Therapy With a Human Face

Therapy With a Human Face

The feminization of therapy is crucial to understanding how it became both devalued and out of reach.

In the universe of Eliza, a video game and visual novel, the American mental health crisis is total: everyone needs treatment. For a start-up in Seattle, the solution is an AI bot, which inducts its patients into confessional quasi-therapy. Hooked up to a heart rate monitor, the patient is reduced to a data stream. The player controls Evelyn, a human counselor with no mental health training, who reads the computer’s script. At the end of every session, she is awarded a star-based rating. Patients can leave a tip.

The game takes its name from ELIZA, Joseph Weizenbaum’s experiment with Natural Language Processing. In 1966 the computer scientist developed the first proto-therapy chatbot while trying to demonstrate the absurd superficiality of communicating with machines. Weizenbaum named his bot after George Bernard Shaw’s Eliza Doolittle, the ultimate mimic. ELIZA, like Evelyn, was purportedly a woman who learned to listen like a therapist without being one.

Eliza offers a critique of the state of contemporary mental healthcare. As rates of symptomatic anxiety and depression have soared, face-to-face, non-corporate therapy has become more difficult to access. Even those with insurance often find inadequate coverage, and many areas don’t have enough providers. Today, more people might be “in therapy” than ever before, but what that means is vague. A five-minute text exchange with a cognitive-behavioral therapy (CBT) app and multi-session weeks with a psychotherapist are now rendered equivalent under that convening term: therapy. Mental health workers increasingly seek out employment on digital platforms like Talkspace and BetterHelp, which pay their therapists between $20 and $30 an hour. Nearly all digital apps are unregulated and the quality of care has declined alongside the compensation. And millions use an AI-powered chatbot to receive their mental healthcare. Eliza is supposed to depict a dystopia, but it’s closer to a realist portrait.

The game also includes a second, quieter exploration of the status of therapeutic labor. Who can perform it? For what fee? Is it any good? Is it at least better than what one can do alone? At the center of these questions lies a history of the feminization of therapy—the fight to include women in its practice and its subsequent devaluation. In the United States, the standard account of this story begins in the 1980s, when the requirement that an analyst must hold a medical degree was lifted. But there was already a flourishing psychology community in the early twentieth century, a third of whose members were women. For women in the West, therapy did not go from an impossible profession to a possible one; the feminization of the field happened again and again. To find the origins of our present-day crisis, we have to look back beyond Weizenbaum and his 1966 script to the beginnings of professional psychology in both Europe and the United States. This history is crucial if we want to understand how therapy became, paradoxically, both devalued and out of reach.

On June 4, 1938, Sigmund Freud fled Nazi Vienna for the relative safety of London, accompanied by his youngest daughter. Anna Freud was also a famous psychoanalyst, both in her own right and because of her last name. She lacked the medical training that was typical of early psychoanalysts, but it wasn’t only nepotism that allowed her to enter the field. In fin-de-siècle Vienna, psychoanalysis had slowly opened up to accommodate a number of lay (non-medical) analysts, mostly women, especially if they treated children.

While Freud was alive, psychoanalysis was synonymous with his theories, and analysts who departed from his beliefs were marginalized and kicked out of societies. After his death in 1939, the British Psychoanalytical Society was beset by two dilemmas: how to survive during the Second World War and how to practice analysis at all. These challenges generated a schism, with two major camps represented by two prominent women lay analysts, Anna Freud and Melanie Klein. Their dispute, which became known as the Controversial Discussions, centered on Freud’s disagreement with Klein’s attribution of capacities like fantasy and destructive aggression to babies. Each side had its own supporters and detractors; some analysts, like D.W. Winnicott, tried to find a middle ground. In all three branches, maternality replaced paternality as the central focus of analysis.

Despite the contemporary truism that psychoanalysis always blames the mother, Sigmund Freud was much more focused on the pathogenic role of the father in the mind of the child, while showing little interest in real children at all. For Anna, and others like Winnicott, analysis meant attending to the real mother—and real children—and the mental life of reproductive labor. This theoretical process began before the Second World War and was intensified by it while many fathers were away.

A strong association was forged between the practice of “the maternalists,” as historian Shaul Bar-Haim called these analysts, and the work of actual mothering. Holding became a central metaphor for the work of an analyst, and therapy became inextricably linked with domestic life. According to the psychologist and historian Janet Sayers, the maternalists thought this association between the expert care of the analyst and the non-expert labor of mothering might help mothering be taken more seriously. Instead, the entrance of women into the field, and the theoretical and practical shifts in the work of therapy that accompanied it, inadvertently laid the groundwork for the devaluation of the profession. If therapy is like mothering, why pay for it?

Anna Freud ended up in England in part because of strict laws and quotas that made it much more difficult to immigrate to the United States. Additionally, lay analysts like Anna were not recognized at American psychoanalytic institutes, even as Sigmund Freud fought against the “medicalization of psychoanalysis.” His American disciples didn’t listen to him, and psychoanalysis became the purview of psychiatry, which was practiced almost exclusively by men.

In the United States, the first recognizable feminization of the psy-fields took place between 1900 and 1930, when an expansion of social work brought more women into the profession. Its leaders, like Mary Ellen Richmond, provided a “social diagnosis” framework that added a dimension to the emerging category of psychoanalytic diagnoses. The field’s power was greatly expanded during the Progressive Era, culminating in the 1920s as the Bureau of Child Guidance broadened its scope.

During and after the Second World War, psychoanalysts were called upon for expert care in treating soldiers and veterans. A long series of congressional hearings led to funding for an increased number of non-medical therapists to meet a psychological labor shortage—non-medical because it took less time to train them. This brought the category of the clinical psychologist (increasingly women) into prominence. No longer would lay psychologists remain subordinate to psychiatrists; they could now establish private practices of their own.

This boom moment for the clinical psychologist occurred while the culture at large was growing ever more concerned about the effects of the working mother on her child. As the historian of psychology Alexandra Rutherford has detailed, this tension spawned a feminist framework within the field, leading to research, policy, and workplace demands whose aim was to adjust work requirements to allow for the compatibility of motherhood with professional life.

Clinical psychologists were enlisted to mitigate a labor shortage—part of a cost-saving cluster that also included drugs, short-term evidence-based treatment, volunteer counselors, and automated technology. These time-saving devices carried with them an implicit devaluation of therapeutic practice. As the historian of psychiatry Jonathan Metzl has shown, it was in the 1950s, at the height of Freud Mania, that prescription drugs were introduced to complement talk therapy, often in the hands of the medicalized psychoanalyst. These drugs were marketed to and used to treat women, usually white housewives, suffering from “the problem that has no name.” Psychopharmacological drugs increased in diversity and dominance and, with their money-saving potential for insurers and their inherent ability to scale, eclipsed psychoanalysis. Why talk when you can dose?

In the 1960s and ’70s, in the long aftermath of mental healthcare reform, where the asylum model of care was replaced by a fractured, patchwork system of community-based mental health services, the use of alternatives to talk therapy increased. Therapeutics shifted to low-cost, non-intensive behavioral treatments that could be concluded in far less time than traditional psychoanalysis. CBT was set up as a treatment that would liberate a patient from her therapist—so much so that it did not need to be delivered by a human therapist at all. Both Aaron T. Beck (the father of CBT) and Albert Ellis (who founded Rational Emotive Behavior Therapy) instead made the medium of care fungible. CBT was understood to be as effective when delivered by a workbook as by a therapist. Thoughts were reduced to automatic scripts that could be reprogrammed. The unconscious was bracketed, and introspection was denigrated as navel-gazing. Emotional complexities—the provenance of the feminine and the analyst—were increasingly considered more the sign of neurosis than its cure.

This shift put further pressure on therapeutic labor. Short-term, quick fixes became the gold standard; anything else was seen as a waste of time and money. During this period, volunteers and peer care—in Alcoholics Anonymous and consciousness raising groups, on suicide and crisis hotlines run by a wide range of organizations from evangelical churches to the Young Lords—radically undid the status of the expert and the fee. Meanwhile, technological projects that followed from Weizenbaum’s 1966 therapy bot sought to do away with the human altogether. Their hyper-economizing vision imagined the batch processing of patients and the automation of care for all in the form of a friendly, almost-always feminized bot.

As therapeutic practice shifted toward quick treatment covered by insurance, psychoanalysis found a new audience. In the 1970s, Anglo-American second-wave feminists discovered Freud. Feminist psychology became its own subfield, and the American Psychological Association formed ad hoc committees on women in the profession. Psychoanalytic studies of mothering once again thrived. Freud was not a feminist, but psychoanalysis was seen as offering a conceptual-political path toward gender equality. In the famous words of Juliet Mitchell, Freud offered a description of patriarchy, not a prescription for it.

The American psy-fields had their own problems with patriarchy. The refusal of institutional psychoanalysis to grant training to psychologists did not officially ban women or people of color, but the medical profession was so overwhelmingly male and white that it didn’t have to. Far from content with this state of affairs, lay analysts, often social workers or marriage therapists by training, made their own paths—their own institutes, conferences, journals, and activities. But neither academics nor psychologists were welcome in Freudian institutes, and very few were allowed to join the American Psychoanalytic Association (APsaA), which meant they were also not recognized as analysts abroad. Those who were turned away eventually took legal action. In 1985, building on earlier lawsuits and advocacy efforts, four psychologists, two men and two women, filed a class action lawsuit against APsaA. Four years later, it was settled to great fanfare: lay practitioners were finally allowed to train as analysts.

This period of the feminization of psychoanalysis occurred amid a widespread feminization of work in all corporate cultures, which changed the standards for how one was supposed to feel and behave in the workplace. Therapeutic labor has a special dual status in this regard. For decades, it had been configured as a type of reproductive labor while understood to be a completely rational science. It was either warm and fuzzy, lower-skilled work, or a cold, theoretical occupation that required a decade of scientific training. Ultimately, these two views of therapy merged into one figure: the all-around clinician who practiced as a psychoanalyst, clinical psychologist, or social worker. Disciplinary provenance mattered less and less, because all therapy was assumed to be feminized.

The rise of feminist psychology, the opening of psychoanalytic training, and the increasing dominance of women in the field occurred alongside the ongoing devaluation of talk therapy in favor of expediency and low-cost interventions like drugs, self-help, peer-help, CBT, and technology. All were poised to solve a therapeutic labor shortage that began after the Second World War and continues today. Women are one resource among many posited to address the gap.

In Eliza, the player is the counselor, but they have no control over what Evelyn says; they must watch on in uncomfortable passivity. Some of the sessions spiral out, with one patient claiming, “This is making me worse!” When, finally, deep into the game, the player can deviate from the script and ignore the algorithm, things go better for everyone. Evelyn is awarded a five-star rating. She can be far more responsive to the patient when she is allowed to move beyond the diktats of the machine, but she can never escape the platform that hosts her labor.

When Nancy Fraser wrote of feminism that “the recent gains would be entwined with a tragic loss,” she was referring to the outcome of feminist agitation in the age of neoliberalism. A similar situation has occurred in women’s fight to practice the most ambitious forms of therapy. While estimates are a challenge, psychoanalytic patients only make up somewhere between 0.1 and 0.5 percent of those in psychotherapy in any given year. Because insurance companies make it incredibly difficult for providers to accept insurance, these some 9,000 patients are almost all seen for a high, out-of-pocket fee. It is unlikely that today’s psychology graduates, mostly women who are saddled with debt—$80,000 on average—will find work as psychoanalysts (nor do they necessarily want to). After fighting for access to train and treat patients, women have found that practically no one can find them or afford their hourly fee, or knows the difference between short-term treatments and therapies that offer greater depth and insight. This loss means that many therapists must resort to gig work, with little control over their hours, fee, and working conditions.

During its medicalized years, psychoanalysis was the default mode of psychological practice. In the 1940s and ’50s, it was supported by massive governmental aid through the National Institute of Mental Health, and by the mid-1960s the vast majority of trainees identified as psychoanalytically oriented. Once women robustly entered the frame, the practice became specious. Freud and psychoanalysis began to be taught, throughout the empirically oriented disciplines, as an unfortunate period of charlatanism in the history of psychology.

Today, most therapists are trapped, like Evelyn, by the labor demands of platforms. The scene of therapeutic care in the present conforms just as readily to the hallmarks of gig work and call center labor as that of the medical office and consulting room. Devaluation has made it no easier to purchase good mental healthcare. Even as therapy becomes increasingly accepted and popular, it doesn’t receive the public investment required. Instead, potential patients are offered a vague language about wellness and self-help. Automated CBT scripts, CBD, and micro-dosing are all deemed quick-fix equivalents to traditional therapeutic care. The feminization of the field has led to the ultimate devaluation: care without carer.

Despite claims to the contrary, technology alone will not democratize mental healthcare; we cannot rely on teletherapy to fix what is broken, whether delivered by algorithm or human, especially without insurance parity for mental health. Instead, we need to harness every available form of access expansion, not just for therapeutic workers but for patients too. The battle will have to be refought, this time not for gender parity but for a livable wage, clinical autonomy, and a human presence.

Hannah Zeavin teaches in the History Department at UC Berkeley. She is the author of The Distance Cure: A History of Teletherapy (MIT Press, 2021) and at work on her second book, Mother’s Little Helpers: Technology in the American Family (forthcoming from MIT Press).