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Let’s also not forgot iatrogenic harm from psychotherapy.
Those lengths are common for trials needed for FDA approval.
You said it! Psychotherapy informed consent is atrocious. Professionals offering much cheaper, more concrete, more time limited services go through more robust consent processes than psychotherapists (ex. fumigators, plumbers, etc.), even though therapy is often conceived as a multi-year, expensive, and energy-consuming endeaover that has no guarantees
I don’t think you are claiming that the services you found helpful in the 80s or the ones you now provide are only understanding and listening to people nonjudgementally.
However, I am still not all that convinced that professionalized helping has been a net good, even if many people have been “helped” by professional helpers.
I’m confident that the psychoanalytic rackets of training analyses, engaging in ways that lead to unnatural, iatrogenic transferences that lead to staying in analyses to deal with them, lack of meaningful consent processes about the many risks of such processes, and the requirement for sustained income for analysis as means to for analysts to knowingly lie to and harm people, build up their false hopes, make people permanently dependent zombies for their own financial gain. As psychodynamic therapies have replaced more formal analysis as the primary psychotherapy, I don’t think this has changed all that much.
If all you really do is give people a chance to talk about what is on their mind to a fellow human while listening and understanding non-judgmentally, I don’t see why health insurance should pay for such services nor should working as a psychotherapist require any advanced schooling or special licensing, or how anyone (let alone hundreds of thousands of people) makes a fulltime living doing this. I mean, many of us listen to fellow humans with understanding and without judgement quite often and for free. You are able to work as you do because you have medical pedigree, you have state license to better claim legitimacy, and people think you are an expert of models, theories, and cures due to a long history of psychoanalytic therapists and psychiatrists (and related mental health professionals) claiming such understanding to the public and convincing the state, criminal courts, educational services, and individuals/families of such (sole) expertise.
Even your MiA bio is not about how nice of a listener you are, but a resume of your participation in all of the steps it takes to become a psychiatrist.
Psychoanalytic zeitgeist and hegemony did not allow for much “to each his own” for ways of coping. It pushed a single method of framing and understanding distress at the expense of other ways, sometimes with forced treatment or proof of “insanity” if disagreeing with that hegemony. I would argue that it has to to have therapeutic effect. Just like drugs “work” primarily from placebo due to a cultural saliency of the chemical imbalance theory, the hegemony of medicine for healing in general (seeing a doctor is not just the most respected person to see when ill, but seeing another kind of healer is not respectable), well-respected experts being nice to you in a difficult time, past positive experiences with medication, etc., psychotherapy “works”/worked because of the cultural saliency of psychoanalytic theory, psychoanalytic hegemony of mental health (having an analyst is very respectable, but having a priest or astrologer or whatever is not), someone willing to listen to you, past positive experiences with helper figures, etc. But psychoanalytic therapy has never been well practiced as one option among many. Freud and followers had an agenda to to make psychoanalytic theory a “theory of everything” that made it the true way of dealing with the mind/distress/society/whatever at the expense of other false ways. This is really inescapable if you have any expectation of people choosing psychotherapy (which requires its saliency, co-option by medicine so that health insurance can be used to justify the super high costs, etc., disapproval of non psychomedical ways of thinking about distress, etc.)
I think examining Freud is useful in that Freud’s work is an example of another kind of false hegemony over distress gives a historical understanding that it doesn’t really matter what that hegemony is (biomedical or psychoanalytic), but it is that there is a hegemony that buttresses the powers at be that is problematic.
You are playing it both ways here, Dr. Kelmenson. You point to Freud the social philosopher when psychoanalysis as treatment is criticized but then return to psychoanalysis as treatment when Freud’s social philosophy is criticized. This to me is indicative of psychoanalytic double speak that is crazymaking when made be healers with a lot of social and intellectual prestige and expertise.
Plenty of psychoanalysts use stigmatizing labels and prescribe or refer for medications.
People didn’t turn to medical psychiatry because Freud was debunked, but they did because psychoanalysis was time consuming, expensive (and hence limited to the very few), and not all that helpful (let alone often harmful).
It’s tough to rehabilitate Freud in the #MeToo era. He basically laid out the theory that provided (and continues to do so) justification for not believing women and children’s experiences of sexual assault, and worse, that they wanted to be assaulted and somehow conspired to make the assault happen. Not only did it make anyone who made allegations of assault “crazy” it also made them somehow the oppressors and the men accused victims, not the other way around. I would argue this has led to a lot more “distress” than psychoanalysis has ever alleviated.
Freud and Psychoanalysis since has failed to address the social/political/economic conditions that lead to many people’s distress. Psychoanalytic Social Policy never really got off the ground because most attempts at implementing them were failures, and the more “successful” ones were quite reactionary (post-war renaturalizing of nuclear families with men as leaders of households and the workplace, misinformation campaigns to discredit democratically elected governments, and marketing of unhealthy products like cigarettes). There is a reason why people with a lot of family wealth, the well-educated and the well-employed, and white people do better in psychoanalysis than other people: psychoanalysis at best helps people just adjust to the conditions as they are. When you are already highly privilged in those conditions, that’s a pretty good deal. When you aren’t, however, psychonalysis can be crazymaking to the point of breakdown and often leaves poor, non-white, queer people a lot worse off than when they started.
Freud’s understanding of the way psyches interact with society was pretty basic and just reified the social order as it stood (and stands). Basically, “Ya, modern civilization can be dehumanizing, but it’s worth it considering the alternatives. Better to know that and participate in it while winking at this truth than fighting it.” This only works for people for whom civilization makes their lives more secure at the expense of making other people’s lives more vulnerable. For vulnerable folks, telling people to go through the motions of society while winking at its absurdity is even more dehumanizing. Those “motions” are what makes their lives insecure and leads to psychological distress, not their maladjusted reactions to them.
Long term psychodynamic therapies are also bad science. Shedler likes to criticize science that does not support his views and basically calls criticism psychodynamic therapy penis envy.
Falk Leichsenring’s group has a history of inflating the effectiveness of long term psychodynamic therapies to further his goals. Psychotherapy research of all kinds is pretty poor, considering the amount of time and money spent on mental healthcare services.
I am irked when therapists/therapy apologists add caveats in response to peoples criticism of therapy that they hope they can somehow find it in themselves to give therapy another go, implicitly or explicitly (like in this response) positing that their life would be better with therapy.
I dont think you would continue to make analogous statements to people writing posts re: criticism of psychiatric drugs.
I love all of this. Thanks, Chaya.
I wish MiA would be as incisive at critiques of psychotherapy as it is with somatic interventions. For all of the poor oversight, corporate investment, poorly conducted studies, poor theory (etc. chemical imbalance), potential long lasting harm of drug/somatic treatments, psychotherapy suffers many similar issues (poor study design, tremendous bias, lack of testable theory, high cost, risks of severe negative effects) with even less oversight, possibilities of redress, less informed consent especially regarding risk/harms.
Mental Health and mental health justice can’t just focus on psychiatric drugs.
I am just revisiting this after many years…
Dr. Moffic really said that psychiatrist who work on insurance panels DO not give proper informed consent or make careful diagnoses. While I agree that payment systems for psychiatrists make this difficult, it is the PHYSICIAN who has an ethical responsibility to practice ethically, including careful diagnoses, going over treatment options, and informed consent. It is unethical to be on an insurance panel if you cannot make this happen with your patients.
I never said I think therapy is harmful, I said that it can be harmful, and that we don’t have a good understanding of the extent of the harm, engage in informed consent processes about the risks of harm, and deny/obfuscate that harm with talk of “bad apples, individual relationships, readiness for therapy, some gains were made, etc.” This is troublesome to me.
I am skeptical of folks who make an enthusiastic case for psychotherapy without this understanding, when they advise caution to psychotropics because the developing understanding of potential harm and limits of zeal to its general use.
I am not in a place comb through research right now, I’ll post some later if you like.
Leichesenring’s group is notorious for poor analysis and overstating outcomes.
I am not blanket denigrating psychotherapy. I definitely do believe that potential negative effects of psychotherapy are rarely looked by the same people who have sophisticated critiques of negative effects of psychotropic drugs. I don’t think psychotherapy should get a pass.
There are certainly many who have been harmed or more harmed by their experience in psychodynamic therapy as they had been with drugs, with even less recourse of action.
Yes anti-psychotic meds often lead to hopelessness and statis, however, intensive psychodynamic therapy can be quite destabilizing and damaging too. To me, they are more similar in effect than not, and both require belief in falsehoods about yourself, overemphasize undeserved trust in a medical provider as source of healing and that trust can be easily broken, and are likely very expensive.
I am always concerned about how patients know what they prefer, given a bunch of options that they never have tried before.
As a patient, I prefer the treatment that shows the greatest chances of success with the fewest risks and costs.
However, if patient preference is determinant in successful treatment or not, research on efficacy and effectiveness of treatment is kind of redundant. Just do what the patient likes.
But why a patient likes something can be heavily influenced by media, advertising, provide expertise, previous good/bad experiences, what a person thinks others should want them to like, etc., so this can be manipulated to serve the needs of others.
Basically, whenever patient preference becomes a factor in overall success of a treatment, I think it highlights that placebo effects are are most at play, and perhaps a rethinking of diagnosis/treatment altogether is in order. At the very least, it should prompt a meaningful discussion early on about how there are several options that may be helpful, and what is most helpful is that you like and can tolerate and can pay for an option enough to stick with it, and go from there.
Im with you!
I think anti-psychiatry is actually weak when NOT inclusive of a critique of professional mental healthcare – including psychotherapy, psychology, social work, alternatie healers etc.
1) Therapy and social work do not 100% help. What makes you think this? This is really quite the statement.
2) if you do believe this, why not study to be a therapist or social worker?
NOT documenting or downplaying risk.
Ugh, Shedler’s manifesto. It was not research. It was a rallying cry tucked into a poorly defined systemic review of not very well designed studies…
I haven’t been particularly impressed with Leichsenring’s work. Lots of issues in analysis and reporting, and making claims that data do not suggest. I’m not against psychotherapy or psychotherapy research, but I think we are naive to give it a pass not reporting on negative effects. The research just becomes the same as drug research, showing statistical effects for indicators that may not be all that meaningful and documenting or downplaying risk. We forget that the drug paradigm came after half a century of psychotherapy-based mental health care that did not have all that successful of a history.
Good luck getting funding or psychodyanmic therapists interested in conducting the research.
A 14% depression recovery rate vs a 4% recovery rate isn’t that great considering the extreme cost difference. Also considering natural recovery rates of depressive symptoms this isn’t glowing for any kind of treatment. I know they were other benchmark outcomes that psychotherapy outperformed Treatment as Usual, but this is the big outcome and it doesn’t impress me. Follow-ups are more impressive, but time not in treatment is also good for depression in turns out.
The Fonagy study was therapy + Treatment as Usual (not including short term therapies) vs Treatment as Usual. They did not exclude medication use. Actually, the Long Term Psychoanalytic Therapy group had 21% of of folks on medication vs the control group who had 37% of participants on meds.
I didn’t do a thorough read of the whole article, but I didn’t see any documentation of negative effects or individual worsening. I wish these longterm studies, especially of analytic therapies, would include data of the people who did not get better or got worse.
Though common sense, this is an important line of research. Talk therapies are a billed as nonharmful, benign, and effective. They can have cause iatrogenic harm like psychotropics. There is rarely any mention by clinicians of risk of worsening which limits informed consent. Many psychotherapists also see some worsening as an indicator of progress and are encouraged by it. Hopefully more of such research will push clinicians to have more honest and thorough conversations about the potential risks of treatment and whether or not the benefits of such treatment outweigh the risks for an individual and lead to less active treatments by clinicians.
Actually, if the expensive placebo effect could be statistically separated from cheaper one in such a small study, the effect is actually pretty relevant. More participants would reduce the threshold for finding a difference, meaning you could detect smaller differences. If this study detected a difference, it was a big one.
The “let me know how I can help you” line is one I’ve come to resent from mental health professionals. I usually get it when im open about my skepticism of drugs and therapy. I take it as a “what else do you expect me to do if not drugs or therapy?” response. I also dont like it because if I knew what would be helpful I wouldn’t be seeking help. My experience in social work school demonstrated social work professionals submit to p sychiatric domination for a bigger slice of insurance reimbursement mental health industry pie.
I unwittingly participated in a psychoanalytically oriented treatment which made things much more difficult for me for a long time. Psychoanalysts scam folks like everyone else.
Read Michael Warner’s “The Trouble with Normal.” It’s a late 90s semi-academic take the conservatizing of the gay rights movement, but it spends a huge part of it unpacking our ideas and values enmeshed with normality
I find this validating. I was considering pursuing a complaint through the ILDPR, but after waiting many months for a response from them, to find out that the department was on and off furlough, made me far less trusting in opening and reviewing a case with them.
Very APA. They are trying to both get out of the business of being expected to predict violence (psychiatrists can’t, and least not any better than anyone else), but still keep the appearance that they are the experts at predicting violence. It seems too little too late to have much policy impact…
It seems your argument boils down to:
You can’t isolate problems of Psychiatry from problems of Medicine
AND Medicine is not going away
AND People will continue to use psychoactive drugs available to alleviate suffering.A
common way people to do is from visits to medical professionals, including
SO If Psychiatry doesn’t take a stance between people suffering and drugs, then
something worse might.
I don’t have the energy/time to try to tackle this right now, but I just want to double check this boils down your stance to why you do not take an “abolitionist” approach to psychiatry as an institution or systemic force?
Part of why I quit social work was that I had trouble with the notion of social work as a distinct profession. Our national organizations and schools insisted that both social workers be professionalized and at the same time defined the profession so broadly as to lack any meaning. Because of that desire to be recognized as professional but also lacking coherency, it was easy for social workers, particularly clinical social workers, to be tacked on to the mental health professional family, where psychiatrists run the show. I didn’t see how I can work in any clinical context and not be “mid-level” therapist where my very existence supported the labeling/drugging/oppressing forces that shape the entire field. Lots of social workers are ok with this situation, our representing organizations certainly are, and I refuse to buttress it.
The social workers who make a career out of organizing or advocacy or community development or evaluation often do not carry the professional identity of a social worker. They went to social work school. There are lots of ways to be active in justice work, we do a disservice to folks who want to do that work, even at micro-levels, by trying to professionalize that work under the umbrella of “social work.” I found I was a much better, resilient, and flexible at working for justice without having the label of social worker over my head and the problems of being a particular kind of professional, licensed by the state and co-opted by psychiatry, brought. I’m still trying to relearn what I used to know and forget when I was taught in school.
What happens when people stop believing they can get well? What happens when their experience with treatment solidified that belief?
These advertisements are great! It is great to see how pharmaceuticals were advertised to doctors when psychiatry was still predominantly organized around psychoanalytic theories. Do you have a link to higher quality images of the advertisements?
Thank you also for offering a thorough history of prescription drug use in the 20th century and making it clear that psychoactives have been used in cultures around the world long before modern medicine became the means to which to access them, and that people used them for all sorts of reasons (recreational, therapeutic, spiritual, temporary boosts in concentration, etc.).
I guess the other concern then is what Chrys has alluded to. This model is predicated on a fully voluntary approach to seeking care when in distress. How would these psychoneurologiss interface with law, commitment, forensic evaluation, etc? Psychiatrists currently have a big role in these areas, precisely because they are physicians and are considered the leaders of mental health care. What would reducing psychiatry to a limited branch of neurology that are not considered the end all of mental health expertise do to the coercive powers/”responsibilities” psychiatrists are currently structured to use? Would a move to such a model you present also require a dismantling of this interface of psychiatric evaluation/diagnosis/assessment with the various legal aspects of psychiatry?
I’m really not trying to knock what you envisioned. I think it is a much better alternative to what we have now. It just requires a lot of structural changes, as you say, generally and within medicine. I’m afraid, however, it is the bigger issues that still make the most difference in this shift of models. Otherwise what we get are consultant neuropsychiatrists that might end up behaving similarly to current psychiatrists.
I think Sandra is offering something great. I think it is right on that physicians should not only not be in the lead of what we call mental health care, but should pretty much get out of the way. I agree both that physicians (neurologists) should understand known pathophysiology of of nervous system (and other organ systems) that could lead to psychiatric distress and should make treatment recommendations based on known pathophysiology. I also believe that some doctors (maybe the same neurologists) should know about what we now call psychopharmocology as you say, drug use (psychiatric or otherwise) isn’t going anywhere anytime soon.
The problems I see with this model is it doesn’t make more distinct that that psychiatric drugs are not curative of brain pathology or psychiatric distress. I would fear that combining psychopharmacology and with people who study/treat the physical pathology of what we call mental health issues, we would get the same problems in psychiatry we do now. (Eg. The nerve doctor says there might be something wrong with the chemicals in my brain and gave me drugs that fix them so that I will be better). This model would have to make it known your belief that psychiatric drugs are treatments at best that produce broad effects that probably have little to do with any brain pathology and if they feel good they feel good in the way all “drugs” might feel good. Basically, it was the mix of physician prestige, patient trust, and the “biological” focus of physicians that led to chemical imbalance craziness to begin with. I don’t know how your new psychoneurologists will manage this better than psychiatrists do. It really depends on the big cultural shift that physicians shouldn’t lead mental healthcare and wouldn’t have the prestige effect tainting care.
I find discussant’s argument pretty compelling. I do not see therapy as an art (i read that as “guessing game” mostly) or science, but as ideally an applied, science-informed skilled practice. I do think descriptive statistics about therapy are important for consent process. If you think most therapy is bad, and clients do no know what therapy will be bad for them from the get go, it would be ethical to tell them you are likely to have bad therapy when they start the process, as that would be true, and leave it to them to choose or not to risk it.
If most therapy is bad therapy, and as a client, it’s not easy to discern much about therapist/therapy early on in treatment, is it safe to say that patients are likely to enter into bad therapy? Is bad therapy potentially or likely harmful/wasteful? How do clients make determinations about helpfulness of therapy(especially when many therapists say you are supposed to feel worse, have lots of negative feelings, more isolated/etc. during much of therapy)?
I hope this response is sarcastic.
If not, your unsolicited advise sounds like a lot of work, expense, and discomfort just to rewrite an already excellent essay. Especially if Daniel would have lots of reasons why it isn’t benefiting him…
In more seriousness, viewing psychotherapeutic interventions with a critical eye is important. The therapy industry is large, distressed people put a lot of money into it, and results are often less than stellar (more precisely pretty mediocre at best). Does anyone really think that psychopharmacology would have become so widespread of people actually experienced substantive benefit from psychotherapy for the past century(even if they could pay for it and wait for the benefits)?
Thank you writing this piece, Daniel. As someone who quit social work school and felt very hurt by my own experiences in psychotherapy, I find your piece validating and appreciate your willingness to think openly about your own future with the field.
Can you please post this beautiful comment on Easley’s blog?
Ted- I agree that arriving at a forum of people who have experienced oppression in a position of power without being thoughtful about the dynamics at play is counterproductive. Coming into a space of folks who have deep experiences of marginalization from a priviliged perspectives requires some thoughtfulness, flexibility, willingness to be called on for things that may be difficult to here, and a sincerity engage for personal benefit (not just altruistic or paternalistic or exploitive reasons).
While I don’t like the word “respect” without operationalizing it, I think you are right on not to expect respect unless you are willing to give it and not give respect when it has clearly not been given to you.
Matt- Can I refer you to a post I wrote and revisited after reading some comments here about allies and engaging in spaces of folks marginalized by oppressive systems?https://www.madinamerica.com/2012/05/human-rights-and-managed-care-part-5-conclusion/#comment-10716
Thanks for the thoughtful post and the increased clarity about posting guidelines, Matt.
I wonder if training programs/students weren’t well targeted for the boycott. I know a lot of professionals don’t care for the DSM, but students in psychiatry, social work, psychology, and other mental health professions have to buy some versions of the DSM as part of their course material. I bet this is where much of the profits from the DSM enterprise comes from. I wonder if it would be a better strategy to target training programs/universities, especially now that the Insel at the NIMH says he is shifting research (aka funding) priorities away from the DSM project, to keep them from asking students to purchase DSM and to even stop teaching it.
I guess the same critiques could be leveled against all psychotherapy, which is fine.
“Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care…Yet, what may be realistically feasible today for practitioners is no longer sufficient for researchers. Looking forward, laying the groundwork for a future diagnostic system that more directly reflects modern brain science will require openness to rethinking traditional categories.” -the Joint Statement.
I think this illustrates a crucial change in DSM narrative from years past. I have been hearing for years that the DSM was mostly useful as a research document, but should not (and is not) taken seriously as a clinical one. I feel like the most serious praise the DSM endeavor had was least in having some reliability in research, even if that research was never really well applied to practice. Their statement is a reversal, saying the DSM is not a good research document (even though new domains in research have not been well developed yet), but patients, families, and clinicians should still trust and use the DSM to inform practice (which “good” clinicians and APA leaders have very frequently said they don’t do).
I agree with cannotsay, their initial statements/reactions still stand and this new joint release is a poor attempt at double-backing.
I guess what is happening now is finally some overt and widespread dissemination from Psychiatry that the DSM is not supposed to be final word, however, it has already been built into many institutional systems and the cultural imagination that I don’t know where this leaves us. I don’t know if the power of the DSM can be so readily decoupled from its uses in insurance, law, benefits, etc. The RDoC is a poor and unready substitute, but the point of this whole breakdown is that there should never have been a psychiatric “bible” to begin with.
Focusing back on patient care, what do psychiatrists say they treat without a DSM? Patients? What about them?
If only psychiatrists could convince policymakers, insurance providers, judges, families, of their lack of interest in the DSM, lobby for the reduction of diagnostic requirements for benefits or just understanding of ditress. However, we have seen decades of organized lobbying of the opposite.
I think this double speak psychiatrists do of both preparing and profiting from DSM as a cultural (and legal and economic and political and religious) document that is needed to maintain their expected expertise of psychopathology but at the same time do not demonstrate the interest or competency to use it actually guide diagnosis irked me a lot when I was in clinical social work school. As a student, I was expected to memorize DSM diagnostic criteria (and did), was extensively tested on differential diagnosis (and was graded favorably), and told that this is what clinicians do, use the best available science/expertise available and apply it to practice. If social workers were being indoctrination into the use of DSM (a Faustian deal they made to abandon previous previous principles in order to get insurance reimbursement in private or community practice), how could psychiatrists be so careless and snide and proud in their own “healing” powers to blatantly disregard the document. I don’t think I ever believed that diagnoses were particularly valid, but I did believe that many were constructed to be rarely diagnosed so if a diagnosis was given, it was because something very serious was being experienced by someone (whether or not it was a brain disorder). So when I saw psychiatrists diagnose bipolar disorder because someone said they had sometimes been sad and was currently talking at a speed the doctor thought was fast(without consideration to medical history, substance use, or how long symptoms were around or even asking about someone’s typical rate of speech) and then billed insurance and prescribed mood stabilizers, it really was disillusioning. This happened in all sorts of evaluations.
Dr. Datta, I appreciate your apparent understanding of a lot of the cultural frames in which psychiatric power embeds itself and emerges, but I would love to hear more about what you might suggest Psychiatry do in getting out of the business of defining personhood and what else you think they should be doing? As I reread your article, I am struck by your ability to make distinctions between how Psychiatry as systemic force has such profound impacts on legal proceedings, cultural understanding, and personal subjectivity and that somehow psychiatrists themselves (at least the “smart” ones who have clinical professorships in university settings) can go along just fine without being influenced by that systemic force or act without regard to it. I just don’t see how that is possible. If psychiatrist don’t use the DSM in practice, why keep making them? Why get resentful at other clinicians for engaging in mental healthcare for not finding it important either? I guess I am still seeing psychiatrists wanting to have it all ways, to be leaders of the mental health field and claim expertise of people’s inner experiences, claim that their leadership is based on their intelligence, training, and understanding and application of science, but then when science is lacking also claim that leadership just on their cultural power that the science supposedly gives them in the first place through the development of such documents like the DSM(even though it is lacking in science).
Perhaps I am trying to get an answer to what you think “good” psychiatric practice looks like, why do you think it looks that way, and why don’t more psychiatrists practice that way. What would have to be different systemically for this to happen? How can psychiatrists help in engendering those systemic changes? How are they impeding them?
In my experience with Psychiatry, I have actually found pretty limited training in CBT in psychiatric residencies, and that psychiatrists focus on primary psychopathology and foundations of dynamic psychotherapy. Maybe it is a US thing, but I feel that psychiatrists in the US often feel like CBT is too easy/manualized and doesn’t require the “abilities” of someone with their education/intellect to practice, so if they do to psychotherapy, they do dynamic therapy. It is also a divide between psychiatrists and psychologists, the latter who take scientific methodology more seriously and tend to conclude CBT approaches more helpful. This may play into psychiatric power getting more professionals to buy into a mental health care systems that privilege short interventions (psychiatrists do meds, psyhologists do CBT, both get reimbursed), but I would not disregard interest to more systematically study how interventions are helpful or not for people. Psychiatric power does not come from actual science, but popular and psychiatric belief that trained mental health professionals don’t really have to have science to justify their beliefs/actions regarding intervening with someone in distress. To me, part of the proliferation of CBT, for a while at least, was an example of a confrontation of a psychiatric system that did not have justification for a lot of its interventions and did not have to have it to become more focused on doing things that actually engender robust outcomes. While the outcomes of CBT may not be all that robust and focused on “symptoms” of invalid diagnostic schemes, for me (and perhaps this is too naive), that the shift in mental health thought that has made CBT more commonplace can be used to hold psychiatry power more accountable, and I think it already has in some ways as seen now in a more widespread rejection of DSM-5. Because of CBT, we can now say, “Show me the evidence that this diagnosis is valid,” “With what evidence do you have that this kind of treatment/policy is helpful, and helpful for what, and and what costs?” When there isn’t a good answer (and orthodox mental health care doesn’t have many), I think it gives some leverage to support the work of HV and folks asserting more determination in what is both just and useful for them. I think it can work to destabilize some of the power relations between “mental health experts” and others, and allow some space for folks of all training/experience/life to come together to work on new ways forward.
I really appreciate you pointing out to Dr. Pies that in further defending his initial assertions about the value of diagnosis, that his original point was pretty meaningless. He basically was saying, just from a linguistic standpoint divorced from lived social and historical context, diagnosis is not inherently stigmatizing. You can say this about anything. Without context, things don’t have meaning, thanks for that lesson, Dr. Pies. However, diagnosis exists in a particular context moderated by systemic forces that are difficult to challenge to their overt and covert penetration into our institutions, daily lives, and even subjectivities/identities, so his whole assertion does not move a discussion anywhere, just obfuscates it.
I would also entreat Dr. Pies, as it seems that many critics of contemporary psychiatry and mental health practice more broadly and psychiatrists agree that poorly informed policy and conflicts of economic interest create a context where diagnosis and treatment can be quite damaging, please rally psychiatrists to lobby agressively and for change. This is ultimately in psychiatrists interest, as given the condition of the state of psychiatric science, public trust in their competence, ethics, and knowledge is really the only thing that gives psychiatrist any meangingful healing power, and that is eroding rapidly. Whether psychiatrists like it or not, your practices and research are severely limited by state intrusion, uninformed funding priorities, and ties to some of the most reprehensibly greedy and profitable and exploitative corporations to ever exist on the planet. You are your own best advocates, and no group of anyone has more influence to do this than psychiatrists, please work with yourselves and folks you purport to want to help to make systemic changes that lead to more helpful and just care and living and limit oppression and hurt at the deepest psychical levels.
Does Ronald Pies really consider himself abused by comments made by folks online? I really resent when professionals have or feign such sensitivity, but then when patients demonstrate such sensitivity to coercive power or abuse (which I’ll define as “is the improper usage or treatment for a bad purpose, often to unfairly or improperly gain benefit”), it is often used as a criterion to meeting a threshold to diagnosis that compounds that abuse.
Again. Even the research on particular symptomology/disorders I find suspect due to the lack of validity a these “disorder” have. I do think there is growing psychotherapy literature that is showing some effect for some kinds of issues people face, but the results should not be generalized past their intent. Dealing with obsessive symptoms and and panic can alleviate a lot of distress, but it won’t help with a lot of other things people struggle with. I think by investing too much in individual clinical care, we do not invest in our social/economic infrastructure that allows people that affords more people the autonomy, relationships, and stability to live lives with less impairing distress.
I think you may have misinterpreted my assertion about alliance and therapy outcome. I believed you were citing a now commonly argued notion that therapeutic alliance is the best predictor of psychotherapy outcome (not therapist skill or particular therapy technique for particular issues), and using an illogical correlation equals causation logic, that good therapeutic alliances lead to good outcomes. I countered with the assertion that there is growing evidence, in at least some kinds of psychotherapies, that good outcomes cause/lead to good alliances. People who start to feel better due to psychotherapy start to feel a better alliance with their therapist (because therapy seems to be working). They don’t feel better because of the alliance, but the alliance improves because they feel better. These are very different explanations.
Additionally, the studies/researchers that advocate for the “dodo bird hypothesis,” basically mix outcomes of all sorts of different studies with different outcome measures of different psychotherapies dealing with very different client/patients dealing with very different issues and with all of the noise in the data, can’t find a lot of difference, and everything seems about mediocre. The takeaway from such studies should not be that all kinds of psychotherapy are good for all people for whatever they are seeking help for, but that we do bad science in psychotherapy. For example, psychoanalysis is not likely to be helpful for folks with OCD symptoms, but exposure therapy is likely to be. Dynamic therapy may be helpful for panic, but other treatments may have been shown to be more likely to be helpful and take less time/money. Mixing outcomes of very different kinds of studies and then seeing after you mix enough of them up that technique/approach doesn’t matter is a wrong conclusion. Ultimately, everyone should decide what they think can be helpful for them. For me personally, I would like access to quality research to help me make more informed choices about what will be helpful and why it would be.
And just a year ago it seems Ron Pies was making a different argument. http://psychcentral.com/blog/archives/2012/01/07/why-psychiatry-needs-to-scrap-the-dsm-system-an-immodest-proposal/
I left off informed consent to my list in the last paragraph.
There is actual still quite a bit of debate about the “dodo bird hypothesis,” that is that psychotherapy skill is a minimal factor in treatment outcome while alliance is the great predictor of outcome for all issues psychotherapy clients face. There is a lot of evidence against this, and it’s the kind of thinking that is using medications without scientific basis, (“if people feel better when they take drugs, why does it matter what the data show?”) Even if quality of alliance is associated with better outcomes, this does not mean it is the quality of alliance that determines outcomes. Studies that address change in psychotherapy over time and therapeutic alliance often show that alliance improves AFTER people start to feel better, not the other way around. That makes sense for a lot of cases, as a lot of folks probably don’t trust clinicians as much until after they see that therapy is helpful for them. I think in this regard just saying people should seek quality therapeutic alliances is not supported advice. It also leaves folks who have a lot of trouble forming therapuetic alliances the way they are often fomented in psychotherapeutic frames, potentially leading to a lot of negative feelings, shame, and more stigmatizing diagnosis.
I’m not warring on psychotherapy, I just think critique of science, politics, and economics of biomedical psychiatry should also extend to the broader mental health field, including psychotherapy. I want good research in psychotherapy, and if that research yields quality findings, I want those findings applied. I just don’t think the science of psychotherapy is all that strong, let alone how the structural elements of mental health law, insurance, diagnostics, stigma, privacy, and payment are currently aligned in regards to therapy.
Your experience as a therapist and in your personal therapy are valid. Lots of people will say the same about their medications, diagnoses, and chemical imbalances. Let’s be clear than that your argument is to not based on review of quality science, but on your individual experience. Again, I’ not a fan of how good research in psychotherapy does some reifying of DSM disorders as part of their research process, but the American Psychological Assocication has compiled lists of best first-line therapies given the current evidence for different issues people face (http://www.div12.org/PsychologicalTreatments/index.html). It’s a start, but it is far from saying that more psychotherapy will mean better experiences for folks.
I’ll quickly add to my comments about the Cochrane review of STPP. In the conclusions printed in its abstract, the authors note: “STPP shows promise, with modest to moderate, often sustained gains for a variety of patients. However, given the limited data and heterogeneity between studies, these findings should be interpreted with caution. Furthermore, variability in treatment delivery and treatment quality may limit the reliability of estimates of effect for STPP. Larger studies of higher quality and with specific diagnoses are warranted.” I agree with this all of this, and think that it demonstrates that the question of the effectiveness of STPPs is far from established.
I value research sophisticated research in psychotherapy. I support the evidence-supported treatment movement (despite a lot of problems reifying DSM diagnoses as part of demonstrating applied treatment effect). I do think lots of poor science is done in psychotherapy research, science similar to ones for psychotropic medications. Similarities include high publication bias, allegiance bias (clinicians who ascribe to particular theoretical orientations who do studies on their kind of psychotherapy show high effectiveness of that kind of therapy similar to the effect of drug companies who that fund research on their own products), inappropriately powered studies that lead to confusion in the meaningfulness of statistical significance of statistical equivalence (psychotherapy studies are often underpowered, drug studies are often over powered), inappropriate selection criteria,poor data cleaning/analysis (not including drop outs in in the final analyses, or doing intent-to-treat analyses), etc. I could go one. Control/comparison groups in psychotherapy research are often no treatment or an intentionally poor treatment, which doesn’t tell you much about the comparative effectiveness of a psychotherapy (beyond it being better than doing nothing), and when comparison studies to happen, they are so under powered that it’s hard to demonstrate anything but equivalence. Psychotherapy research has also not been good at assessing and mitigating potential harms that have been demonstrated to reliably occur (at frequencies higher than many of the more common side effects of drugs).
Again, I do not think psychotropic medication research has been quality science the past 30 years, but because that is so does not lead to an increase in psychotherapy services, as I believe psychotherapy research has also been poor (though in some circles getting stronger). I also think a broader issue, if we want to use the money we spent so wastefully on (mental) health care, more efficient uses in social and economic policy outside of the mental health world may actually be more beneficial for people’s mental health.
Beyond that, I would like to comment on some of your evidence for the effectiveness of psychotherapy (even beyond the fact that you list disparate studies of very different kinds of therapeutic interventions for very different issues using particular kinds of outcome measures that many would say lack clinical meaning).
In the group CBT vs Paxil for moderate to severe depressive symptoms, saying the CBT is equally effective as Paxil for depression isn’t saying much about CBT, as Paxil, of all the SSRIs, show’s the most modest drug effect (if any) on depressive symptoms. So this study echoes perhaps at best Irving Kirsch’s analysis that depression alleviating effects of Paxil are placebo, in that taking it feels like taking a positive step and associated drug effects increases hopefulness. This is proposed mechanism of CBT, increasing hopefulness through changing behavior and thought processes. If CBT is as good as taking a placebo pill though, is it worth the cost to engage in it?
Evidence of dynamic therapy for reducing panic symptoms is in the study you note is stronger. But again, this is a basic efficacy study, showing that dynamic therapy is better than doing nothing to treat panic symptoms. I bet a lot of things are better than doing nothing for addressing panic, and doing some well-powered comparative studies next would be able to help make stronger claims about the value of dynamic therapy for panic, and whether other interventions may be better first or second choice interventions.
The Cochrane study mixes outcomes of broadly defined short term dynamic therapy for many “conditions” in its analyses. That adds a lot of noise to their meta-analysis, a method that requires some thoughtfulness in study selection as it is prone washout effects when combining too many kinds of things being studied with different kinds of outcome measures. I do know that Abbas is also a huge advocate of intensive STPP and seems a biased author. Even more, again, they only found STPP better than minimal or no treatment. Again, I bet just talking to someone for many general adult conditions is better than doing nothing. This study does not tell much about the efficacy of STPP for particular concerns or whether its comparative effectiveness is meaningfully better than cheaper or less burdensome interventions.
The 20 year old Consumer Reports study main outcome measure was people’s satisfaction of their experience in psychotherapy. Satisfaction is not a meaningful outcome (I consider it an output), as satisfaction is not a value engendered by a treatment, but a reflection on the process of it.
Seligman notes the many drawbacks and methodological limitations of the study, I think the most important is that is neither an efficacy or an effectiveness study. There is no comparison of psychotherapy to anything, not even nothing. It could be that people in this study were worse off due to their treatments than doing nothing, no matter how satisfied or not they were with it, the study doesn’t help with determining this. I’ll quote Seligman in his conclusion, “The study is not without flaws, the chief one being the limited meaning of its answer to the question ‘Can psychotherapy help?'” This should not be included in the category of effectiveness literature, and full of all sorts of biases that the make answering the question of effectiveness mute (Seligman notes these too).
The Leichsenring and Rabung meta-analysis has been severely challenged I think to a point to be discredited. The methodology of their metaanalysis was poor, they do not compare treatment group to a control, but individual patient at endpoint to baseline. They include all sorts of disparate diagnoses that add so much noise to their data. For more detailed critique of this study, see here: http://www.psychotherapybrownbag.com/psychotherapy_brown_bag_a/2010/05/wading-through-a-sea-of-bad-science-a-closer-look-at-a-metaanalysis-comparing-longterm-and-shortterm.html
Cindy, my main argument this whole time is just that psychotherapy research is similarly poor to medication research, so trying to increase psychotherapies as treatment for mental health issues instead of drugs does not have strong research support. Eysenck (starting in the 1950s), Mors, Lillienfield and others have done research in the potential limited effects of potential harmful effects of psychotherapies. Additionally, iatrogenic effects of psychotherapy is not taken nearly as seriously as iatrogenic effects of medication, and folks who experience it have little redress, support, or acknowledgment that engaging in what was told to them is safe and “just talking” can actually lead to worse outcomes from when they began. Finally, non-clinical interventions (beyond drugs or therapy) should be part of the conversation on supporting people’s well-being as a potentially effective and efficent way of doing so. As you say, if 90% of visits to doctors are stress related, I bet we can work at more systemic changes in reduce that stress and increase well-being than engaging in more clinical treatment.
I don’t want to hawk, but shouldn’t therapists who are poorly trained, burnt out, and have issues that interfere with their ability to provide helpful therapy ethically not be working as therapists? Isn’t it their responsibility as well-meaning, experienced, highly-educated professionals to do so? My assertions also extend to only licensed therapists, and to be licensed, therapists need advanced degrees, practicums, thousands of hours of supervision, and continuing education. Which psychotherapists are poorly trained or do not keep up with training? Ones that are engaging in unethical practices, are unlicensed, and hence should not be seeing clients anyway. I also find it strange that research also indicates no meaningful difference in outcomes of therapists based on degree or experience, so why should clients pay more for more experience or more school for their sake?
You’re right that few people have the resources to pay psychotherapy fees. Perhaps that means they are too expensive. This doesn’t mean other health services are not also too expensive. If anything, this should lead to folks challenging the reimbursement system and/or lower the cost of care. I also think people would pay for psychotherapy if they thought it would be helpful, but folks don’t, often with good reason. Arguing that it helps to reduce medical illness and utilization cost is a nice sentiment, but people don’t seek mental health care in order to reduce medical utilization costs. It’s far from a primary outcome. I will add that Psychotherapeutic interventions can have side effects that land folks in hospitals (or jails) too, and when folks experience them they are often instructed to take psychiatric medications as part of that process, now getting them into a situation of paying even more.
Medication is not actually intended to be taken for a lifetime, folks often think they won’t be but then find to late that withdrawing is more difficult than staying on despite adverse effects. A great deal of psychotherapy in conducted in the US is open ended, with no time-limitation set in the beginning. I bet it is underestimating cost of treatment that ends up ending it (folks are in therapy longer than they can continue paying), whether or not anything has been helpful.
We are spending lots on healthcare primarily because of an aging population that is living longer, being treated for diseased states (not acute disease) linked with environmental factors (heart disease, diabetes, cancers. etc.), including the expense of end of life care. Healthcare has also become profit driven in the pay-for-output model (number of prescriptions writen, number of therapy sessions, etc.) that has no incentive for addressing the factors that lead to such disease states or in anything related to curing them (just chronic treatment).People may have spent more in the 70s on mental health because psychotherapy was the primary treatment offered and it was expensive. The folks who could pay for it could pay for it, but the folks who can’t pay for it now couldn’t pay for it then, either, insurance or not. Part of the reason insurance companies gravitated to paying for medications and shorter term psychotherapies was precisely because what was being offered was not all that helpful. They were paying a lot and not seeing good outcomes. Might as well pay less to not see good outcomes.
If the big issue is payment and insurance reimbursement, I’d recommend advocating for an outcomes-based payment structure, either privately contracted or from insurance/government payers. Privately, therapists and clients decide what outcomes of treatment they expect to be able to get and the cost of of that treatment. With insurance/government payers, they will have some say in the price of those outcomes. They can even factor in the reduced medical utilization costs you cite for paying more for good treatment. The more clients therapists reliably help clients in the most efficient amount of time, the more money they will make. Therapists who reliably engender good outcomes would make zounds more than therapists generally make now, their practices would be filled with people who have evidenced trust in the competency of their therapist, and therapists can afford all of the training and lifestyle standards their level of education supposedly entitles them to. Therapists who don’t engender outcomes reliably will soon be looking for other work, as spending their time trying to help and not being helpful will not longer be profitable. This is good for patients to, as these would be therapists who are apt to be burnt out, supposedly poorly trained, or have other issues interfering with offering helpful treatment. If therapists can demonstrate good outcomes, they can charge heftier fees, and still make a lot of money even if they end up not being able to collect payment from the minority of patients who they end up not helping. Clients who are helped more gladly pay for their help, while clients who aren’t at least don’t have to deal with the financial loss on top of failed treatment.
While meaningfulness of intended psychotropic drug effects and their harmful effects are poorly studied, poorly regulated, and highly influenced by financial interests, the meaningfulness of intended psychotherapy effects and their harmful effects are even less studied and regulated. Cost of psychotherapy can be as high as the most expensive psychotropic medications.
I would leverage similar critiques against psychotherapy research and treatments as I would against pharmacological or somatic research/treatments. I don’t like when psychotherapists use this crisis in biopsychiatry to try to reinsert psychotherapy as a primary treatment, even though harmful effects of psychotherapy are even less studied (or reported) and folks harmed by psychotherapy have less redress. As a social work school dropout, I was highly dismayed by idolizing of the biopsychosocial model as a way to frame people’s experience of distress, but in practice, I just saw how by tacking “social” to the end of model, allowed social workers to take a piece of the insurance reimbursement pie from clients who had it by submitting to the hegemony of psychiatry. Social workers diagnosed the same, relied on the same crappy studies, referred for the same medications, and spouted the same ridiculous etiologies (ex. chemical imbalances).
I agree that health care resources spent on issues that are more related to stress and lifestyle would be better spent on making life less stressful and life more meaningful. I don’t see why spending this money on psychotherapy would be more cost-effective than in policy programs that let people access high quality food, support fitness, have secure housing and child/elder care, have meaningful work with living wages and paid vacations/sick leave, and works to undue overt and covert institutional oppression. I bet this would all still be much cheaper than our current health care expenditures on managing symptoms of stress of the fragility of our existence in a highly dysfunctional society and of the added negative effects of the drugs prescribed in the first place. Psychotherapy still relies on a giant clinical infrastructure, money few people have, and lots of harmful diagnosing.
No side effects? Psychotherapy literature is full of evidence of folks who get worse in psychotherapy, and some psychotherapies themselves (like Critical Incidence Stress Debriefing, a very short-term targeted psychotherapy) are likely in general to increase and add to the very symptoms they are intended to alleviate. What about all of the folks who spend years and thousands of dollars in unfocused/eclectic insight oriented psychotherapies that don’t seem to get their lives any better. Or the folks who decompensate in such therapies and are left much worse and poorer than where they began, with fewer emotional, social, and material resources, let alone trust, to seek any kind of support in the future?
Part of the whole move to remedicalize psychiatry in the 70s and 80s was precisely because of the dogmatism, inaccessibility, and poor outcomes of the psychoanalytic hegemony of the previous decades. I know that all kinds of psychotherapies have grown and “advanced” since, but the bigger issues still stand. Before advocating for more psychotherapy, I’d rather see mental health professionals advocate for saner social and economic policy/relations, and then see how much mental health treatment is needed.
I think part of the issue in the US in the payment system. Axis I disorders are considered potentially treatable (even when we have no evidence of specific, helpful treatment), while Axis II disorders (personality disorders mostly), are considered untreatable or not worth treatment. Because of that, providers don’t often like to diagnose them, as insurance won’t pay for treatment that they don’t think can be helpful, and people don’t like to be labled with them because it undercuts credibility, sense of self, and future accesss to treatment and sometimes just basic rights (parenting/custody, parole, licensure for certain professions). Despite this, personality disorders, when diagnosed, are often done as a punitive or defensive measure. Patients who don’t get along with their providers or respond well to their chosen treatments are often labeled with a personality disorder to explain why their treatment isn’t helpful. It also can be used to cover mistakes/errors, and make patients seem less credible if professionals fear litigation. Basically, the diagnoses basically label people bad patients and bad people, despite their distress or past history, and it does so with sense of permanence and depth that makes seeking change seem hopeless.
So, a stigmatizing personality disorder diagnosis?
I have been unsure how to enter this conversation, and now I feel a little silly wanting to enter as you exit, Layla. I just wanted to say I appreciate your involvement in this discussion. You are willing to bring your own quirks into your writings, and know you work hard to be engaging and kind.
I will also speak for myself in saying I don’t feel so free from psychiatry. I think I will always somehow be trapped by psychiatry as I have a record that follows me now and a lot of missing time in my life caused by treatment.
I’m gay too, and I now live with a lot of fear and anger about my lack of ability to adopt children (something already more difficult for gay folk and something that I had previously hoped to one day do), as I am fairly confident that how I was labelled after I began to raise concerns in my treatment makes me pretty much ineligible. This may be able to change if I can engage with more psychiatrists and somehow prove I am not what my notes say, but even doing that would be ammo for relabelling me.
For me, and I think you get at some of it in your response to Jonah, that the ability to predict good and bad outcomes in engaging with mental health treatment is so poor, but as a patient, you have to submit yourself to that risk. I did not know what risks awaited me in treatment, and wish I had a better sense of what it could be before I engaged. I sought treatment because I wanted to stay engaged with my life, and found that treatment derailed me from it, and then stripped me of a lot of hope/interest for even trying to reengage with again. Being hurt by treatment is trapping in that it makes talking about what happened to you so difficult. For me, I’ve lost trust in mental health professionals, regret even intending to be one (I was planning on being a clinician before I engaged with treatment), and I fear further alienation from talking to others about the experience.
For me, I no longer feel ethical seeking to become a clinician, knowing the poor outcome data, pseudo-diagnostics, and the real harm that treatment can engender. I do wish you care and luck in your path.
The message is clear, be wary of Swedish fish.
I’m still trying to challenge the notion, taking off from Jonah, about the value of formulation to people who are wary of mental health system. It still requires an engagement, and one seemingly with a professional, in which to me leans towards having a coercive element and lack of authenticity/mutuality but attempting to have the illusion of it.
It still feels like you’re paying someone to tell you what’s wrong and they know how to fix it, and if you disagree/disengage/feel off, well, that sucks, or, maybe you would still be diagnosed with something as to cover the professional’s reputation.
I kind of feel this is similar to John Hopkins Psychiatry’s theoretical export, “The Perspectives,” a way of doing psychiatric evaluation through the lens of four perspectives, disease (or biological lens), dimension (personality/intelligence), motivation, and life story. It bills itself as somewhat at odds with DSM/diagnosing but not mutually exclusive.
Perhaps, I guess as someone who has lost interest (and increased fear) in engaging with mental health professionals and pushing for a severe reduction of the mental health care apparatus in our lives/societies, I’m trying to see why we would try to maintain it for what I still feel is like psyhological diagnosing.
I guess it still comes down to “how it’s done,” but I think that can be said about most anything. I also disagree with the binary distinctions you made with DSM diagnosing and formulation, particularly in the extent that they both require engaging with mental health professionals which is not necessarily normalizing, often stigmatizing, assumes expertise differences (otherwise, why seek a professional), and is certainly not culture-blind.
narcoleptic should be neuroleptic.
I agree with Dr. Steingard, your example seems like a pretty typical psychodynamic formulation and doesn’t seem like something that would early on in a treatment relationship be co-created. It seems a clinician had very quickly made dynamically informed hypotheses about the the etiology of symptoms/experiences and very quickly made interpretations about the meaning of someone else’s experience. What if Jane didn’t share this view of the meaning of her difficulties/voices? This might feel kind of like an assault early on, let alone keep someone from seeking support again. Perhaps if Jane does have “self-awareness,” “intelligence,” and “motivation” to talk about her past, she may be amenable to a psychodynamic approach, but not necessarily. But I always kind of resent the often dichotomy I see in psychotherapy communities (particularly psychiatrist led circles), that push for as much exploratory therapy as possible, see patients who possess traits that they think make people do better in dynamic therapies as somehow ideal/better, regardless of what the patient feels about such a treatment plan or lack of evidence to back it up.
I’m not sure this formulation also suggests particular paths forward for recovery. I can see many clinicians have this formulation and still recommend narcoleptic medication. I bet a lot of clinicians/patients could also come to the conclusion of: “you have experienced a great deal of trauma for a long time, so at this point, you are likely to have to be on medications for the rest of your life. Your intelligence and self-awareness of your illness are assets in this treatment because you know that you have to comply to medication use to feel well and avoid relapse.” Either treatment recommendation can come from the formulation, and again, they seem more clinician developed and not co-developed, and a little coercive/depend on the explanatory power of a professional.
I’m not really convinced yet that this process has any more validity or reliability in terms of describing the issues people face and the helpfulness of intervention (ex. relationship with therapist/worker) than the research of application of treatments to reduce particular symptoms and increase well-being based on diagnostic criteria. I don’t want to sound like a stick in the mud, but this all just seems neo-neo-analytic and I’m not yet convinced how accessible and helpful such an approach will be.
I do want to push back a little bit about the Dodo Bird hypothesis. While I agree that the lack of validity of DSM diagnoses, the criteria used in diagnosis, and hence the difficulty of comparing treatment efficacy in helping people with particular diagnoses, different psychotherapeutic strategies do show different outcomes for particular kinds of diagnoses.
A lot of the problems of of the meta-analyses used to supposedly confirm the Dodo Bird hypotheses is that they lump all sorts of outcome measures relating to all sorts of different kinds of outcomes on very different people. With that in mind, there is quite a lot of washout effect and the meaning of statistically significant differences become pretty meaningless as all sorts of measures get mixed together in unsystematic ways, really obscuring extent of effects of various interventions on various outcomes. It does not surprise me that such studies do not show meaningful differences between treatments, because the assessments themselves are not meaningful. Furthermore, these kinds of analyses do not then demonstrate that common factors are the key to psychotherapy (particularly for everyone with all issues).
I would also add that some of lack of differences in efficacy in psychotherapies may be precisely because of the lack of validity of diagnoses in the first place, with a lot of variability in research participants that wash out effects. While this is often an argument now made by psychiatrists in regard to the very limited effects of antidepressants in related to the broadness MDD diagnosis, agreement with the Dodo Bird hypothesis based on the current studies might be actually be due to the poor validity of diagnoses to begin with.
Mike Anestis at psychotherapybrownbag.com has written a lot about this.
I think the concept of “industrial complex” implies a system where different parts play product, costumer, seller, payor, payee, subject, object, instigator, victim, etc., depending on their relations to the other parts. Part of the literal “complex” is that it is difficult to discern a meta-motive or benefactor, because the pieces function together in a way where there is not a lot of choice to participate in the system or not, and that the pieces only exist as parts of the system and cannot imagine themselves ineligibly in a different context/relation. This is complicated by the resiliency of industrial complexes, as they respond to challenges and challenge by trying to maintain itself, often seamlessly reconfiguring and disciplining the components of the system to stay functioning. There is not all that much agency for individuals or individual parts, because the parts of the system become themselves only as part of the system.
So your more direct question, “what is the ‘product’ in the…[mental] health care industry,” I think is difficult to answer as such, as there are all sorts of products in transaction as part of the systemic aparatus. I might propose a different question, who/what tends to materially benefit least from the system. While not a great question, I think it does help keep in mind that while all players in the system have limited agency in their participation, some are more exploited and duped for the benefit of others (who rely on that exploitation to stay in business). I think in the mental health industry, patients tend to most meaningfully fit the bill here.
Dr. Carney, I appreciate your attempts to energize social workers to develop an actual professional identity and one based on their presumed core values. One of the reasons why I quit social work school is that I found such a lack of pride (and even remote consensus) in professional identity, and where I did find it, was in the regulated role of social workers to the bottom of mental health hierarchies where the were the best at “collaborating” with other mental health professionals (ex. taking orders from psychiatrists) and being self-sacrificing despite the little impact they have in that role.
My other issue was combined the lack of development of social theory in social work practice and lack of intervention development and testing based on those theories. There was such a disconnect between supposed values but the work I was shown social workers did was never their own (and if it was, it was just as unfounded as much of psychopharmicological interventions and intuitively applied psychotherapies).
The failure to sign on to the DSM-V boycott was a big blow as well. I think the Faustian deal clinical social workers make in managed care environments is that if physicians give lip-service to “biopsychosocial” approaches to mental healthcare, social workers will be allowed to be reimbursed for doing the kind of clinical work they approve of, as long as they don’t try to rock the boat and remember that bio and psycho are listed before social in the chain of command. Clinical social workers make a living these days only because of the DSM agenda and that they are willing to get paid less by insurance companies as long as they get paid. The ICD is still in arbitrary classification system and switching to it does not make approaches of social workers any different.
I’ll also point out that the other early 20th century movement in psychology, psychoanalysis, also was deeply tied to the expansion of Capitalism/marketization at a similar time. Edward Bernays, Freud’s double nephew, is heralded as the the father of political/economic public relations and propaganda.
I see the dangers of “benevolent” control freaks, but I am also suspicious of those who use people’s desire/belief in freedom or their potential for freedom for their own interests (the way Bernays and the analytically informed marketers worked.)
As for “token economies,” that’s what we live in now. Money as valued capital/currency that allows different people with different access to its accumulation and flow leads particular kinds of people to make certain political/economic decisions, mostly for the benefit of the people who are configured to accumulate and direct the most capital, “aka ‘not necessarily benevolent control freaks.'”
I just think it is great, and should actually me common practice, to systematically monitor and evaluate your own practice data. There are ways to do it with more intention, but I would suspect that doctors’ beliefs about the process and outcomes of their own practices are meaningfully different than what a systematic appraisal would show.
Evaluating practice data is a needed next step from just reading the results of a pharma-funded drug trial. It helps doctors get a better sense of how their own patients actually respond, a deeper appreciation for the risks, and in lieu of more experimental studies of tapering, at least some systematic data linked to client characteristics that can be used a guideline (beyond our anecdotal level of data now) and point to where the most productive research should be directed.
So again, I think it’s great you are taking a serious and systematic approach to at least monitoring what is happening in your practice. I think it is a shame that this is not common practice. It can be highly informative, reduce all sorts of biases, and helps clinicians make decisions with information that is not just based on their belief, beliefs about their past experiences, heuristics, or whim. Though I think insurance companies pool data from their contracted physicians for more nefarious purposes, I think it would also be great for doctors doing similar work with similar patients to at least informally collaborate on their monitoring so that they can question (with some supporting data) what their own effects on treatment process and outcome might be.
Didn’t Peter Kramer base his whole argument in his Defense of anti-depressants on the idea that some obscure study he thought indicated that they were helpful in recovering motor functions after a stroke?
I think he tried to assert (without evidence) that because SSRIs might (already leaping from what the data actually say in the french study) increase “neuroplasticity,” that he proposes that the mechanism of change in antidepressants is that they help people who are taking them make brain changes to get them not depressed.
That’s what this article makes me think of, Peter Kramer’s lame defense.
So… young people who are bored at work because because they are underemployed are a new potential market. When I read about any psychiatrist that is interested/specializes in adult ADHD I know that that person is really just in it for the “market” share.
You may want to get in touch with the maker of SuperBetter, Jane McGonigal. She designed the game to help her recover from suicidal ideations and depression following a concussion. It is both an individual and community game, customizable to fit ones own needs, and I believe can be played/shared on existing social media platforms. Check out the website. https://www.superbetter.com/
Os “do no harm” really “do as little harm as possible?” As I think more about it, “do no harm” and the Hippocratic does “jive” well with harm reduction, more than many approaches that risk patient safety, stability, sanity, dignity, etc, and I’m surprised than that it is not strongly embraced by Medicine (my guess is because it is lay-led and non-directive). To me, harm reduction is a way to engage with situation that is already having undesirable/risky/harmful effects in a way that reduces/mitigates some of that risk/harm in a way that doesn’t risk more and in a way a person in that situation is willing to engage with full access to needed information and full control/responsibility of the decision-making process. I think that fits as “help, or at least do no harm,” not “do as little harm as possible [even if trying to help.]”
The focus is not on the harms associated with the intervention of a clinician/doctor/outreach worker/helper of any kind, but on recognizing how a situation that is already risky/harmful/unstable can be made less so by a person in that situation, and how others who may be interested in helping can support them in reducing some of that risk/harm.
Harm reduction is mode of interacting/engaging often found in non-physician led community health organizations (though not exclusive). It’s origins were to provide an alternative to addiction->abstinence->relapse models of substance addiction treatments that a lot of people felt judged in (by themselves, by a higher power, by clinicians, by other patients/clients, etc.) or worthless/hopeless if they relapsed or had hopes of living life not seeing themselves as always addicted, abstaining, or using. This led and still leads many folks who don’t do well in that paradigm to lose hope and stop trying to make any change that they hoped to make in the first place. Harm reduction approaches, on the other hand, allows people to make decisions about their own behavior and the risks they were willing to take, learn about the risks of doing or doing certain things, and get support in living a way that works the best for people at a particular time while always allowing an option for change in the future.
Principles are applied by needle exchange programs to reducing individual and community health risks (HIV/Hepatitis B transmission, skin infections, thousands and thousands of needles not properly disposed, etc.) as well as avoid unhelpful punitive legal intervention for folks using and/or wanting to stop using injected drugs. Condom distribution/education is also considered harm reduction.
I’m sure many physicians have employed harm reduction principles in regards to addiction/withdrawal issues for both illicit and prescription drugs of all kinds. They have done it because it is often very helpful, is led by the decisions of the person wanting to reduce some level of harm/risk to their own experience, and because of that, can actually be collaborative/non-coercive/non-judgmental.
This resource is great because it is free, comes with a bunch resources one does not usually find when working with a doctor, and actually does a good job of laying out what risks are for all sorts of choices related to psychiatric drug use and all sorts of ways to mitigate some of the harm those choices might have.
Decision is not the word I would use, but I think I understand what you mean. By systemic, I mean that we really don’t have much decision or say in how things happen. Psychiatry has been entrenched with law, morality, health, capitalism, that it’s quite difficult to avoid its influence, like it or not. It is a regulating force enmeshed with those other system that creates a sense of what emotions/thoughts/behaviors/people are healthy/legal/good at the expense of pathologizing other emotions/thoughts/behaviors/people as sick/criminal/evil, with consequence of losing the privileged status punitive enough for folks to work hard to limit their emotional/cognitive expression to seem more “normal” while feeling righteous and fearful enough to need to control those who are regulated to the ill category. Being “ill” becomes a stigma that can never really be eiliminated, but only mitigated by taking steps to attain a semblance “normalcy” by acting in proscribed ways (constantly reaffirming one is sick, taking/buying medications to show compliance, paying for mental health services to avoid “relapse”, not working jobs that are too stressful [read: high-paying and/or meaningful], hanging out with people who are healthy or want to be “healthy,” avoiding protesting injustice as the injustices seen by such people are actually delusions and delusions mean you are sick, etc.). This sick folks who engage in this understandable mitigating process creates an interstitial buffer between the “healthies” and the “sicks.” Who would blame them? However, this buffering supports the paradigm in that in gives credence to the regulators that people are actually sick (“look, they even say they are sick!) and want their help, and makes folks who don’t engage in this process seem scarier, more distant, and hopeless, which would legitimize more coercive monitoring and control of them.
Psychiatrists, insurers, politicians, or whatever, everyone does their jobs hoping to do some good, but they have to play the part in the systemic forces they are involved with, as the punitive consequences for not doing so is too great (lose livelihood, prestige, professional connections, etc.) and often overrides any concept of personal morality people have.
Not to have another discussion about art and science in psychiatrist (I don’t believe there is much of any), the hope of many psychiatrists to have more “power” and time to engage with peoples subjectivities comes back to other fundemental questions we’ve talked about. What makes psychiatrists qualified to have this power? It certainly isn’t taught well in med schools. Why not pay clinical anthropologists or clinical social theorists if skill in understanding unique subjectivities is important to mental health? Why pay psychiatrists more than any other mental health professional then?
“As individual psychiatrists, most of us wanted to have enough power to do more than just med checks, a quest most of us have lost.” Many many psychiatrists work in private practice in wealthy urban centers and their surrounding suburbs without being associated with any insurance panel. They charge high fees ($200+/hr) to do just what you say psychiatrists want to do. If such care (regardless of how effective it is, costs so much, than how can anyone who does not have huge savings, high incomes, substantial familial support, or excellent out-of-network insurance coverage able to access such care? If psychiatrists want to treat other kinds of people than those who seem to be able to keep high incomes, how do they expect anyone else to pay? If you already agree that your training is no more legit or helpful than any folk healer (I do think than you have done a 180 from you first post if this is true) and biological pathology does not play a role in people’s emotional/cognitive expressions/distress, why are you entitled to such high pay/reimbursement? Either work with folks with a lot of money willing to pay you for having a special friendship (like many psychiatrists in private practice do), or take the reimbursement or limited pay that is available to you or that other non-physician mental health providers get.
There are still a few graduate programs in psychological anthropology, cultural (or transcultural) psychiatry, and cross-cultural psychology, with interrelated aims. It is very much a research discipline, and I have found it has had little impact (beyond some lip service) in professional mental health services, particularly psychiatry.
In fact, the current trend is to push forward a nosology that is ahistorical, neurobiological in the most important regards, and somehow universal. I know the DSM has a subsection on “culture-bound syndromes,” but as I have noted before, demarcating a subsection as such creates the illusion that only some syndromes are culture bound (ones held by patients who are “primitive,” “pre-literate,” tend to me non-white, etc.), while the official DSM diagnoses are universal without cultural consideration. See: http://en.wikipedia.org/wiki/Culture-bound_syndrome#DSM-IV_list_of_culture-bound_syndromes
The truth is that DSM diagnoses are also culture-bound, and a product of a particular modernist cultural/intellectual tradition that I believe has acted quite violently since its inception in trying to define itself as trust/correct/normal/healthful/scientific/most respectable, while delegitimizing other understandings of wellness and lack thereof. Even though drawing power from the belief it is allied with science, the contemporary mental health industry (which is led by Psychiatry) has failed to offer much more than pseudoscience to rationalize its standard operating. Psychiatrists are “our” culture-bound “healers” we go to first, precisely because it has supplanted the infrastructure of and how believable other notions of health are by tying itself to medicine/rationality, but we have seen that the outcomes of psychiatry may not be all that much better than other culturally meaningful healers from different times and place.s
I know you don’t seem to agree with me on this Dr. Moffic, but I believe Psychiatry needs to be constantly defining itself as ahistorical/universal/scientific and in doing so denigrating/analyzing/limiting other understandings of mental health in order to maintain its own powered position in our world and to maintain any positive effect people to experience from interacting with it. Its a systemic feature beyond anyone’s individual intention. It also is not the case that psychiatry’s nosology is universal/ahistoric, as even the history of the DSM project shows so much historical, cultural, political, and economic influences at play with each subsequent edition/revision (remember neuroses or gay people manifesting sociopathic characters?). Each time, Psychiatry has to say something ike , “this time we have it more right, and it is righter than what anyone would say, and whatever happened in the past that was harmful was just because we didn’t know enough to be right enough yet. Of course we’re not sorry, we just weren’t as right as we are now. Keep on trusting us to make these distinctions, as no one has ever been more right than us.”
To challenge it, I think it is important to do what Laura did, and find a sense of Self and community that can function outside of the nosology/pathologization of psychiatry, find novel ways of interacting and caring for ourselves and each other.
Malene: No problem, Malene. It made perfect sense to me when I read it. Online communication can be tough though, particularly with things like analogy, metaphor, sarcasm, and satire. I personally try to avoid them unless I put in the energy to write them out more formulaicly.
Dr. Moffic: I think some of your attempts to make broad points through metaphor get lost in translation in online forums because of the limitations of the medium. Perhaps this above misunderstanding/situation can illustrate that point in a different way.
נ נח נחמ נחמן מאומן
Thank you, Dr. Moffic, for the reminder to speak true, to listen with care to others, to say our minds when appropriate, and to communicate with intentions beyond humiliation or hurt.
I think we have done an ok job at doing that here. Feelings are strong here, perspectives varied, but there is room for constructive, critical, heated dialogue. I will rededicate my intentions as a desire to express with others my evolving thoughts about many complex issues we have discussed here (as I don’t have much of community in my daily life to do so right now), think through what can be helpfully different with folks who have varied perspectives, and make sophisticated links between mental health liberation movements/theory with other movements/theory, and to do so with as much sincerity and humility as possible.
Where did I say Psychiatry was a curse?
“states” reason should be “stated” reason
I think the analogy was:
the Chinese government tries to shut down critique of their occupation of Tibet for the states reason that it is offensive to many folks in China,
psychiatrists try to shut down critique of their work for the states reason it is offensive to psychiatrists and people who experience benefit from their experience in psychiatry.
In both regards, while some people may feel offended by such criticism, that is not a rationale for limiting expression of such criticism. It also links the power of the Chinese government to limit critique in order to protect its own interests to the power of Psychiatry to limit critique in order to protect its own interests.
You could just assess people’s comments, assertions, and evidence as they are posted. You’re right, we know very little about the people behind a lot of monikers here. We can, however, assess what people post regardless of where it comes from.
As for blanket criticism, I think people are speaking more of the Power of Psychiatry (capital P) and psychiatrists, without (much) judgment of individuals in that field. Because like it or not, our sociopolitical system is structured in a way that requires Psychiatry to function in particular ways to maintain that system, often to great duping, harm, and coercion of many. This is difficult to change, particularly as individuals, in Psychiatry or not. Perhaps it is more difficult for you to see how Psychiatry functions systemically because as a psychiatrist, you have more nuanced experience than most with schools, residencies, journals, conferences, professional organizations, insurance companies, drug companies, regulators, colleagues, students, etc. The system is more personal to you, differently than the way many of us have felt hurt/duped/abused/ personally by a system (regardless of our doctors or whatever). I don’t discount your experiences/perspectives with a full professional life in psychiatry, but please recognize people have had radically different experiences than you have and those experiences are starting points for valid critique.
As for your “Psychism” article, I appreciate your attempt at an apology here. Though I don’t think apologies that follow the phrasing: “If my [words or actions] [did/seemed to] [do something that others found hurtful/offensive}, I’m sorry,” are actual apologies and more like offering of pity, it is a gesture of something. I believe for people to apologize, they need to own and recognize what they did, even if it was unintentional. An apology is a recognition that words/behavior, sometimes even despite intention, caused offense/hurt, the apologizor realizes that, expresses that, and wants to reconcile. Pies’ article that you referenced made as if anyone who ever had any criticism of psychiatry was actually saying
“I hate shrinks. Shrinks should die. Shrinks are evil” (without actually citing anyone who said that) and shame on all of us for being so crazed/uniformed/hateful. Blaming the lack of interest of med students in psychiatry on open criticism as if that was a stigma was insensitive and disingenuous. Maybe med students have seen the problems facing Psychiatry and don’t want to be a part of it. Maybe they just have other interests. Maybe they want to make more money than psychiatrists. Maybe they want to make less.
Stigma, similar to stigmata, is an embodied marker that at once separates people who experience it from those who don’t and allows folks who do not experience stigma to see themselves as normal/good, have to police/limit their own lives to avoid being stigmatized, and maintain a stigmatizing system of others in order to maintain their sense “normalness/goodness” that the separation by stigma provides. On the flip, it also leads people who experience stigma to feel less worth because of their stigmatization, often try to divert stigma to those already more stigmatized in order to “identify” with the folks do not share that stigma (to feel better about themselves at the expense of others), and internalize that because they are not “normal/good” they are really as freaky/bad/hopeless as everyone else seems to think.
Lots of folks experience all kinds of “stigma” in this regard, an embodied, never-goes-away marker of somehow deserved “less-than status.” In the US, gay folks certainly experience stigma, and we see how straight folks have to police their own behavior in order to not seem gay, and the contemporary gay rights movement led by professional non-profit orgs in DC has tried to identify with middle-class/straight norms to experience less stigma and in doing so pushes gay folks who do not aspire to those norms to experience more. People labeled with mental illnesses also experience stigma, as after their labeling they are treated with suspicion/fear/mistrust that people who even have documented histories of violence/abuse/coercion are not treated. Organizations like NAMI form that try to mitigate the stigmatization of people labeled mentally ill by “identifying” with the psychiatric establishment. This of course is failing strategy because it will never eradicate the effects of stigma of mental illness from folks labeled and throws more stigma on people who resist identifying with “establishment” as being more sick, more dangerous, more hopeless.
Perhaps there is an argument to be had that once someone is labeled a psychiatrist, they experience a kind of embodied marker of difference/denigration in comparison to perhaps other medical specialties. However, people have to compete for a med school admission, pay hundreds of thousands of dollars for tuition, go through at least 12 years of post-secondary education to become a psychiatrist. They have to really invest to get that marker, it’s not slapped on them without their consent, and in fact, they have to struggle hard to get that marker. They are basically assured a comfortable income and societal prestige. While Psychiatry as an institution may try to mitigate its sense of stigma by trying to be more scientific/doctorly aka identifying with more privileged specialties in medicine (by making all sorts of neurobiological claims of illness in the DSM-5, explaining mental health, pathology, and treatment in terms of biochemical functioning, etc.) and throwing more stigma down the ladder of respectability (claiming other mental health professionals, primary care doctors, and “mid-levels” lack the qualifications they do and are less deserving of payment/reimbursement for mental health services, by denigrating peer-led movements or folks offering suggestions to each other without medical consultation, etc.), in the scheme of things, based on its role to demarcate mental health from illness, psychiatrists as a whole have it pretty good. Lumping “stigma” psychiatrists face with those who are labeled mentally ill I believe showed remarkable insensitivity. Throwing more stigma on critics/survivors by lumping them with less respectable groups like “haters” and “scientologists” in order to further delegitamize their critiques/experiences is beyond troubling from someone who seems to always want more “equal” dialogue.
The psychiatrists you say who are reading but not participating, waiting for the climate of the website to be more favorable to their views for them to join, even though they could comment under an alias, seems strange for me. They seem like the folks who would have the different opinions, who have different points of view, who you think having on this website would be beneficial.
I don’t know what they are waiting for. If they don’t like the comments they get, if other psychiatrist bloggers on different forums are any indication, they can fee smugly satisfied in labeling their detractors “hater.” I do think that different opinions can stimulate a lot of interesting discussion, and if folks have thought about participating, they should go ahead and do it.
I think we are repeating the same dynamic of reform (to what extent and to who’s benefit) vs revolution (to what ends). Dr. Moffic seems to interject caution and fear of change, the real potential loss of benefit many people experience with psychiatry, and (more than he cares to admit) lots of apologist notions to some of the more distressing aspects of psychiatry, its power, and our relation to it. He also offers some points of I think more easily agreed upon reform (that I think could easily be psychiatrist led) like direct-to-consumer advertising issues, pharmaceutical company influence in psychiatric education/practice/research, and I think stronger research ethics.
I suppose if psychiatrists are waiting for this MiA “movement” (really, this right now is just a website bringing together a bunch of diverse interests and people with different agendas, growing, but I don’t think in itself constitutes a movement), folks here can just as easily wait for psychiatrists to engage in the reform that we all seem to be ok with happening in their own profession/industry/publications before we jump on board to support them. It can go both ways. The problem is that critics/survivors don’t have the luxury of benefiting from that system as is, are de-legitimization by it, and can’t just wait around for it to reform or not. So we are here, trying to start something new, bring ideas and voices together, and start engaging in change. It is great that Dr. Moffic can engage here, and if other psychiatrists want to put in their perspectives too, have their ideas reviewed and potentially challenged (something that we all benefit from), then come and join already! My suspicion is that there is not all that much will to make much change from the professional side.
I apologize to Dr. Shipko for contributing off-topic, as I thought his initial post was well stated and interesting, particularly in regards to the importance of reviewing raw data (should be a no-brainer.) When I worked as an evaluator, even some of the smallest funders were interested in seeing raw data so they could assess if reporting was accurate, that the FDA and many journals don’t want to check the results or conclusions of papers sent to them is tremendously irresponsible.
I find that the biopsychosocial model is often used as a cover for biobiobio models (No matter what the mental health concern, if there is a medicine that can be thrown at it, it often will be, no matter if there is good research supporting its use), a way for psychiatrists to in show welcome perspectives of other mental health professionals while still ruling the roost, and even if the best intentioned clinicians deny/avoid the above two uses of the model and try to use the biopsychosocial model seriously, in practice it is a sloppy framework for addressing people’s concerns.
When in social work school, I found the big push for biopsychosocial model to be social worker’s in to increased share of insurance reimbursement, as finally “social” has a role in legitimate mental health treatment. But in gaining entry to the club of folks who can get paid by insurance, they had to submit to medical model of mental health work, and actually do not bring much of their unique training/perspectives/research to clinical work, but continue to expand the medical model into their own ethos. This mostly benefits psychiatrists, in that it forces deference to Medicine by other mental health professionals, and because everyone is not seen as doing similar work, psychiatrists feign expertise in psycho/social/spiritual issues to seem comparable to other professionals, and psychiatrists are still the bio-experts who can prescribe, psychiatrists are still viewed as the most expert/definitive mental health experts deserving of most pay/respect.
As to psychiatrists only using the DSM for insurance purposes without paying attention to criteria, that is a huge scam, loaded with a lot of hubris. It assumes that mental health professionals (psychiatrists in this instance), are willing to give someone a stigmatizing label that they carry through their life without assessing criteria, willing to lie to to payers about the health/treatment of their patients, and the most distressing part to me, that they are confident enough in their knowledge/skill to treat someone with all sorts of interventions (bio, psycho, social, spiritiual, or whatever,) without having a strong evidence base to support those actions(especially if DSM criteria is what APA funded/sponsored/partnered journals require test interventions on.)
Basically, Dr. Moffic, you’re saying you and other psychiatrists are actively involved or knowingly complicit in a scamming of insurance companies, scamming patients/public in regard to the importance of your own diagnostic criteria, all for the sake of getting payment to treat patients in a way that you would like and believe is helpful (despite lack of evidence for that belief). I may be ok with this as long as the treatments psychiatrists used have been shown to be robustly helpful to justify the time/cost/risk, but the evidence for this is poor. I think most people here are reasonable enough to recognize that if treatment is a lot more helpful with some more time, it is prudent and cost-effective to fund effective treatments that take time (as opposed to mediocre treatments that take less time), but I have yet to be convinced that longer term treatments (be they bio/psycho/social/spiritual as administered in current practice are generally all that much better than non-professional intervention or placebo.
Funny you mentioned your psychiatrist saying “…prescribing medications is really more of an art than a science…,” as a psychiatrist I saw said the exact same thing to me when I wasn’t very responsive to medications. It also took me aback, as to me, the comment shows poor understanding of both art and science, and made me seriously question the value of seeing a medical professional for help (as I sought support precisely because I valued science). It eventually led to a lot of anger about putting trust in someone else’s knowledge, as “art” in the sense our psychiatrist used it is not how most folks think of art, but just a prettier word for “guessing game.” He later went on to say “Well of course you have to believe in medications for them to work,” which was more infuriating to me, but that’s another story, but also highlights how these interventions gain false legitimacy by being cloaked in medical/scientific language/settings/practioners, when science, the process in which you can make increasingly accurate predictions about causal phenomena, is absent.
I’ll also add that I found off-putting your description of the art world and “primitive” artists. Not to get into a long and useless debate about what art is in this forum, but saying that somehow some artists are legit/professional/sophisticated and are leaders of the world of art, and folks who do expressive works who are not part of that world lack the “technical skill” of real artists but still produce “emotionally” evocative work comes of as condescending, arrogant, with undertones of classist/racist/colonialist ignorance, however unintended. Especially the notion of sophistication and technical skill being a hallmark of folks in the art world, proxy terms for civilized/controlled, and the notion that emotional/mystical components of art are a hallmark of folk/primitive artists.
I suppose this does fit into an understanding of the mental health world that somehow lost/forgot the idea that people have been supporting others in distress since the origin of distress in all sorts of novel ways. Professionalization of that support and the kinds of distress it alleviates is a relatively new concept from a social/intellectual tradition tied with colonial power used to demarcate difference between who is civil and who is “primitive,” and used that demarcating power to keep professionals in position where their beliefs/practices/ideas are seen as normal/correct/ahistorical/transcultural and deserving of praise/recognition/payment, while other folks who work to alleviate distress are culture-bound/from a different time/unsophisticated/lack needed tools/lack needed training.
Just like the “world of art” is actually just one folk tradition of art among many, that happened to have been tied to cultural/political/economic forces that situated it as “real” art and labeling other art folk or primative, so has the mental health industry raise few models of mental health/suffering/care as if it was the best/most true and disregard other concepts of health/suffering/care that have been helpful for some people. The big difference is that Art, no matter how sophisticated, has long been considered a subjective field, while modern mental health is tied with more predictive/”objective” power of science/medicine.It claims scientific/medical legitimacy by extolling the requirements that the leaders of the field study life and physical sciences, that they where special white coats that indicate their intelligence and knowledge, and that their knowledge is more trustworthy and certainly more deserving of payment than folks who lack such study/coats, even though systematically gathered evidence does not lend much support to nosology and and vast majority of the applications of treatments of contemporary mental health practices.
The thing about “natural therapist” is that they tend to work for free, from their own position of compassion, or even some of their own condition of need (their survival depends on their acting like free therapist for others, much like Joseph)). In many cases, “natural therapists,” just means supporting a friend through a time of need with wanting or expecting anything in return during that distressing period.
In former posts, Dr. Moffic, you extol why psychiatrists are the best/most effective/efficient mental health practioners, and go even as far as saying they are the only ones qualified to use the DSM (while I disagree with much content of the DSM and how it is use, I also believe that it doesn’t take 8 years of school to use it competently and many psychiatrists also misuse/abuse it). You talk about the dangers of lay people offering suggestions or doing peer work without consulting a psychiatrist.
So which is it, do people need a lot of training to be effective “therapists,” or do people need no training? Do we value people’s “natural” wisdom or are we deeply concerned by people’s lack of “expertise.” What happens to natural therapists when you want to create a registrar and professionalize them? I think it may further comodify/privatize feelings/relationships even further than the mental health industry already has.
What are their licencing requirements/competencies/required experience so that we can differentiate them from those who offer “false promises”?
I don’t think many people who you think are “natural” therapists want to be on a registrar or want a reward/award. Does your wife want to start working as state-certified natural therapist? I think when she met you, see didn’t see you in terms of pathology, conflicts, negative repetitive patterns, or symptoms, but someone interesting she wanted to get to know. She also seemingly liked you and enjoyed your company enough to marry you, so she also got something out of the relationship. If people supporting each other was helpful/meaningful to you, why push professional intervention that commodifies such relationships of care?
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.
Yikes I am out of it. Last sentence should remain as is.
rectified should be reified.
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.
I appreciate the use of quantitative instruments to assess various domains of change of symptoms/experience. It’s amazing how so many clinicians in evaluating clients/patients miss/assume important domains of information, that having a more systematic approach would capture. I particularly appreciate more structured assessments of subjective experience because when done well (proper consent, introduced well, etc.), allows patients to share difficult things and have a conversation with a clinician on more equal footing (as opposed to feeling examined/judged/probed etc.). It also lets clinicians and patients have a conversation about how accurate the assessments seem, if they have missed anything, and what are the more important domains for clients to focus on at a particular time. To assess change, they help guide a conversation about differences in experiences that can be difficult to assess/remember just from individual memory.
I am wary, however, of to what extent they are “validated,” and especially communicating between paradigms of mental health, that scores or changes in scores reflect much more than what they actually indicate. People sloppily use screeners as diagnostic tools for disorders that have not shown to have validity in the first place. In that regard, a couple of questions are used to label someone indefinitely with disorders that can have really negative effects on people’s lives for little reason. Perhaps one clinician may see more nuance in interaction besides use of screeners, but often just a screener score moves with a file, and patients can be stuck with people reading much more into it than should be.
You are right, Alto. I was doing a bit of thinking out loud so to speak. I did not mean to apply that Dr. Moffic should personally apologize or hasn’t, just that the acknowledgement of hurt often comes and can be received in that form.
I also did see this article as an attempt to reengage in a novel way and I appreciated it.
“people have been grievously harmed by psychiatry and that psychiatrists needed to keep that in mind everytime they dealt with someone new.”
I think this is key. Even if you believe that grievous harm is rare and there has been a lot of good from psychiatric intervention, every psychiatrist, regardless of their personal practices/belief, carry the history of psychiatry with them, whether they like it or not. Not all harm was caused by individual bad doctors, but by systemic power of psychiatry, and anyone who embodies that power in both real and metaphoric senses, has to keep that in mind.
This isn’t unique to psychiatrists (though psychiatrists do have unique state-sanctioned powers to coerce others). Social workers experience this (no matter what kind of work they do), public health professionals do too. Clergy also experience this carrying of historical and contemporary abuses/damage of religious dogma with them when they work. Part of being a professional in these fields (and deciding to become one) is to own and unflinchingly study and understand harm done, work to mitigate harm now, and move forward in work with others that acknowledges those harms and being explicitly and authentically intentional (if you believe in your profession) to make a more helpful and ethical future.
Sometimes an apology is helpful in this regard, though I understand that it is difficult and in many ways unreasonable to apologize for things that you didn’t yourself do. Perhaps apologies are proxy for attuned acknowledgement, a demonstration of understanding of harm and willingness to try to undo or support in moving forward from it.