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.
I can see how this applies to CBT – which in the UK is seen as the panacea to everything, even though clients don’t see it that way. Also the idea of brief therapy, or people having a limited number of sessions, say 6 or 10, often to deal with immense trauma and a horrid life.
Someone I know did an analysis of his clinics clients and found that the same people kept coming back, thus proving those 6 or 10 session contracts did not work.
Could you comment on how the idea that anti-depressants and therapy are seen as more effective than therapy without drugs, or that talk therapy for psychosis is discouraged by most counselling schools or that if it does happen it is widely thought that the drugs help? All of these seem to be prevalent believes but not held up by any research evidence that I know of. These ideas promote, or work along side the medical model but in a way that does not make scientific sense. Is it a brain disease or a psychological problem? If it is a psychological problem then how do drugs make it easier to have productive conversations? No adequate explanations are given and yet these ideas seem prevalent with therapists and counsellors.
The UK is different from the USA, we have an National Health Service that limits the amount of talk therapy people can have but which also is going for more and more, “Evidence Based,” treatments, so CBT gets promoted, though I tend to think the evidence is dodgy and skewed and does not fit my personal experience.
My rudimentary understanding to combine therapy + medication, is ironically not to bolster therapy, but to add support to the efficacy of the medication (?!).
Strangely, medication effects “work better” if combined with therapy. Whereas the effectiveness of therapy is not increased by medication.
To your point, it’s either biological or it’s not. If I have a physiological issue, no amount of talking could fix that…just as therapy won’t fix diabetes!
Sorry, I meant “strangely” as if the meds are needed to correct a physiological issue, then how does talking improve that?!
The answer is that bio-med’s “Talk Therapy” is not genuine Psychotherapy. Talk Therapy as practiced by Bio-med therapist is in fact “anti-therapy” and a method of control – just as psychiatric meds are a method of control.
Some talk therapists try to do what bio-meds do but without the bio-meds -they try to establish a rigid control on the client. This still, with or without meds is anti-therapy.
Reformers must regain the past and use the word psychotherapy for genuine psychotherapy and realize that anything labelled “talk therapy” is in fact a paradigm of failure.
Most effective psychotherapy involves emotional transformation – talk therapy does not – just the denigrating prefix “talk” shows this.
“Talk Therapy is a term invented by Big Pharma in the ’90’s – it indicates therapy run by people who do not understand emotionally transformative processes and are not involved in such.
I think compassionate, attentive care to anyone, including someone in the throes of psychosis, is helpful, out of simple humanity. Now, you probably wouldn’t want to do any rigorously structured, programmatic therapy, and certainly nothing designed to impart “skills.” But you can be present, and attuned emotionally even if the words don’t make a lot of literal sense. How can that not help?
The lore on “meds plus therapy” is surely strong. I suspect the impetus for clinicians to believe it is mostly,”Whew–we can stop fighting and divvy up the pie!” In the U.S., the talk therapy professions are so thoroughly in the thrall of psychiatrists that anything that lets them claim crumbs from the table feels like manna from Heaven. And psychiatrists have so little training in how life works that they have little or nothing to say to patients, so they’re happy enough to let the talk therapists have them. The “meds plus talk” canard gives everyone a fig leaf.
But you’re certainly correct that the ideological explanations make no sense: a broken brain, one suffering a chemical or other malfunction, isn’t likely to think productively, hence isn’t likely to be all that available for talk therapy. It’s a bit like prescribing a good jog for a sprained ankle, isn’t it?
Empirically, though, it does seem to be the case that by some measures–though the measures are debatable–some people do better with the combination. That would suggest that the ideology is wrong. As with most things, we don’t know why it woud work. Generally, I think, meds provide one or another sort of sedation or stimulation, and it’s surely conceivable that for some people, under some conditions, being calmed a bit or goosed up a bit could be of use. I do know that with some patients for whom antidepressants seemed to provide a “floor” so they didn’t fear going into their worst lows, they seemed to have more courage to look at issues that they’d seemed to shy away from. That’s just my anecdotal observation, though.
I only have anecdotal and speculative thoughts on how people who can’t get enough talk therapy cope. Some, I am sure, seek other care under the guise of physical maladies–just having someone taking care of them offers some comfort. I suspect a lot of “fringe” or “alternative” healers make their living off troubled souls whose mental health benefits didn’t do the trick. Drgus and alcohol provide something resembling solace for some souls, of course. Religious ardor can genuinely help some folks–I am sure that many strict religions provide for their adherents a way of organizing and understanding their troubled inner lives, and rituals for finding something like relief, over and over.
Thanks for your thoughtful comments.
Yes, I’d agree, compassionate caring attention is what helps the most with people who are severely distressed, although CBT and psychosis is being developed in the UK and I know someone who found it extremely useful.
I like to quote Bertram Karom’s experiments: He had three groups of people, all of whom had been recently diagnosed with schizophrenia (I know this diagnosis is contentious and is not one I like to use myself, and I’m generally in favour of diagnosis free treatments). Group one had conventional psychiatric care, group two had drugs and therapy and group three had drug free therapy.
His best results were for drug free therapy, the worst from conventional psychiatry. He worked with psycho-analytic therapy, but he said any therapy would do providing the therapist is good at their job and has adequate supervision.
While I could not say this indicated that drug free treatment was always best it certainly gives an indication that this approach should be promoted and studied more.
Karom’s conclusion was that the drugs were for the therapist or where the client lived, ie if the persons behaviour was too distressing for the therapist or the home then drugs might help improve those relationships so that the client could then be helped, though I wonder if he thought the drugs were more for the therapists benefit rather than the client? He generally treated people without drugs as he wanted to of most help to people and this approach is what his research indicated would help the most.
I tell my local service provider about his work but they do not listen.
Hey ho
I believe there is just one study, out of psychiatry, that found meds plus therapy to be superior to either alone. (Perhaps someone has the citation to hand.)
Otherwise, in the medical literature, the strategy of adding meds to therapy is a “just in case they work” argument, completely leaving aside the possibility of adverse effects.
In other words, the meds are considered a safety net.
I remember when I was a young counselor (younger than I am now Batesy!) the agency I was with was just making the switch to embracing Medicaid as its primary revenue source rather than self-pay and insurance. Our staff of 12 clinicians included six Ph.D.’s Within a year and a half they had all left the agency. Some had left the field entirely. Their reasoning was similar to Fancher’s points. They didn’t want to “sell out” to this new DSM, illness like any other, cook-book approach to helping people. They didn’t believe the medical model and didn’t want to be at an agency that promoted it.
Which begs the question, for all those social workers and counselors who didn’t leave, are you(we) part of the problem too? Until I got my head straight, I believe I was. My experiences convinced me that system change was necessary. I had to be in a position where I could do something about the medical model, DSM, Insulin-for-Diabetes juggernaut. Fancher’s history lesson is a good one, unwinding this mess is going to be tough. I’m grateful for Bob, this website and everyone’s efforts to bring reform.
Thanks, David. “Unwinding this mess is going to be tough”–truer words were never spoken.
Thanks for this great piece of history and analysis. You touch on the fact that psychiatry has usurped the traditional role of the church in these matters. Today the clergy, having firmly embraced the medical model of the so-called illness, fails to see the irony behind how religious leaders are chosen (they hear a voice and are called by God) and the guys lining up at the church’s many soup kitchens, a.k.a. the “mentally ill.” My own clergyman casts my son’s condition as a “mental illness.” I now find this attitude more funny than just sad. The best way I found to get proper help is to trust my own instincts and to cherry pick the kind of support that I feel would be beneficial – and this means mentally distancing myself from psychiatry, psychologists, social workers and the church, only tapping into them when I feel they have a particular product to offer that might prove useful.
Thanks for this story on how talk therapy regressed from “life counseling” to medical therapy for alleged “biological illness”.
But as to the causal factors, including money/insurance, I was more convinced by one of your first blog (“Setup for the Con”) as to why psychiatry became the “guardian” of talk therapy: what was there before was not always better on average. If the choice was between numbing pills or a high risk of creating false recovered memories, I see some collective intelligence into selecting pills as the least destructive path. Although the even smarter choice would be to reject both as pseudo-science.
Putting aside the topic of whether mental issues are part of ‘health’, I bet health insurance companies, even as of today, would offer good money do to talk-therapy to their troubled customers with a non-DSM/non-medical system, and to have that non-DSM/non-medical system compete with current psychiatry to prevent costly (for everybody) and traumatic (for the patient) hospitalizations. Of course insurance will require some minimal but reliable evidence that this alternative-system can compete reasonably with psychiatric outcomes about caring for people, preventing hospitalizations/invalidity-periods/social-issues or enabling recovery after them.
An individual alone cannot be considered as a competitor to the psychiatric system. I am sure there are some psychiatrists that rely mostly on patient-based talk therapy, have read your book, and consider your book one of the major influence on how they define their practice. That’s probably good for their patients, but that won’t improve the system globally.
There are many burgeoning organizations that are currently aspiring to compete, reform, criticize or overthrow psychiatry, maybe the biggest problem with psychiatry so far was that none of the similar past organizations reached enough maturity and growth to keep psychiatry honest (and exploring the limitations *internal* to those organizations might be the best path to enable a breakthrough).
I am glad and relieved to read a reply that hints at the real issue, in my opinion. I think the real problem is the DSM. If this manual had not been written, psychiatry would not be able to bill insurance, etc but more importantly, emotional distress would be far less medicalized, and diagnosis would be much harder (rightfully so) to apply. With a non-DSM approach to emotional distress (aka mental health) nearly all of the harm caused by psychiatry will be reduced dramatically. Everything starts with the DSM, and removing this piece of garbage would level the playing field once and for all.
In the U.S., insurance reimbursement is required by law to be linked to a diagnosis–this was part of the “deal” for insurance parity during the Clinton administration.
I agree with you, and despair, about the impossibility of individuals changing the direction of the tide. Actually, I’m less sanguine than you, in that I don’t think the various new organizations are likely to accomplish a great deal beyond shoring up their respective members. There’s just too much money, and too much prestige,behind the status quo–the American Psychological Association,no less than the psychiatry and pharmaceutical interests. I’m pretty sure none of the new organizations have the money or clout to overturn existing law.
So I think the only hope available to individuals in need of help is to find individual providers of care who, for their own reasons, have opted out of the status quo.
“So I think the only hope available to individuals in need of help is to find individual providers of care who, for their own reasons, have opted out of the status quo.”
Absolutely. Doesn’t Thomas Szasz refer to these as contractual (as opposed to institutional) arrangements?
I don’t know that particular quote, but it sounds right.
The Open Dialogue team at Keropudas Hospital in Tornio, Finland, a team of psychiatrists, psychologists, nurses and other clinicians, seems to be offering an alternative medical model of response to “acute psychiatric crises” . But they have shifted “away from an immediate emphasis on trying to eradicate symptoms. The conversation, or dialogue, is not “about” the person, but a way of “being with” them and living through the crisis together” , mitigating
“the sense of isolation and distance a frightening episode can produce”, leading “to a path of recovery”(http://www.dialogicpractice.net/open-dialogue%E2%84%A0/). Apparently, there are other hospitals in Finland who take their orders from big pharma, read the Finnish translation of the DSM, take the drug money, push the drugs and predictably their clients’ outcomes are as terrible as ours are in Canada and the US. The evidence and research is there to read. Hospitals, with their teams of psychiatrists, psychologists, nurses, social workers and other clinicians can choose. Seems to me there are effective alternatives for us to shift over to. Now.
Open Dialogue is not a medical model. It’s a psycho-social model. With emphasis on “social”.
In social work school, I was pretty dismayed about how some of social work’s more radical history and practices were being overshadowed by the rush to biopsychosocial models of clinical care. I always found the mental health field’s adoption of the term biopsychosocial was just a farse obfuscating the biomedical model actually in play. Psychologists and social workers got to get paid for “psychosocial” interventions by adopting the use of Psychiatry’s DSM and psychiatrists got to keep their top spot in the mental health hiearcharchy by being competent in bio and psychosocial interventions. Also the fact that no mental health practitioners in any of the fields actually put much of a focus in the social (political, economic, cultural, hierarchical, historical etc.) as a means to alleviate people’s suffering and support their autonomy.
Talk therapy already sold out when it tried to isolate suffering as an individual problem rectified by entering a hierarchical and coercive relationship that reifies the same dynamics of oppression in the real world.
rectified should be reified.
Yikes I am out of it. Last sentence should remain as is.
I agree with you completely that locating “the problem” “inside” the individual is a travesty. One of the many reasons I despise CBT is precisely that: The fundamental message of CBT is, “Everything is fine, if you’d just learn to think straight.”
I found CBT very unappealing. It was too dogmatic for my taste. You are forbidden to have certain thoughts or describe them using certain words; the therapist is the judge.
It reminded me of Neuro-linguistic programming (NLP). It was irritating.
Of course, my therapist was a jerk. In the right hands and for the right situations, I think CBT could be quite effective for certain people.
I have no doubt that “CBT could be effective for certain people.” But I think “effective” is an inadequate criterion. For instance, the most effective way to cure warts around the fingernail would be amputation of the finger at the first joint–but no on recommends it. I believe CBT has a variety of effects that we should not countenance, whether or not it reduces people’s distress.
Your point goes for other psychotherapuetic interventions as well, having effects beyond reducing (or not reducing) distress.
I don’t really believe in fundamental messages but if CBT had one, I think it would be “let’s do what we can to be mindful of how we are interpreting our experiences and reduce enough distress so that you are in position to make more informed decisions about how to proceed.”
I think analytically-inspired therapies are far more individuating of problems. Even without examining theoretical underpinnings of treatment interventions (which often ignore more systemic influences on people’s experiences), the emphasis of long-term, open-ended, pay by the hour therapy pushes people (and the rest of society as these therapies have been and still are the dominate talk therapies) to look introspectively for pathology and believe insight will be healing as opposed to questioning and challenging the the systemic forces that manufacture that distress. Talk therapies, particular analaytically-inspired ones, funnel the time, money, energy, and will away from that effort.
“biopsychosocial” is as you say, nothing but a lie to cover for the biobiobio model.
Who can take a biopsychosocial true believer seriously? let’s say for a moment I’m willing to take such a person seriously. That it’s a ‘three pronged’ approach. The first one being ‘bio’.
Ask these people what they believe is the ‘bio’…. and you get nothing but the standard biopsychiatric articles of blind faith.
Run.
There seems to be some confusion among the correspondents in this thread as to what I was arguing in my original post.
Historically “the medical model” does not mean biological psychology, but that the distress that brings patients in for help is the result or manifestation of a deficit, disorder, or malfunction. Historically, the medical model treated psychopathology as “functional illness,” as distinct from organic illness. The role of biolgy in psychopathology has always been up for debate.
By “medical model,” I mean only what the term has meant historically: that the patient’s/client’s distress is the result of a defect, a deviation from correct function.
Haha, people often stare at me in total disbelief when I tell them that I think Freud paved the way for biological psychiatry.
Bob, in light of Marian’s comment I go back to another I made about one of your previous blogs. Help me understand this. I was always taught that Freud was critical in ushering in biological psychiatry because his contemporaries refused to see “mental illness” as organic illness and so in their minds it was not-illness, often called malingering. Didn’t Freud create functional illness as a way to say things like hysteria are in fact illnesses too?
Thanks,
D
David–
I don’t know what Marian’s reasoning would be.
I don’t know how one can see Freud as an originator of biological psychiatry, though I’d be open to seeing that argument. He justified his account of the unconscious in terms of the legitimacy of giving a “purely psychological” account, against those who would see people’s difficulties as organic. And as I said before, he argued against the idea that psychoanalysts needed to be physicians–many of his inner circle, like Otto Rank and Anna Freud, were not, and he was livid with the American Psychoanaltyic Association for refusing to train non-physicians or accredit non-MD-admitting institutes.
Historically, in this country the biological psychiatrists have been opponents of the psychoanalysts and vice-versa–in the thread in which you made your original comment, I was talking about how all forms of depression got conflated into Depression; that development in the DSM was vehemently opposed by the psychoanalysts within the American Psychiatric Association, and a major loss for them.
Your teacher may have been making a different point: that many people who would simply have been seen as malingerers before Freud can be understood as suffering unconscious conflicts beyond their control, hence in need of professional care.
Freud and his followers certainly vastly expanded the field of psychopathology–e.g., “The Psychopathology of Everyday Life”–though he neither thought psychopathology to be necessarily organic nor of medical provenance. It’s certainly true that psychoanalysis was crucial in the development of psychiatry–psychiatrists used it to become economically viable and culturally influential, for one thing, since it offered ways of understanding the distress of people who were fully functional, capable of paying for therapy, not in need of custodial care.
But it true neither that Freud originated the concept of mental illness, nor that he supported biological psychiatry in anything resembling the form we know it. ‘Hope that helps.
It does and I appreciate you taking the time with me on this. Have a great weekend!
Well, my reasoning is that Freud located the problem inside the individual (at least after he abandoned his seduction theory). Just like biological psychiatry. And most of psychology.
My understanding is that Freud said there is neurosis (which are the result of inner conflicts and thus accessible to his method) and psychosis (which involved some sort of disordered relationship with the world, and he did not consider accessible to his method but rather hoped someday medicine would find a way to understand) and something in-between (which he referred to as “borderline”). I believe there was actually a split between the American psychoanalysts and Freud which was provoked (at least in part) by the Americans’ desire to gain the credibility that medical “science” could give them.
I’m pretty sure that’s mistaken on all counts. If memory serves, in Freud’s account, in psychosis the ego has been defeated by the id, and primary process thinking has overpowered secondary process. So far as I know, Freud never thought that his theory of mind failed to encompass psychosis–and while he certainly didn’t try to put psychotics on the couch, I don’t think he was hostile to the widespread use of psychoanalytic principles in asylums. Your rationale for the American psychiatrist’s refusal to allow non-MDs to train in ther institutes does not match anything I’ve ever read on the controversy.
I agree about the comparison to drugs being a cop out that avoids the real philosophical questions that need to be addressed. Specifically, let’s say for the sake of argument that drugs and talk therapy both do about the same in reduction of symptoms. Does that make them equally valuable treatments? Absolutely not. For starters, the “side effects,” especially physiologically, of talk therapy are likely to be very small or non-existent, at least if it’s done well. Drugs automatically increase risk of harm, and if there’s no benefit, it’s obvious that the less risky treatment is the treatment of choice.
But more fundamental is this: does the “symptom reduction” actually lead to improved long-term outcomes? It’s really clear from Bob Whitaker’s work that the long-term outcomes for psych drug treatment are awful. What if therapists focused on comparing long-term outcomes instead of short-term symptom reduction? I have to believe that talk therapy would come out way ahead, if only because the worst that happens is generally that the person doesn’t improve, whereas the trend with drugs seems to be that the longer you use them, the less likely you are to recover full functioning in your life.
By accepting psychiatry’s “terms of engagement”, or the insurance companies’, talk therapy has already lost before it even leaves the starting line.
A shift away from eradicating immediate symptoms by just being with a person as they find their own way seems like there may be room for some talk.
“By accepting psychiatry’s “terms of engagement”, or the insurance companies’, talk therapy has already lost before it even leaves the starting line.”
But that’s exactly what has happened–which is my point.
If the Affordable Care Act stands, and receives funding, this will get worse: everyone will have access to insurance-funded mental health care, which will give the insurance companies a powerful incentive to enforce “evidence based” standards for talk therapy (and to promote medication treatment because it’s cheaper), which will make the financial survival of therapists who aren’t willing to comply next to impossible.
Bob, I agree with you 100% and appreciate the article. I’ve been saying the same for 25 years. Thanks for putting it out there in the public eye!
—- Steve
I hope the psychology professional organizations are using their resources to get a seat at the table discussing ACA standards for mental health care.
The DSM committee on anxiety disorders is populated not just by psychiatrists with conflict of interests, but by intellectually challenged psychologists like Lee Anna Clark. I think immense damage is being done to the evidence supported treatment movement by bracket creep of the anxiety disorders into lower and lower levels of severity. Among the problems is that clinical trials to establish evidence base status include disproportionately paid patients with little in common with seriously impaired persons seeking therapy. The risk is that treatment parameters validated with these mildly distressed persons will be insufficient for persons who suffer from serious disorder.
In the old days I used to lament analog studies treating ersatz disorders like spider phobias being used to validate treatments. Now I see patients with ersatz disorders being included in clinical trials of “evidence-based treatments”. No wonder that the effect sizes for evidence-based treatment are so modest and that is so difficult to demonstrate that one credible structured psychological treatment has a clinically significant advantage over another.
Greetings Dr Fancher. I really enjoyed your book “Cultures of Healing.”
I like to make a few comments that are not directly related to this particular blog entry but since I came across this blog entry by accident today and see that you are replying to some entries, I might as well use this opportunity and make these comments with the hope that you get to see them.
Years ago I graduated from college with a degree in psychology. I was originally studying biology but because of my mother’s mental illness, and generally a family environment that was hostile to emotions and could not understand nor contain them, I was slowly drawn to psychology, in the hopes of gaining some power and understanding over these matters especially because I was a particularly emotionally sensitive kid.
I obtained a degree in psychology but years later when I did apply to and get accepted to a great and very scientific clinical PhD program, I found myself very much torn as I started to have more and more questions. I was unable to fully commit to the program because for starters I was less interested in the actual conducting of research, and more drawn to the readings and discussions in my principal clinical class–which covered philosophy and history of clinical psychology.
I felt I was being vaccinated against certain powerful worldviews seeing how we were fed certain superficial philosophical views that formed the foundation of the program’s psychological school of thought. I suddenly had all these questions and nobody was interested in going deeper. Covering the philosophical stuff was merely a formality apparently. Not only that, religion and religious beliefs were “explained away” using psychological concepts and I thought to myself this is not right. I was never a devout religious person but always had a spiritual side to me and felt that it is presumptuous to psychologize religion that way, given that psychology was not some hard scientific and somehow more valid point of view, and that if it were, I was not given a chance to go down the basement and look at its foundation. In short, I felt I was being taught a lot of dogma.
I was similarly disturbed by the field’s problems in defining “mental illness” and also the weaknesses of “harmful dysfunction” concept. The idea was that we should essentially ignore the concept of mental illness and simply treat whoever comes to us. That was philosophically weak! That’s why drug companies can advertise for drugs and create that need in people. So apparently if I, based on ads or a society hostile to my personality makeup, feel like I need help, then I will go to a therapist and get help. Great, the therapist makes money, I get help, everybody’s happy and we did not have to boher with all the messy stuff like if I actually needed help in the first place and for what kind of problem and why not go to a friend or philosopher and not a therapist. :p Doesn’t sound very scientific to me.
There were other problems too, like all this emphasis on what’s “functional” or not. It gives society and status quo too much power. So if I live in a fast paced society and within a culture that values assertiveness or independence, my shyness or closeness to my family can be seen as pathological and dysfunctional, and I would be encouraged that it’s “healthy” to be independent or more assertive (and bullshit my way through a job interview). Suppose if I lived in a different place/time, it would be “healthy” for me to eat another human being because hey, there is nothing more heartwrenching than a depressed cannibal. 😉
In short, becoming a psychologist felt like the wrong thing for me. Fell way short of my ideals. Not only I realized I could not help many people (not everything can be changed, people have to want to and even then…) but more importantly, I realized that this supposedly sure scientific endeavor was not what it claimed to be. So I quit school.
I came back home, went into a deep depression for several years. I have always had two aims in life: understand the world and people, and help people. As a younger person I was more religious and hoped religion would help me do both. It fell short, especially when it came to understanding the world and people. It seemed that science and psychology were quite better than religion in some ways but also quite worse in other ways. Trying to help people to make the most of whatever they got or become happier did not seem sufficient at all. Nor was giving people the full authority of being the writers and narrators of their own lives. A certain kind of authority seemed needed, one that was not created by people themselves. It had to come from outside.
Because it is a fact that science and in particular psychology keeps coming face to face with all this messy stuff called “values.” Psychology keeps coming up against philosophical and spiritual concerns. We can’t do a double blind study to help us define values. We can’t do a double blind study to help us decide if existentialism is better than humanism. It is comforting and wonderful to be told by a therapist that “You are valued.” But it is a fact that neither the physical world nor people around the person convey that message to the patient all the time or even that often. It’s nice to read that Yalom values a certain patient but so what? Unless the patient is going to depend on Yalom for the rest of his/her life, s/he needs to believe in that idea and not because it’s functional or it makes them feel good.
Psychology divorced from religion and philosophy is weak. Last couple of decades there has been an emphasis on mindfulness. Buddhism is safe, political neutral enough, it was smuggled in carefully. Now it’s in thousands of articles. Mindfulness is good for this and good for that. But what some people don’t realize is that all those other aspects of religion are what make a religion a powerful system of thought. It is like trying to take the theory out of physics, to try to focus only on what you can see with the naked eye, so no atoms, no gravity, no quantum physics. Spirituality opens one’s eyes into another world the way theoretical physics opens one’s eyes into worlds beyond our senses. To say that mindfulness is therapeutic or “good” because some studies showed that it makes people less anxious is not the same as finding a magnetic field useful in that it moves certain electrons across. We are not television sets with limited use and made for a known and limited purpose. Frankly, the arrogance of the therapeutic thinking and certain practitioners who see journal articles or DSM as Bible, is disturbing. Similarly, it is not religion itself but the dogma and narrow-mindedness of the fundamentalist religious folks that is disturbing. It was the disproportionate power of the church that was and still is in certain circles, the cause for concern. But these days everywhere I look some therapist is psychologizing a certain matter as if there is no other way to look at something.
Anyhow, so one day at the library I came across your book “Cultures of Healing” which I read with great excitement and energy. Before reading your book, I had considering going to grad school and studying philosophy but I realized I needed to take two years of philosophy courses (senior level) in undergrads and even then unless I get a PhD in philosophy and perhaps become a professor, I can barely make a living with a masters in philosophy. Not to mention that philosophy students are amongst the brightest and that getting into a grad program is as hard as a clinical psych program.
But I digress. But when I read your book, I did note that in the introduction you mentioned how philosophy did not have much real life application which is partly why you decided to become a therapist. You were also disenchanted with your public policy career. That was saddening. I felt that no matter what area of study I choose, I will be sourly disappointed, be it choosing to help others by reaching a deeper level of understanding of the world through philosophy and communicating that to others, or as a therapist and by focusing on helping people gain understanding/control over their emotional life and become more “functional”, or at higher levels as a sociologist or public policy expert.
When you learn philosophy or general science or psychology, when you are able to see the many ways something falls short of your expectations, and when you have no tools to help others in a way that feels meaningful and genuine, that’s recipe for helplessness and depression.
Oops, the last paragraph did not get through. Sorry, this is become awfully long and I’m all over the place but it’s like finding an old friend, you just let loose.
I wanted to say that I’m shocked that your book has not gained more fame. It should be taught everywhere. After I read your book, I started looking for other similar books written by yourself or others, but did not find any. I was very happy when recently I found an interview of yours on MentalHelp.net. I particularly found insightful your comment on different research methods used by different “cultures” and you referred to process studies of the 80s. I wish we were doing those kinds of studies these days. I wish you could write another book and go into much more details. Anyhow, sorry for this very long post but again, really enjoyed your book and I hope some of what I have said makes sense.
Wow–thank you. Every step in your path makes sense, to me. I hope you’ve found a satisfying way to be of use. I appreciate the kind words.
Trying to build an empire, perhaps? Total control?
Financial empowerment very often cannot be beat. Once the “industry” has raked in enough empowerment, shifts will begin to take place that will continue to ensure the beast’s survival. I wonder if it’s true – 300 BILLION dollars per year? Really? Alright.
I fully believe that “psychiatry” / “mental health” is a branch of government.
Thank you Dr Fancher. I have not unfortunately found a satisfying way to be of use in the world out there, as you say, and it’s been a long journey but hopefully I’m close enough to the answer. It’s about coming to terms with reality, imo, and it’s painful and confusing and exasperating and also elating. The very fact that I was able to communicate–in my stream-of-consciousness style–some of these ideas here on this blog feels strangely cathartic.
Often times the psychologists and psych students I’ve met have shown no interest in philosophical discussions. I know that in the world out there, there are practical concerns. There are the practical matters such as making enough money to survive and also the fact that we have limited time on Earth and try to make the most of it given our limited resources. Every path taken is another path not taken. We can’t do it all.
My thirst for knowledge and need for having a meaningful purpose and staying true to my romantic notions and ideals need to be balanced against these other concerns. but I try to reach out and hopefully through looking inward and communicating with others such as yourself I will get closer to answers. Thanks again for responding to me. We need more people like yourself who are intelligent and educated and open minded and willing to question fundamentals, lead and not just follow.
Sara, thank you very much, you’re too kind. I certainly recommend “Cultures of Healing” to you or whoever is interested in examining different schools of psychology and examine some of their fundamental differences from a more philosophical point of view that is still very accessible to non-philosophy students. And I agree with Dr. Fancher that therapy DOES work. It’s amazing that it does despite all these differences. Which is why for many decades there has been all kinds of debates about what it is that makes it work. As far as that, I also recommend Frank’s “Persuasion and Healing” and “The Heart & Soul of Change” by Duncan.
Ron–
I re-read your original post, as well as this new one, this morning. Your thinking is very sound, and your story quite moving.
As you know, I originally decided to study how minds work via philosophy rather than psychology because I did not intend to become a clinician, and psychology’s institutionalized refusal to criticize–even be aware of–its own assumptions put me off. Years later, when I decided to become a clinician after all, I went back to school for that training. In subsequent decades, the intellectual weakness of clinical psychology has become far worse. That fact is utterly shocking to me, since the same period of time has been one of stunning advance in other fields of psychology, and especially in interdisciplinary efforts to understand minds. I really think studying clinical psychology is second only to studying psychiatry as a sure way to become stupid about life.
When people ask my advice about becoming a therapist, after trying to dissuade them–since the field is changing so drastically–I advise that they study social work to learn something of the context of distress and to get their union card–I mean, license–and then study something else to learn how minds, and life, work. Anthropolgy, sociology, social psychology, cognitive neuroscience, philosophy, even literature or business–something that studies life.
Hang in there, buddy. Here’s hoping you’ll have the luck needed to find some satisfaction.
Sorry for the long delay in replying, some personal issues….
Thank you for your reply and your care and concern. I love your saying “I really think studying clinical psychology is second only to studying psychiatry as a sure way to become stupid about life.” I think clinical psychology tries to tiptoe in the dark, like Santa Claus bringing us the gift of peace and happiness, and not bother attempt to seek clarity about it’s philosophical foundations or value system. And since most people do benefit from some kind of therapy, for reasons that are still not quite clear, be it a myth or reality let the the jolly old man bring us gifts and why bother turn on the light. 😉
Sara–
The most bizarre development in clinical care during my lifetime has been the utter perversion of what counts as science within clinical psychology and related fields. We’re now educating a generation of clinicians who have a completely false understanding of the many roles many different scientific efforts have played in understanding (and treating) distress, who possess an idiosyncratic notion of science and its uses.
That we consider clinical studies to be science at all is rather peculiar. They’re more like engineering than science–they’re product development, quality assurance, technical testing. They don’t tell us much of anything about psychology. If you haven’t looked at my post on “Therapy Works. So what . . . ?” you might find it useful.
The 2005 APA report I reference in my post above is worth looking at. It’s a very political document, but you will discover there that may estimable scientists and clinicians within psychology are unhappy with what’s being done under the rubric of “evidence based” care. The bibliography will point you toward some very fine critiques and studies.You might get a lead to someone with whom you’d enjoy studying.
Thanks for articulating with clarity, something I’ve been thinking about and saying for years. Psychiatry and main stream psychology are corrupted by economic interests.
http://relatedness.org
In fact, to make my point, everyone using the phrase ‘talk therapy’ to mean psychotherapy has already sold out. I was cured in the late ’70’s by psychotherapy – “talk therapy” did not exist. The Bio-med industry invented this word in the ’90’s.
I find this term offensive, what I went through, all my efforts were not just ‘talk’. But that is what their talk therapy is meant to be – just talk, the intellectual function is used to control the emotions and behaviour, emotion is actually avoided and suppressed in ‘talk therapy’. For example, sympathy,”support” and happy face fascism direct clients away from facing their emotional conflicts. Bio-med Psychiatrists decry the ability of talk to reach major dysfunctions – and they are right – just talking is not emotional transformation. So why not call it emotional therapy, consciousness therapy or personality therapy? Answer: because they don’t want that – they want the word “talk” to be definitive which is to say they want transformation failure or in other words their success is the human beings failure.
Talk therapy is a paradigm of failure, the term is intrinsically designed to point the mind towards failure and approach psychotherapy the wrong way.
It not just many therapies but our culture that is largely mis-directed towards emotional health. There are many therapists, who just reflecting their anti-growth cultural values think they can alter clients emotional lives but somehow by completely keeping the client from experiencing certain emotions in therapy. So the term ‘Talk Therapy” just exacerbates this general problem.
If people want to achieve success in clearly definable terms and goals they need to separate themselves from Pharma’s terminology and paradigm of control and transformational failure. Talk Therapy is anti-therapy, it is something completely different from psychotherapy but disguised as psychotherapy.
..
If you don’t like the simple word word psychotherapy then find another one but the last thing anyone should be doing is adopting terminology from an industry of mind control, behaviour control and emotional death/emotional suppression.
Dare to free yourselves – reject the industry’s terminology!
There definitely is a practice of anti-therapy -therapy designed to control and prevent growth. I can cite many examples and even individuals who have websites. It is clear that wat they do is behaviour control. This needs to be clearly distinguished form genuine therapy and is distinguished by clearly identifying this practice as “Talk Terapy”. If anyone practices real psychotherapy why confuse others and mislabel what you do as “Talk Therapy”?
It’s best to clearly distinguish yourselves from the bio-med practice. Then you can work towards definitions of success.
And I wish the majority of therapists would stop actually practicing “Talk Therapy” and start practicing psychotherapy – start generating legions of the cured , or the restructured or the resolved ..however you wish to define it, but define it as success – if you don’t know how – find out how it used to be done.
How it used to be done before Psychotherapy sold out to become “Talk Therapy”.
Actually what you are showing here is the creation of bio-med “talk therapy” or control anti-therapy. These practices did not originate from traditional psychotherapy. It was probably influenced and founded by Pharma bio-med money. Then this group of bio-med talk-therapists took control and made the definitions (played word games) to simply exclude traditional or real psychotherapy.
..
The new therapy “Talk Therapy” even removed the word psychotherapy making it seem like the only psychotherapy was “Talk Therapy” with it’s new directives and practices which completely oppose traditional or historical psychotherapy. The new psychotherapy was not in fact competitive with Bio-med psychiatry. The bio-med’s early enthusiasms and triumph quickly waned as they found that many patients were non-compliant. So anti-therapy was developed and designed to assist the med program by helping them stay on their meds.
…
It’s a guarantee Bio med talk therapy has never had any cures or successes in the same way Bio Med psychiatry never has. It is theoretically possible that the practice may replace the meds but then in the same way the ‘client’ needs to continue the treatment/brainwashing constantly. So the bio-med talk therapist is guaranteed a lifelong full wallet
Traditional psychotherapy, as well as other forms of assistance from society – meditation groups etc, though has had many cures or successes . I know because I am one of them.
And I am soooo lucky it happened in 1977 because today I wonder if there is a single real psychotherapist out there?
I judge that by comparing the practices (which I internalized) of the former group I was in with narratives of current practices – so far I have come up very short with no real certainly any such practices still exist though there are hints that they do but those people are not posting on the internet so far as I know.