrists should confine themselves to the care of “real” mental illness, such as schizophrenia and manic depression.

A charming, handsome and rich man, perhaps it was no wonder that Wood didn’t take neurosis seriously, describing it as “a bogus psychological condition”. He regarded neurotic symptoms – worrying, tiredness, irritability, sleeping problems, sadness and so on – as “normal but unpleasant mental states which are an inescapable and often valuable part of everyday living”. He had no time for the “huge industry of therapists that created itself to minister to and profit from the plight of these ‘neurotics’”.

He was incredulous that, according to reports, 40m Americans had mental disorders and 10m needed psychiatric help in the mid-1980s. What would he have made of current figures that 
8m British adults are suffering from a neurotic disorder, rising to almost 10m mentally ill if psychotic and other disorders are included? Or the recent proposal by Lord Layard that the government fund 10,000 new psychotherapists to treat them?

The book’s British publication in 1983 was met with a haughty silence from Wood’s profession, although the eccentric writer Auberon Waugh called for a copy to be kept in every house in the land. But in America, where Freudianism had become the defining ideology of the 20th century, Wood was treated as a heretic. He was reviled on late-night chat shows by psychiatrists and professors of psychoanalytic theory, but hero-worshipped by popular 
stars such as Oprah Winfrey, who championed his revolutionary message and offered him a regular spot on her show. Wood declined her offer but relished the intellectual battle with the Freudians.

A leading psychiatrist, Dr Paul J Fink, said: “I don’t agree with anything Dr Wood has to say. His book is the most insipid and overstated I’ve ever read.” A colleague from Philadelphia was even blunter: “Wood really has so little understanding of the mind that I don’t know how he got trained in psychiatry.”

Garth Wood hit back, saying that therapists could be “charlatans who can’t deliver. They prey on the weak and the gullible – people at a low ebb, whose judgment is clouded – with the promise of happiness and no pain”. At best, talking treatments might provide a placebo effect, he said. And in any case most neurotic symptoms get better spontaneously.

Instead of psychoanalysis, Wood advocated taking responsibility for oneself or “moral therapy” from a tough-minded friend or priest. “A psychotherapist is going to tell us it’s not our fault,” he said. “Friends and loved ones say, ‘Look, frankly you have made a mess of your life. You are drinking too much, you’ve had extramarital affairs, you aren’t nice to your children.’ We’re not always good people. Instead of trying to be happy, we should try to be good.”

His passion was to marry moral philosophy with psychiatry. In contrast to the “anything goes” ethic of the later 20th century, Wood thought guilt was a useful compass indicating that your life was going in the wrong direction. He advised following the road that seemed more difficult, to find real satisfaction in life. Taking care of the body by diet and exercise was a better route to mental health than psychotherapy.

Many of his ideas would have resonance today, although few would see guilt as a useful tool. The new disciplines of positive and health psychology suggest that leading a meaningful life and taking good care of your body are stronger foundations of wellbeing than focusing on misery. But to Freud’s many advocates, Wood’s theories were anathema. He’d long been a “mental maverick”, as his wife calls him, and had followed an unusual path into medicine.

Born to a GP and a sugar heiress, Wood attended Harrow and Cambridge, where he studied philosophy, and he worked briefly as a merchant banker, drove fast cars and dated 1960s dolly birds. Life changed when he married the ultimate Chelsea girl – blonde-haired, blue-eyed Pat Booth, who was in turn model, boutique-owner, photographer and bestselling novelist. Booth had lived in the East End of London over a jellied-eel shop until she left school at the age of 14 with only self-confidence and an unshakable Catholic faith to make her way.

The golden couple had a solid 25-year marriage, two children and glamorous homes. Their friends included showbiz aristocracy and the real thing – from Dudley Moore to Princess Margaret. With Pat’s encouragement, Wood trained as a psychiatrist. But after clinical training and research at top teaching hospitals in England and America, Wood grew disillusioned with psychoanalysis and the lack of resources in the NHS to treat genuine mental illness. He took Harley Street consulting rooms to set up a “mini health service” that would treat anyone, rich or poor, suffering from serious disorders such as anorexia nervosa or manic depression. He charged nothing for 75% of these consultations.

Right or wrong, Garth Wood was the first in a succession of iconoclasts who have subjected psychotherapy to intense criticism. They argue that therapy has replaced religion as the “opium of the people”, distracting those in distress from taking more useful steps to resolve unhappiness such as seeking support from friends and family, or making radical changes in their lives.

This growing chorus would rattle but never really shake the psychotherapeutic establishment throughout the 1980s and 1990s. From Against Therapy, by Jeffrey Moussaieff Masson in 1988, to Why Therapy Doesn’t Work and What We Should Do about It, by David Smail in 2001, the most stinging attacks have come from within the psychotherapy stronghold.

Today, Masson lives far from the fray of warring psychotherapists, in New Zealand with his family, three cats, a dog, two rats, a hen, a rooster and a rabbit. There he writes bestselling books such as When Elephants Weep: The Emotional Lives of Animals, or Altruistic Armadillos, Zenlike Zebras. Formerly a professor of Sanskrit, he started to train as a psychoanalyst in 1970. He began having doubts during his analysis training – did he really understand the “emotional problems of living” better than anyone else? Working in his own practice in California did not dispel his worries and he soon turned to research. In 1980 he penetrated the heart of the Freudian empire as project director of the Sigmund Freud Archives. Masson was expected to become director and even move into Freud’s house in Hampstead one day. Instead, his attempts to cast a searching light on the often obscure origins of Freud’s theories angered Freud’s daughter Anna, and he was fired.

Not content with alienating the Freudians, Masson targeted the whole of psychotherapy. In a now-famous book, Against Therapy, he argued that it was a confidence trick that did not and could not work. The power imbalance between therapist and client made it unethical, leading in the worst cases (of which he gave shaming examples) to physical, emotional or sexual abuse of the client. When therapy was not harmful, it was ineffective because rather than really listening to clients, therapists would interpret and twist their words to fit their pet theories.

The response to Against Therapy was often personal and vicious. Masson was described by one therapist as a “helpless and traumatized child” who lives in a “perverse and faecal world in which everything is smeared and besmirched”.

Neurosis was not recognised until the 19th century. Before then, the hallmarks of madness were taken to be delusion and hallucination. But in 1835 a British doctor, James Cowles Prichard, came up with a new phrase 
to describe mental disturbance without psychotic features. The term “moral insanity” caught on, especially among entrepreneurial psychiatrists who ran fashionable sanatoriums for headstrong young ladies in Europe. In elegant prisons like the Bellevue in Switzerland, run by a pupil of Carl Jung, neurotic women were incarcerated by their families, usually against their will, to undergo the new traitement morale (similar to psychotherapy).

The Countess Ilona E, whose family sent her to Bellevue, had been a sore trial to her mother because “she read novels by Zola, had a love affair with her tutor and wishes to earn her living as a piano teacher”. Ilona told a doctor that she was perfectly sane but “one could not help but become neurotic in my family”. The doctor found in Ilona “a pronounced ethical defect” because she showed a lack of love for her mother (who had just had her locked up) and diagnosed a “light case of moral insanity”. Her father wrote to the clinic asking for a medical certificate to deprive his daughter of any future inheritance or independence. Ilona stayed at Bellevue for six years, from 1893 to ’99.

Freud, who sent patients to Bellevue in the 1890s, developed his own treatment for moral insanity over the next 10 years: psychoanalysis. Arguably the first case of psychotherapy ever recorded was Freud’s case history of the industrialist’s daughter Ida Bauer, or “Dora”, published in 1905. Dora was distressed by sexual advances made to her since the age of 14 by her father’s friend, Herr K. Dora knew that her father was having an affair with Frau K and believed she had been “handed over to Herr K as the price of his tolerance of the relations” between her father and his wife.

Although Freud knew Dora was telling the truth about her father and the Ks, he came up with bizarre interpretations of her behaviour. Her lack of sexual excitement at being kissed by Herr K at age 14 was “entirely and completely hysterical behaviour”. He believed she was in love with Herr K and Frau K, and she told 
her parents of his advances out of a “morbid craving for revenge”. Masson says Freud “simply ignored Dora’s needs in the service of his 
own, which was to find more evidence for the correctness of his psychological theories”.
Some modern-day clients feel that instead of curing, therapy has harmed them. Anna Sands was not depressed when she went into therapy to explore difficulties in her marriage. However, long-term psychotherapy led to a breakdown. “The therapy room began to feel like a pressure cooker, and eventually I lost a sense of self,” says Sands. “My analyst saw it as an ‘intense transference’. My husband and children saw it as a frightening change in someone who had until then been relatively stable and easy-going. For me it felt as if I had gone permanently crazy.”
Sands asks how patients are helped to feel “normal” when they are sometimes treated in 
an abnormal or even rude way. She gives this example in her book Falling for Therapy:

Patient: I have just been to the dentist. His drill slipped and he has hurt my tongue. It is difficult to talk.

Therapist: I think you are afraid I will be careless with you; that I may not exercise enough care with you… so that my words could bore holes in you and leave you feeling hurt…

Like Masson, Sands was attacked by some therapists for speaking out. The psychotherapist Linda Martin wrote on her website that she found Sands’s “expression of unquenchable anger against her former therapist quite chilling. There was no humour, insight or self reflection in it that I could discern”. In fact, Sands’s book is 
a calm critique that other therapists, such as Professor Colin Feltham from Sheffield Hallam University, say there is much to learn from.

Most of the criticism discussed so far concerns Freudian psychoanalysis or psychodynamic therapies that derive from it. The head of steam building against the founder of psychotherapy culminated in Why Freud Was Wrong, by Richard Webster, in 1995. Freud created a pseudoscience, says Webster. There is no proof for the existence of Freudian concepts such as the id, ego and super-ego, or of the five psychosexual stages in child development. They are elegant myths, dreamt up by Freud and propagated by loyal disciples.

Freud’s stock is low among scientific psychologists, who argue that his theories depend on constructs such as the “unconscious” that are untestable and unfalsifiable. His methodology is criticised for relying on introspection and evidence from a few case studies, backed up by scanty notes. His sample of small numbers of mainly upper-class Viennese women is clearly unrepresentative of people in general.

Psychoanalysis has had some success in helping people with personality disorders, who are notoriously difficult to treat. Short-term treatment in a day hospital led to considerable improvements in mood and personal relationships in a randomised, controlled trial and over 18 months of follow-up. But 
mostly, psychodynamic therapists have been unwilling to submit to scientific trials. Their claims that psychotherapy outcomes cannot easily be measured have not been heard sympathetically by NHS commissioners. Freud may have sunk in academic and clinical esteem but his ideas still pervade popular culture. We talk about being in denial, or repressing our feelings; accuse other people of being “anally retentive” or “orally fixated”. It’s a truism that our parents and upbringing are to blame for everything that goes wrong. The sociologist Frank Furedi has described Freud’s legacy as the therapy culture, in which everyone is taught to feel vulnerable and at risk. Societal problems are blamed on individual, emotional failings that can be remedied only by therapy.

As Freudian therapy has declined, newly fashionable therapies have replaced it. Chief of these is cognitive behavioural therapy (CBT), recommended for many conditions from social phobia to chronic pain to post-traumatic stress disorder. CBT is a hybrid of “behavioural” techniques that can eliminate phobias or unwanted behaviours, and “cognitive” therapy, which challenges irrational thought processes that may underlie anxiety and depression.

CBT has found a powerful champion in Lord Layard, the economist and new-Labour happiness guru who is urging the government 
to fund 10,000 new psychotherapists offering CBT on the NHS. This would be good news 
if it reduced the bill for £338.5m that we spent on 29.4m antidepressant prescriptions in 
2005 alone. The sorry picture of a Prozac nation drowning in misery is backed up by a 2000 psychiatric survey that found one in six adults has a neurotic disorder. Only one in four of these receives treatment, leading Layard to argue that we need more therapists to get depressed, fearful people off incapacity benefits and back to work.

But close examination of the survey suggests that the number of neurotic cases is an overestimate. First, it is based on interviews by lay people given one day’s training. It is known that clinical interviewers find lower rates. Second, discrepancies have been found between the type of interview used in this survey and others. Finally, people with short-term problems inflate the rates of such surveys.

The highest rates occur among people aged 40 to 54, the generation that shoulders the greatest economic burden and responsibility for caring for children and older people. “Neurotics” are also more likely to be separated or divorced, to be a lone parent, to be “economically inactive” and to be physically ill. There may be arguments about cause and effect, but if life circumstances are so strongly linked to “neurosis”, can therapy really be more than a Band-Aid?

Certainly, CBT avoids the worst flaws of other therapies. It is usually brief, around 6 to 16 sessions, and is relatively inexpensive. Its emphasis on “empowering” clients is more ethical than encouraging dependence on therapists. It gives people a practical boost by encouraging them to set themselves goals and 
to work on behaviour and thoughts that are holding them back. Little time is spent dwelling on the past.

Its advocates say there is definitive proof that it works. According to Lord Layard’s 2006 depression report, “The good news is that we now have evidence-based psychological therapies that can lift at least a half of those affected out of their depression or their chronic fear.” Is this too good to be true?

Tony Roth, joint director of clinical psychology training at University College London, says that Layard’s optimism is backed up by research. “If you look at any good studies of CBT for depression, around 50% of people get better. It’s true that if you follow them up later, around half of those who recovered will have relapsed. But then if you look at studies which offer maintenance treatment, say monthly treatments, there is powerful evidence that therapy reduces the relapse rate.”

He points to studies in 2005 that compared CBT with medication for moderate to severe depression. Response rates after eight weeks were 50% for medication, and 43% for cognitive therapy. When patients stopped having regular CBT (but received three booster sessions over a year) they were no more likely to relapse than patients who were kept on medication. Roth argues that for anxiety disorders, CBT is on even stronger ground. “Depression is a very complicated disorder and people are depressed for different reasons.” However, precise models of specific forms of anxiety can be created and treatments tailored to fit.

For example, Professor David Clark of the Institute of Psychiatry, London, has modified CBT to incorporate detailed insights about the way socially phobic people process the world around them. “His treatment is working marvels,” says Roth. In a 2006 study, 84% of patients no longer met diagnostic criteria for social phobia after cognitive therapy.

But some therapists say research results don’t translate into everyday practice. David Smail, retired head of clinical psychology services in Nottingham and author of many books, is today’s chief scourge of psychotherapy. Why does he dispute the seeming success of CBT?
“CBT is a very simplistic approach and theory. And in practice you find that it doesn’t work the way it’s supposed to,” says Smail. “It’s not that people don’t appear to benefit at first from talking to someone. It’s just that they don’t get better the way they’re supposed to. They come back to the health service later with the same problems. If you stick to the rigid approach, it just doesn’t work at all.” If therapy does any good, it is due to the relationship between a particular therapist and a particular client, according to Smail. In other words, having a good relationship with a sympathetic human may help.

Like Garth Wood and Jeffrey Moussaieff Masson, Smail challenges the modern myth of neurosis. “I don’t think the term makes any sense.” Such heretical thoughts are shared by others in the NHS, but it is hard to put your head above the parapet and publicly question a fundamental aspect of your profession. A number of psychologists have formed the Midlands Psychology Group to share their doubts. Paul Moloney, a counselling psychologist and member of the group, explained its purpose: “We thought there wasn’t much room for doubts about psychological treatments within the profession. It’s a taboo subject.”

Therapy may be a feeble weapon against the many factors that can conspire against distressed people – social problems, a difficult personal history, genetics or all three. “People don’t really change unless something in their lives changes – like getting a new job, or a new partner who is better for them. Those things have a bigger impact than therapy,” says Moloney.

How does he see his role as a therapist? “The most helpful aspect is offering comfort, clarification and encouragement,” says Moloney. “There is a modest role in encouraging people to do something about their environment, if possible. But we shouldn’t be making great claims to change people’s lives.”

The therapy sceptics have been given more ammunition by William Epstein, a professor of social work, who has taken a sledgehammer to the foundations of psychotherapy research. His new book argues: “Psychotherapy has rarely, if ever, gone through a definitive test of its effectiveness. At best its outcomes are indeterminate.” Epstein accuses psychotherapy research of breaking the rules about randomisation, placebo control groups and other technical issues. He concludes that the positive results claimed for psychotherapy could equally be explained by factors such as spontaneous remission of depression or researcher bias.

A less scathing assessment comes from Martin Seligman, the prominent American clinical psychologist. Professor Seligman says that both cognitive treatments and drugs such as Prozac are about 65% effective. That sounds good, but placebo effects range from 45% to 55%, meaning the treatments’ actual effect is 10-20%.

Seligman suggests trying specific techniques for specific problems, such as meditation for everyday anxiety, or cognitive therapy for panic. But don’t raise your hopes too high. “These will not be curative. Many symptoms will recur.” Instead, Seligman says we should learn to manage psychological problems and function well in spite of them. We can emulate those like Lincoln and Churchill who achieved great things in spite of depression. Increasing positive aspects of life such as enjoyment and old-fashioned virtues such as courage can lessen the effects of negative emotion.

If you are not seriously mentally ill but would like to improve your mental health, what can make a difference? It may be forcing yourself to go for a walk or bike ride when depressed, learning to meditate if you have sleep problems or reducing sugary food or alcohol if they’re affecting your moods. Research has shown that using certain self-help guides can be as effective as drugs or therapy (see box on page 31).

Perhaps we could be bolder in pushing for social change to improve mental health. You could stand up to a bully at work, join an environmental group or help a homeless charity. The bonus is that helping others makes people happier. Seeing a therapist might give a short-term boost. Even a 10% improvement in mood may provide the resolve to make positive changes in your life. But it is not the panacea for every ill. Of course, people with serious mental disorders need and must seek professional help. But those with milder problems can learn to heal themselves without becoming therapy addicts.

There was palpable shock when suddenly 
in April 2001, Garth Wood, the man who 
fired the debate, killed himself.

What could have gone wrong in such an enviable life? Why had the physician failed to heal himself? Was his prescription for the righteous life too difficult even for himself? Or had he failed to realise that symptoms of neurosis lie at one end of a spectrum, with serious mental breakdown lurking at the other extreme?

In fact, there had always been shadows in Wood’s life. When he met Pat he emerged from a “black cloud” of depression that hung over his childhood and his twenties. Beneath the playboy trappings was a questioning and tortured intelligence that struggled to understand the human mind and meaning of life.

In the last three years of his life, he began to experience manic episodes as well as deep depression. “He hit this thing with the most sophisticated medication available and yet he couldn’t spiral out of it,” said Pat shortly after his death. “He was such a clever man, he hid what was going on. But I could see the strain on his face. I knew he was struggling, and there was nothing I could do.”

Garth, always envious of his wife’s rock-solid faith, had been trying to brainwash himself into religious belief by using behavioural-therapy techniques. He wrote in a book synopsis that the experiment had worked and that he’d discovered the only route to real happiness. But clearly this desperate measure was not enough.

How to fight depression

Mood changes don’t come out of the blue but are usually triggered by events, memories or dreams. Try to identify what starts your mood changes.

Don’t ignore the warning signs of depression — including loss of interest or pleasure in normal activities, eating or sleeping disturbances, or increased irritability. It is much easier to take action before you are seriously depressed.

Challenge negative thinking. People with depression remember bad events and blame themselves, while they forget good events and credit others for them. Pay attention to your assumptions and beliefs.

Take care of yourself and listen to messages from your body. People with depression often don’t eat or exercise properly. Take moderate exercise, eat healthy and delicious meals and allow yourself pleasure in life.

Learn to be more detached. We all worry about things that aren’t very important or that we can’t change. Learn to walk away.

(From www.undoingdepression.com)

Do-It-Yourself Cognitive Therapy

For those who want to take the self-help path, the first step could be to keep a ‘mood log’ of upsetting events, the negative feelings they gave you, and the automatic thoughts they triggered. Then try to substitute more realistic thoughts. Here are 10 distorted ways of thinking that can be debilitating. Do any sound familiar?

1. All-or-nothing: you see things in stark 
black-and-white terms.

2. Overgeneralisation: you view a negative event as part of a never-ending pattern of defeat.

3. Mental filter: you dwell on negative comments, ignoring positive ones.

4. Discounting positives: you insist your good qualities and accomplishments don’t count.

5. Jumping to conclusions: mind-reading (you assume people are reacting negatively to you); and fortune-telling (you arbitrarily predict that things will turn out badly).

6. Magnification: blowing problems or shortcomings out of proportion.

7. Emotional reasoning: assuming your negative emotions reflect the way things really are.

8. “Should” statements: you criticise yourself or other people with shoulds, oughts and musts.

9. Labelling: instead of saying, “I made a mistake,” you think: “I’m a fool.”

10. Blame: you blame yourself for things you’re not responsible for, or blame others when your behaviour might have contributed to a problem.

Further reading: The Feeling Good Handbook, by David D Burns; Learned Optimism, by Martin Seligman; Cognitive Behavioural Therapy for Dummies, by Rob Willson and Rhena Branch.

Times recommends

• Babyboomers still partying on in their sixties
• Do I have a chance of finding love again?
• Video: How to do party make-up