On May 16, 2014, I retired from a 35-year career as a professor of clinical psychology at Miami University. As a part of my retirement celebration, I gave a Final Lecture to my Department. These Final Lectures give retiring faculty members the opportunity to talk about anything they think is important for their colleagues and the attending students to hear. I focused on the changes I have witnessed in the profession of clinical psychology over my career; changes that were not for the better.
I started by contrasting present conceptualizations of psychopathology with those that were prevalent when I was in graduate school. Currently, mental illness is seen as a brain disease, something blatantly stated as “fact” in the DSM beginning with DSM-IV. There are many important implications of the brain pathology position. One of the least explored implications is that brain diseases reside within an individual. In other words, the pathology cannot reside in relationships, in families, in communities, or within cultures. Individuals are diseased, not cultures.
In contrast, early in my career, therapists took more seriously the original meaning of psychopathology: psyche (mind, spirit, soul) + pathos (tragic suffering). Therapists were open toward alternative ways of understanding the tragic suffering of the mind, spirit, or soul. This openness meant that therapists had to be aware of the fact that values played a central role in deciding what is pathological. From the many illustrations I gave in my talk, I’ll include two here.
Homosexuality is perhaps the most famous example of the role of values in deciding who or what is pathological. When the culture (and the profession) was quite homophobic, being gay meant you were mentally ill. It was not voted out of the DSM because people did an exhaustive review of the literature and decided that the brain lesions that caused it did not, in fact, exist. It was voted out because the values of the profession (and the culture) changed.
Alternatively, the latest edition of the DSM assigns “mental illness” to people who are depressed two weeks after the death of a loved one. This decision was not based upon any data; the best data we have indicates that people grieve for at least two years when a loved one dies. I would argue that the decision to define grief as a mental illness after two weeks reflects the values of the profession. It suggests that the profession minimizes the essential role of suffering in a well-lived life and maximizes reaping economic benefit from the distress of those who grieve.
Turning to psychotherapy, it is currently conceptualized as something that a professional does to a person in distress. It is the intervention which is curative, just as it is the physician’s intervention (e.g., antibiotics) that is curative for a diseased patient. Therapists need a positive relationship with their “patients” because “patients” who do not trust and value their therapists will not trust the intervention and get better. In other words, a positive relationship is a means to an end; it is not something valued in and of itself.
The current position ignores decades of good psychotherapy research showing it is the relationship itself which is curative. In a relationship that is life-changing, the therapist suffers with the other person and the other uses the power of the connection to heal himself or herself. The client, more than the therapist, is the active change agent. In my talk, I illustrated the ways good therapy works with several examples.
I concluded my lecture by discussing an often neglected key role and responsibility of a professor – speaking truth to power. I focused on the need for professors of clinical psychology to speak truth to power about our field. Professors have an opportunity to bring to the fore things happening in the world of clinical psychology beyond what the mainstream emphasizes. For example, while the treatment-of-choice for “schizophrenia” in the United States is neuroleptic drugs, the National Health Service in Great Britain has decided that therapy for these individuals needs to be paid for because neuroleptic drugs only are effective in about 30% of cases. (As an aside, this 30% figure keeps coming up if you look at medication and psychopathology. A similar percentage of people report “anti-depressants” are helpful. If you happen to be familiar with placebo studies, you may recall that about 30% of people respond to placebos as well.)
Sadly, in this final part of my talk, I forgot to describe another truth we need to speak to power. We know that sexual abuse is among the most under reported of events. We also know, from survey data, that approximately 65% of the people who receive a diagnosis of schizophrenia report a history of sexual abuse. Let me say that again: 65% of those with a diagnosis of schizophrenia ARE reporting sexual abuse and we know sexual abuse is under-reported. This suggests a staggering number of these persons have been sexually abused, yet we do not account for this in our conceptualizations or consider it when we consider etiology. I truly regret not making this point in my talk.
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