Editor’s Note: Over the next several months, Mad in America is publishing a serialized version of Peter Gøtzsche’s book, Mental Health Survival Kit and Withdrawal from Psychiatric Drugs. In this blog, he discusses psychotherapy. Each Monday, a new section of the book is published, and all chapters are archived here.
I know psychiatrists in several countries that don’t use psychiatric drugs or electroshock. They handle even the most severely disturbed patients with empathy, psychotherapy and patience.1
The aim of psychological treatments is to change a brain that is not functioning well back towards a more normal state. Psychiatric drugs also change the brain, but they create an artificial third state—an unknown territory—that is neither normal nor the malfunctioning state the patient came from.2
This is problematic because you cannot go from the chemically induced third state back to normal unless you taper off the drugs, and even then, it will not always be possible, as the patient might have developed irreversible brain damage.
A human approach to emotional pain is very important, and treatment outcomes depend more on therapeutic alliances than on whether psychotherapy or pharmacotherapy is used.3 Furthermore, the more in agreement physicians and patients are about what is important when being cured from depression, the better the outcomes for positive affect, anxiety and social relationships.4
Most of the problems patients face are caused by maladaptive emotion regulation, and psychiatric drugs make matters worse, as their effects constitute maladaptive emotion regulation.5 In contrast, psychotherapy aims at teaching patients to handle their feelings, thoughts and behaviour in better ways. This is called adaptive emotion regulation. It may permanently change patients for the better and make them stronger when facing life’s challenges.
In accordance with this, meta-analyses have found that the effectiveness of psychotherapy compared with depression pills depends on the length of the trial, and psychotherapy has an enduring effect that clearly outperforms pharmacotherapy in the long run.6,7
There are substantial issues to consider when reading reports about trials that have compared psychotherapy with drugs. The trials are not effectively blinded, neither for psychotherapy nor for drugs, and the prevailing belief in the biomedical model would be expected to influence the psychiatrists’ behaviour during the trial and to bias their outcome assessments in favour of drugs over psychotherapy. Trials that show that the effects of a drug and psychotherapy combined are better than either treatment alone should also be interpreted cautiously, and short-term results are misleading. We should only take long-term results into consideration, e.g. results obtained after a year or more.
I will not advocate combination therapy. Doing effective psychotherapy can be difficult when the patients’ brains are numbed by psychoactive substances, which may render them unable to think clearly or to evaluate themselves. As noted earlier, the lack of insight into feelings, thoughts and behaviours is called medication spellbinding.8,9 The main biasing effect of medication spellbinding is that the patients underestimate the harms of psychiatric drugs.
I shall not go into detail about psychotherapy. There are many competing schools and methods, and it is not so important which method you use. It is far more important that you are a good listener and meet your fellow human being where that person is, as Danish philosopher Søren Kierkegaard advised us to do two centuries ago. As there are many trials with cognitive behavioural therapy, this tends to be the preferred method, but if used too indiscriminately, it can degenerate into a sort of cook-book approach that pays too little attention to the concrete patient’s special circumstances, wishes and history.
When we wanted to study the effect of psychotherapy on suicide risk, my oldest daughter and I focused on cognitive behavioural therapy for the simple reason that most of the trials had used this method. As noted earlier, we found that psychotherapy halves the risk of a new suicide attempt in people acutely admitted after a suicide attempt.10 This is a very important result that is not limited to cognitive behavioural therapy. Emotion regulation psychotherapy and dialectical behaviour psychotherapy are also effective for people who harm themselves.11
Psychotherapy seems to be useful for the whole range of psychiatric disorders, also psychoses.1,12 A comparison between Lappland and Stockholm illustrates the difference between an empathic approach and immediately enforcing drugs upon patients with a first-episode psychosis.13,14 The Open Dialogue Family and Network Approach in Lappland aims at treating psychotic patients in their homes, and the treatment involves the patient’s social network and starts within 24 hours after contact.13 The patients were closely comparable to those in Stockholm, but in Stockholm, 93% were treated with neuroleptics against only 33% in Lappland, and five years later, ongoing use was 75% versus 17%. After five years, 62% in Stockholm versus 19% in Lappland were on disability allowance or sick leave, and the use of hospital beds had also been much higher in Stockholm, 110 versus only 31 days, on average. It was not a randomised comparison, but the results are so strikingly different that it would irresponsible to dismiss them. There are many other results supporting the non-drug approach,1 and the Open Dialogue model is now gaining momentum in several countries.
Psychotherapy does not work for everyone. We need to accept that some people cannot be helped no matter what we do, which is true also in other areas of healthcare. Some therapists are not so competent or do not work well with some patients; it may therefore be necessary to try more than one therapist.
Like all interventions, psychotherapy can also be harmful. Child soldiers in Uganda who were forced to commit the most horrible atrocities have survived the psychological trauma remarkably well by avoidant coping.15 If a therapist had insisted on confronting these people with their encapsulated trauma, it could have backfired quite badly. In somatic medicine, a healing wound should most often be left alone, and human beings have a remarkable capacity for self-healing, both physically and psychologically. Obviously, if the healing goes badly, e.g. because a broken bone was not appropriately put together, or a trauma continues preventing the patient from living a full life, it may be necessary to open the wound.
Physical and emotional pain have similarities. Just like we need physical pain in order to avoid dangers, we need emotional pain to guide us in life.16 Acute conditions like psychoses and depression are often related to trauma and tend to self-heal if we are a little patient. Through the process of healing—whether assisted by psychotherapy or not—we learn something important that can be useful if we get in trouble again. Such experiences can also boost our self-confidence, whereas pills may prevent us from learning anything because they numb our feelings and sometimes also our thoughts. Pills can also provide a false sense of security and deprive the patient of real therapy and other healing human interactions—doctors may think they need not engage themselves as much when a patient is taking drugs.16
Being treated humanely is difficult in today’s psychiatry. If you panic and go to a psychiatric emergency ward, you will probably be told you need a drug, and if you decline and say you just need rest to collect yourself, you might be told that the ward is not a hotel.1
To read the footnotes for this chapter and others, click here.
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.
Suicide is an increasingly rational response to the ever mounting existential threats facing Earthlings as a whole. And therapy will not solve most of these threats.
I liken it to Camus’ , “Should I kill myself, or have a cup of coffee?”
Thank You Dr Peter,
I came off Neuroleptics very carefully, but like the person you mentioned – I didn’t come back ‘the same’. I suffered from Overwhelming Anxiety and would eventually have had to return to neuroleptics, if I hadn’t found ways of dealing with my ‘drug induced PTSD’.
I discovered through ‘trial and error’ that if I ‘sat with my feelings for long enough’ that they eventually subsided, and that my mental balance returned. This was a lot more difficult to do, than it sounds!
The ‘Psychotherapeutic’ Approach is described below:-
My original introduction to Psychiatry in 1980 was fairly ‘irregular’.
“Acute conditions like psychoses and depression are often related to trauma and tend to self-heal if we are a little patient.” Isn’t it bizarre how being “a little patient” can have two meanings, in the English language?
It can mean what the psychiatrists assume of their patients – that they are “w/o work, content, worth, and talent” and “irrelevant to reality,” just worthless, “little” patient[s] – prior to ever looking at their work, or actually listening to their concerns.
Or it can mean having patience, and not immediately force drugging every patient you meet, prior to actually listening to their concerns, and looking at their work. Which is what the psychiatrists should actually have been doing all along, but have not been.
Thank you, Peter, for speaking the truth. We truly do need the brilliant and ethical doctors, like you, on our side. I’m very grateful for your work, and your speaking truth to those who’ve wrongly been given undeserved power, the psychiatrists.
Psychological therapy may help some people. The problem is that the research finds it mostly has clinically insignificant benefits. In a meta analysis that tried to include unpublished studies, the effect size for psychological therapies benefits for depression was .39(1). For reference Irving Kirsch found the effect side for short term “antidepressant” use in heavily biased/flawed corporate trials was .3(2). The improvement recorded for psychological therapy for depression comes out to around 2 points in the Ham D scale. For reference saying you are mentally ill is a 2 points improve the. Having the same emotions and problems but telling them to the psychiatrist less is also 2 point improvement.
Therapy according to the research is pretty much pointless. If people wanted to spend their time and money doing it that would be one thing, but our society pressures people into it. Our society even forces some people to do it. If someone doesn’t do therapy or stops they get stigmatized for it. A common response if you tell someone therapy didn’t help is a version of “therapy can’t fail, only you can”
A study found that giving people the money therapy costs improved their emotional well being more than therapy.
There are several reasons to believe the studies are bias towards showing therapy is helpful.
1) There are likely more unpublished studies not included
2) You can’t unblind talk therapy. This accompanied with subjective outcome measures means the studies contain an active placebo effect.
3) Harms are not measured or looked for.
(2) Mad in America’s “the people’s case against antidepressants” has this meta analysis in the beginning.
A study done in 2021 compares giving people slightly less money than the cost of therapy verses giving them therapy.
The result was that the group getting the money had more improvement.
I appreciate actually putting head to head wellbeing when in precarious positions have more resources to weather it rather than pay to talk about it.
I remember being nudged into psychotherapy when I was unemployed and feeling so much pressure to maximize every minute of the experience because it was so comparatively expensive. It certainly did not lead me to feel patient or situated to learn. What I felt was that I wish I had the money I spent on it to pay my rent and keep my housing stable.
Thankyou Peter for writing of your knowledge of psychiatrists who have become non prescribing and who have become psychotherapists. I have experienced enormous help and healing from psychiatrists who became psychotherapists. Most were not inclined to drug me. Alternatively I have met psychiatrists who did not go into psychotherapy.Those were people who perhaps felt they could offer me nothing but medication. I think our society is so pickled in bad psychotherapy that therapeutic rebellions against mom and dad, as ws encouraged in the late nineties, has become therapeutic rebellion against therapy. Throw in a bean bag and an encounter group tennis racket and it all sounds the same somehow. That is not to say psychotherapy is ideal for everyone. I have always felt it has its flaws. But it has been the best and most effective support in my life and in many other people’s lives whom I have met. To me psychotherapy is like a form of befriending. It is a friendship like you make at work but your wellbeing is the work. There are a million ways people can get the same results from just friendship but often friends are limited in how much they can care. Of course doubtless it could be argued that paid care is not care, but then elderly care and nursery care sees wonderful caring people dedicated to being healing yet also accepting of the realistic need for a wage with which to put breakfast museli in their bowl. Psychotherapy as a form of friendship is like ordinary friendships in as much as you do not say your three years with your friend Jill “failed”. Friendships neither fail nor succeed. What relationship does? But a friendship can be nurturing, fruitful, consoling. And psychotherapy can be these things just as easily. And in a tough world with added mental illness like schizophrenia, what is not to like about nurturing, fruitfullness, consolation? Granted there are political and social ways to also increase these emotional provisions by seeing to it that people have economic stability etc, but if I had just lost my newborn baby and felt in pieces with grief or if I was hearing terrible voices nobody else could hear night and day, I am sure a psychotherapist would be a positive team mate in my lonely struggle. Can psychotherapy go wrong? Can friendship go wrong? Everything can go wrong. I have ceased listening to the comments section because it seems all about what can go wrong in ANY paradigm of care and not what are the good aspects or good bits or good experiences. As such I find the comments section a council of despair and so for my mental wellbeing I prefer to just read the articles and do what pleases me in terms of my own free choices of care. It gets to a point where it is depressing to adsorb all the negativity. I am too ill to want to read the comments.
As someone whose culture does not have psychotherapy like approach to mental health because the culture is collective and people who are struggling with basic mental conditions depression, anxiety schizophrenia etc. usually are taken care of family (which creates its own problems obviously), I would like to weigh in this topic from that perspective.
First and foremost, if something can heal it can also harm. Arguing about that is useless. Anytime you have two people in a room for extended period of time, and add a mix of one person having strong boundary of the mind, while the other is expected to empty the mind so both can look at the mind together, is recipe for healing exponentially and also has just as much risk of exponential harm.
That differential of the mind access is something, as psychotherapist we are not fully allowed to discuss in a deeply and meaningful way because most training truly believe one can boundary the mind that hard and that long in this process. Just as much as clients are emptying their mind with their consent so they can see their own inner workings and intricacies, the psychotherapist is also subtly emptying their mind but not open for the client to comment on it.
When I went to therapy to become a therapist, I had no idea how therapy works. I mean that exactly what it means. I knew I will sit in a room with a person but I had no idea that I would be expected to give a ‘consent’ to empty my mind so I could see it with another person. I did not have the concept. I did not grow up in the concept. I wanted to help others and wanted to learn the techniques and I was educated myself in therapy!
I broke down completely due to my own unprocessed childhood trauma that was not oblivious to me but I managed decent life so I never dwell on it. But sitting a room with a person whose mind was boundaried on purpose (just like my mother, whose mind was boundaried unconsciously when I was born), I fell unceremoniously into complete black hole full of extreme regression and dissociative states I did not know I carried. Because prior I did not have any mood or panic or as far as I know organic underlying, I had to anchor myself with my own adulthood memory of I was functional before therapy and now all of sudden I am broken down what is going on????
I decided to learn the process more and break it down.
First the consent to the mind and the inner workings of the client is not understood universally or even culturally. When we are asking consent to treatment, IMHO, what we are asking subtly (this needs to be spelled out) is that I, the therapist, will like to have access to your inner mind, inner dialogue, and I promise to treat that with upmost respect and empathy and whenever I fail as I will as human, I will hope we can work out with your functioning, integrated side. Can you give that consent? Very few people will do until they trust the person and the conversation is very clear not ambiguity.
The harm is this: sign consent – full of words without meaning. Start talking and empty your dissociative, disavowed parts to a person you may trust or not- immaterial. The therapist gets access and does not share the information with the functioning parts of the person that gave the consent. Language is used in obfuscation.
In severe states of dissociative or extreme regression, symbolization, meaning and sophistication are harmful – no different than if you are talking to a toddler about death! The therapist must learn and ask spelled out consent each step of the way until the client’s integration parts are more on the foreground more often than the dissociate states and can digest, metastasized and symbolized the meaning of the things found under regression.
Now the therapy started with the blank state just like the first heart surgeon probably butchered a person to learn but as surgery has become more sophisticated, therapy has become more confiscation.
A therapist that can articulate their inner workings with the client from the client who is paying a very high price and who is working, functioning, striving for health in every day…is the right therapy. A therapist with the mentality of I see your inner workings are so broken, and I am going to function for you without your consent is harmful without even knowing.
Only a highly integrated, functional person can give a full consent to empty the mind at will with another who is not doing the same. A client who is emptying the mind automatically to the therapist, it is the therapist job to name this and make sure there is a consent.
There is a great article by Wolfgang Wöller et al that basically states: for complex PTSD, the therapist should not engage directly, collect information, build a relationship with parts that are showing up in therapy without the functional adult paying side of the client ….there is no consent to treat until the person paying is on it. Most therapists are so eager, excited to access others’ mind that they forget there is a person who owns that mind sitting Infront of them and without that part (the most autonomous and important part that came to therapy in the first place) must be respected, empathic and taught how to take care of the new parts — the functionality of therapists must be clearly stated until the client is almost integrated enough to give full access for the therapist to be functional in much greater ways. Basically Woller is saying, only those very integrated can allow the therapist to have access to their inner mind. Make no assumption and ensure as therapist if you are having conversation with parts of the client that the client is not aware of, stop, get a consent from the functional part of the client.
This my take…maybe too wordy but this is very complex intersubjective experience and going high in the power imbalance or not being aware of it and what it means, causes a lot of the reasons the therapeutic does not work.
The more severe a person is, the less symbolization and more direct, IMHO. And as the person heals, integrates and learns how to carry their own small, primitive childlike parts (their vulnerability), the more they can withstand another person accessing their mind.
The focus on technique is kind of barbaric. Think this way: can we teach mothers how to be even just good enough mothers? No….we cannt because there is no human technique.
It all boils down to asking consent every step of the way to access another’s mind and have conversation about that and allow the client to witness their own breakdown without fear, mystery and confusion…the more they heal, the more they will allow the mystery, the symbolization, the meaning making…but not while they are processing infantile or epigenetic materials that were highly traumatic.
I hope this makes sense but I thought I will share my experience of therapy for the first time and going get out of my mind – you devil, I need to solve this person accessing my mind and resist, to is this person helping me, to ooh this person is trying to help me and support me but they should ask my permission first? and I realized I had no idea what therapy is truly.
Just coming to therapy alone is not a consent to poke around other’s mind.
This is why people in crisis should be helped by people with personal experience of crisis.
It’s also possible for people to regain calm through advice, without breaking confidentiality.
I just want to add that my best psychotherapist was a psychiatrist who left psychiatry and took me with her into private practice. She stuck with me for ten years. She came to my house warming party with her partner and we had a great laugh. She came shopping with me when I said I was out of control with my shopping and running out of food cash. When I couldnt aford to pay her she accepted my terrible oil paintings. Sometimes I gave her my woollens, which she wore respectfully. I once showed up at her door with an antique table and a china egg bowl. Which she took with good humour. I wrote epic letters to her over many years, all of which she brought into sessions for me to read out loud to her. She kept my letters without my knowing, in a bag. When she proudly gave them all back to me I cringed at reading them and later threw them all in the trash. But in many ways she was instrumental in teaching me to write true from my heart. I adored her and wanted to be her. She never pushed pills on me. Indeed she looked utterly crestfallen every time I wanted to ask my family doctor for antidepressants. I gave her lots of music. She gave me lots of music. She had a sort of sisterly boundary where her private life was like a room I was denied access to. I always respected her for that. She tended not to call herself my therapist but described it all as a relationship. It became a relationship where I could learn safely through trial and error what were the kinds of relationship with everyone else that I liked. No closet was not subject to spring cleaning. All lives have trauma. Mine were assiduously scrutinized. What I liked best about it all, the long years of psychotherapy, was the “playing”.
In order to play you need someone who does not take themselves too seriously nor wants to be your saviour. Just your best friend.
In a world where everyone is too stressed out to be anyone’s best friend the notion of community sometimes only replicates such a collossal lack of vital intimacy in its cosy communication famine. She kept my need for “play” and intimacy nurtured.
My next psychotherapist liked me so much he housed me in his vast Edwardian mansion. A very platonic and chaste and witty companionship ensued for two years. He introduced me to fine wine, top restraunt dining, esoteric things like astrology, theology, luxury domestic fripperies, and eventually his work of psychotherapy, where he trained me to become one. I see it all in a medieval lens as a bit like the decadent yet solemnly monastic process of apprenticeship, where you start off needy and a decade later move into helping the needy.
A therapeutic boundary is a necessary structure to keep both people safe from reckless abandon. But a boundary can also be an “us and them” assertion of stellar egotism that has no place in the yeilding space of feelings. I think the Guild of Psychiatry has enshrined such a boundary to devastating effect. I think psychiatry is full of ill doctors who have no one properly caring for their mental health and this is why they are woefully unable to care about anyone elses. It is all very sad.
But there are psychotherapists who saved my life and psychiatrists who also saved my life…and I refuse to do the wokey thing of saying everyone I ever met damaged me.
I am tired of the emotional blackmail in our current times that insists I can only be embraced if I keep banging someone else’s monotone drum and loudspeakering the agenda of strangers rather than telling what I know to be true to me.
I have written some of my truth in the MIA comments section of the adjacent article titled “Drowning in Doubts: why I think about Leaving Psychiatry, by E. Baden”. But if you click on my name “Diaphanous Weeping” you can find my contributions.
From my reading and experience there seems to be three main camps on the claimed effectiveness for any from of psychotherapy and we know the drugs don’t work. We have a range of cultural disorders not personal ones.
One camp is occupied by the main players in each modality or therapeutic school. They are all competing in a market place of ideas, for power and status – most of the research is done by therapists themselves, so those with the most to gain from their approach coming out on top. It also seems that the approaches that are elevated over others are those that are a best fit for the broader political, economic and cultural zeitgeist. Given the research is done mostly by those with the most to gain its horribly biased and therefore of little merit
Another camp is also occupied by those with the most to gain and the research is done mostly by therapists – however this camp eg Bruce Wampold in the great psychotherapy debate etc – are at least attempting to get us closer to truth by looking in greater detail at the research.
This camp assumes therapy is efficacious and they they are interested in what bits of therapy make it useful – dismantling studies and other forms of research have been carried out to try and understand what is it that actually helps in any therapy. What they have shown is the following.
The most important, indeed key factor in any psychotherapy’s success is absolutely nothing to do with psychotherapy – The most important factor is all about the individuals resources coming into therapy – resources in the broadest sense, finances, health, family, friends, meaning, purpose etc.
Next most important is placebo, then how comfortable the person feels with the therapist or the pseudo relationship, then comes shared goals/hope and right at the bottom is modality/theoretical orientation/techniques.
Then we have a third camp, also made up of therapists and people in related fields – these people are even more interested in getting us closer to truth and they assess psychotherapy in relation to its cultural position. There are many authors here but William M Epstein over several books including The Illusion of Psychotherapy, Psychotherapy as Religion and Psychotherapy and the Social Clinic, Soothing fictions has taken the best of the research apart and analysed it on methodological grounds. What he demonstrates is there is no evidence for any psychotherapy being effective and it can be harmful.
It’s really incredible that a field with such terrible research and routine poor outcomes and clearly making absolutely next to no difference to human wellbeing as evidenced by the ever rising numbers of people suffering manages to maintain any sort of cultural power position.
This brings us back to psychotherapies usefulness to power and maintaining the status quo by obfuscating the real causes of so much distress in myriad cultural disorders. As David Smail highlighted it then loads individuals with responsibility to somehow adjust to ever worsening conditions. This constantly and falsely advertised transcendent heroic individualism or delusion is also picked apart by David Smail and William M Epstein.
In my own experience working in the sector most of the people I know and come across aren’t aware of the critics of the research literature and simply carry on like it doesn’t exist even when its pointed out.
Peter states ‘Most of the problems patients face are caused by maladaptive emotion regulation’
really? seems to me that most of the problems are caused by myriad cultural disorders dressed up as personal disorder.
It seems so often the case that the road to hell is paved with good intentions.