Money corrupts, and not just money from pharmaceutical companies. Money’s money, and it spends just as nicely no matter who offers it.
It doesn’t just corrupt psychiatry. The persons who happen to study psychiatry, and those who shape the profession of psychiatry, have no special vulnerability to the blandishments of money. Human frailty is human frailty, no matter the profession one chooses to enter.
Talk therapy has been badly corrupted in recent years, too. The money corrupting talk therapy comes from insurance companies.
In pursuit of money, the professions of psychology and social work have largely abandoned their historical efforts to provide an alternative to the medical model of understanding suffering. Indeed, they have insisted upon, fought for, and funded lobbying battles on behalf of the medical model.
Worse, they have changed how they practice, what counts as good care. Not because they discovered they’d been wrong before, but to insure their own profitability.
We must remember that before psychiatry won its battle to cast intense suffering as a matter of mental illness, the question facing our society—and people suffering intense distress—was not how to treat mental illness. The question was how to understand and treat debilitating distress. It’s only because psychiatry has largely won the battle—and history is generally written by the victors—that we think routinely of suffering as a matter of mental illness or health.
Historically, care for people in intense psychological pain began with religious institutions, but physicians found it in their interest to usurp the role of religious workers. Psychologists, social workers, and psychoanalysts, among others, began trying to offer care late in the nineteenth, and early in the twentieth, century. Psychiatrists fought relentlessly to stop them.
Until the 1980s and 1990s, the opponents of the medical model fought fairly well, winning legal protections—licenses—for psychology and social work in all states. (Psychoanalysts in this country, hampered by the hegemony of psychiatrists within American psychoanalysis, never sought separate licensure until it was too late.)
For the most part, non-physicians understood themselves to be offering an alternative to medical treatment. They didn’t make the argument, “We’re doctors, too,” but, “We have a legitimate way of understanding and helping with human suffering, and people should have the option of looking at their problems as we do.” That was a threat to the medical model–and a persuasive one. By 1977, psychologists were licensed in all fifty states. Social workers made similar progress.
These upstart clinicians weren’t the only threat to the medical model: insurance companies didn’t want to pay for psychiatric care. Psychiatrists needed to persuade governments to force insurance companies to see mental “illness” as “just like any other illness.”
As psychiatrists earned partial victories—getting coverage, but with special limitations on mental illness—the newly-licensed psychologists and social workers decided to jump on that bandwagon, too. Once medical insurance began paying for mental health care, psychologists and social workers began seeing themselves as treating mental illness after all. Now that medical insurance would pay, the talk therapists’ trade associations spent lots of money convincing state legislatures to “mandate” that medical insurance had to cover their services, just as they covered psychiatrists.
One thing everyone in mental health agreed on was that mental illness should be insured “just like”—at parity with—demonstrably physical illness. As mental health parity laws gained traction through the 1990s, any idea that talk therapists were not treating mental disorders just vanished from their professional rhetoric.
As mental health parity laws became widespread, insurance companies quite rightly said, “Okay—you want us to pay for care? Fine. Show us that this patient has a medical condition. Give us a diagnosis. And show us that what you’re doing for the patient is medically necessary for that disorder.”
It was simple enough for talk therapists give diagnoses—they just had to embrace DSM. But this was a huge change. Generally, talk therapists had analyzed their patient’s problems according to whatever school of thought commanded their allegiance, not in DSM terms.
But talk therapists also had to show the insurance companies that they were doing something medically appropriate, which was harder. Psychiatrists have clinical trials, funded by pharmaceutical companies and government and private grants, to show that medication is effective. How are talk therapists to compete?
In 1995, the Division 12 (Clinical Psychology) Task Force on Promotion and Dissemination of Psychological Procedures, in an effort to promote treatments delivered by psychologists, published criteria for identifying empirically validated treatments (subsequently relabeled empirically supported treatments) for particular disorders. . . . This Task Force identified 18 treatments whose empirical support they considered to be well established based on criteria that included having been tested in randomized controlled trials (RCTs) with a specific population and implemented using a treatment manual. . . . the goal was to identify treatments with evidence for efficacy comparable to the evidence for the efficacy of medications, and hence to highlight the contribution of psychological treatments . . . (Levant et al., Report of the 2005 Presidential Task Force on Evidence-Based Practice, July 1, 2005).
Notice two things: the purpose is to facilitate competition with psychiatry, and the criteria for “empirical support” required randomized clinical trials using a treatment manual. (A treatment manual specifies how sessions are to be structured, what questions are to be asked, how to respond to various client statements and complaints, and what interventions to make. The clinician, not the patient, is in charge. Uniformity of treatment, not responsiveness to the individual, is the whole point.)
The need to prove that psychology provides appropriate treatment of mental disorders, comparable to medication, changed what counts as good science in talk therapy. (Social work tagged along later, as it generally does.)
In all of science, method is supposed to fit subject matter—and all sorts of methods are used, since life comprises all sorts of subject matters. Now, though, in talk therapy research the methods were being dictated in advance, regardless of subject matter, to serve the purpose of competing with psychiatry.
No form of therapy that was client-directed, or that depended on a patient’s free associations, could possibly meet these criteria. Nothing remotely resembling therapy as it is actually practiced—eclectic, responsive to unforeseen circumstance, oriented toward patients’ problems rather than DSM symptoms—could be studied.
Prior to 1995, thousands of studies had been done, using methods carefully designed and applied to suit the subject matters. Suddenly, by fiat, a huge proportion of them were declared unscientific.
Like biological psychiatrists, psychologists (and social workers) have their own high-minded rhetoric, their own ways of pretending that they are simply doing the right thing, serving the needs of the suffering masses.
But the historical facts are plain: they deserted the task of providing an alternative to the medical model, changed what would count as science, and promoted specific forms of treatment over others to insure they’d get their share of insurance.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.