I am disappointed to see this study highlighted here with this sensationalistic headline. A cursory reading of this article reveals a number of problems, and MIA staff should be aware that the American Journal of Psychiatry is known to be a biased source of information about both the biomedical model and psychodynamic therapy. The APA’s guild interests cover both domains. Potential problems I’ve noticed in this post and/or the article include: (1) relatively few or no studies of psychodynamic therapy vs. CBT have been conducted for most MH problems, yet they suggest both approaches are equally effective for all issues, (2) they ignore the many psychological problems for which CBT has proven efficacy and psychodynamic therapy has little or none, (3) they ignore the patently pseudoscientific nature of psychodynamic theories (e.g., assuming in the absence of any evidence present-day problems are caused by repressed childhood unconscious conflicts), (4) many of the studies in this meta-analysis compare psychodynamic therapy to suboptimal forms of CBT, typically in studies conducted by psychodynamic proponents who did not collaborate with CBT researchers who could help ensure a proper test vs. the best available CBT intervention, and (5) because psychodynamic therapy takes so long, the usual manner in which researchers conduct comparative trials is to make CBT last much longer than necessary in order to equate the approaches in number of sessions. Case in point, standard CBT for panic disorder is generally conducted in 12-session trials, though studies show it works just as well in 5 sessions. But in the Milrod et al. 2016 study, CBT was stretched to twice its normal length (19-24) sessions just so it could be compared to psychodynamic therapy. No CBT scientist/clinician I know takes this study seriously or would be caught dead delivering CBT this way, yet psychodynamic folks use it as evidence their approach is just as good.
I am disappointed to see this study highlighted here with this sensationalistic headline. A cursory reading of this article reveals a number of problems, and MIA staff should be aware that the American Journal of Psychiatry is known to be a biased source of information about both the biomedical model and psychodynamic therapy. The APA’s guild interests cover both domains.
Potential problems I’ve noticed in this post and/or the article include: (1) relatively few or no studies of psychodynamic therapy vs. CBT have been conducted for most MH problems, yet they suggest both approaches are equally effective for all issues, (2) they ignore the many psychological problems for which CBT has proven efficacy and psychodynamic therapy has little or none, (3) they ignore the patently pseudoscientific nature of psychodynamic theories (e.g., assuming in the absence of any evidence present-day problems are caused by repressed childhood unconscious conflicts), (4) many of the studies in this meta-analysis compare psychodynamic therapy to suboptimal forms of CBT, typically in studies conducted by psychodynamic proponents who did not collaborate with CBT researchers who could help ensure a proper test vs. the best available CBT intervention, and (5) because psychodynamic therapy takes so long, the usual manner in which researchers conduct comparative trials is to make CBT last much longer than necessary in order to equate the approaches in number of sessions. Case in point, standard CBT for panic disorder is generally conducted in 12-session trials, though studies show it works just as well in 5 sessions. But in the Milrod et al. 2016 study, CBT was stretched to twice its normal length (19-24) sessions just so it could be compared to psychodynamic therapy. No CBT scientist/clinician I know takes this study seriously or would be caught dead delivering CBT this way, yet psychodynamic folks use it as evidence their approach is just as good.
This MH professional unfortunately failed to mention probably the most evidence-based way of overcoming a child anxiety problem – facing one’s fears (aka exposure therapy). Instead, he recommends exercise, sleep, diet, yoga, meditation, mindfulness, and a toolbox of calming and reassurance techniques. This is consistent with what research shows about child therapists – they often favor feel-good calming techniques over exposure, and this often occurs among clinicians who view their clients as fragile and unable to tolerate the distress evoked by facing their fears (http://www.uw-anxietylab.com/uploads/7/6/0/4/7604142/exposure_for_child_anxiety_jad.pdf).
Thanks for clarifying, much appreciated!
Monica, thanks for writing this thoughtful post. Given the timing, I’m curious if recent discussions here (e.g., https://www.madinamerica.com/2017/05/unusual-beliefs-objective-realities/) prompted you to write this. In your opinion, do you see mental health professionals here perpetrating against survivors here as they do in the system? If so, did you see this playing out in this recent discussion (and if so, how)?
Richard, I appreciate your thoughtful post(s). Thank you, sincerely. I certainly, obviously share your frustration/anger at a broken mental health system that shows no signs of reform despite a mountain of scientific evidence highlighting the urgent need for it. I have fought the good fight for years and will continue to do so in the future regardless of my involvement (or lack thereof) here. In my view, trying to change psychiatry from within is a lost cause, for reasons described in Bob’s book (with Lisa Cosgrove) Psychiatry Under the Influence. My hope lies in changing the hearts and minds of other mental health professions, principally psychology which has the most power to challenge biological psychiatry. I’m interested in facilitating actual change, not just ranting with like-minded frustrated people in an echo chamber. And so, my thoughts turn to how and where to invest the limited time I have available in order to affect positive change in my own profession.
As I said before, it’s frustrating that to my knowledge not a single one of my 5000+ fellow ABCT members has chosen to engage in this community despite information about MIA and issues related to its mission being widely disseminated. I don’t think the enormously successful PR campaign of biological psychiatry, by itself, is a satisfactory explanation. I suspect that the average person in my profession, upon reading this blog post and the full comments that follow, would decide that the culture here is sufficiently hostile that their participation would be more trouble than it is worth. I’m not defending such a decision, simply pointing out that it seems likely.
Personally, I’d like MIA to be more welcoming to professionals friendly to MIA’s mission. Indeed, some colleagues and I have discussed the idea of a site where like-minded professionals from around the world could meet to share our perspectives and practices about issues related to teaching, science, practice, and so on (e.g., what abnormal psychology textbook to use? anybody have lecture slides to share on the DSM? what articles should I assign to facilitate a critical discussion on the biomedical model?). It did not occur to me, when I suggested the possibility of a place at MIA where professionals could chat just with other professionals, that I had just “declared war on survivors.” The discussion in which that comment occurred suggests to me that MIA will continue to be an especially challenging environment for many professionals who might otherwise participate here, and that seems an unfortunate but largely inevitable consequence of the strong survivor voice that is present here. I understand where that voice comes from, I fully support its presence here, and I am not questioning its righteousness, but I do think it is worth considering the effect it has in limiting MIA’s reach and impact into the mental health professions, and thinking about possible solutions for mitigating these effects.
I used to think active involvement at MIA might be an effective means of affecting positive change in my own profession, but I don’t have any evidence to suggest that is the case, or to realistically hope that it will be in the future. That leaves me being here as a part of this community for my own sake, to interact with people who share my commitment to MIA’s mission. I know discussions can be contentious in this community, but the present discussion sets a new bar in my experience for unwarranted (not to mention unmoderated) vitriol. I have reasonably thick skin but every person has their limit and I have reached mine. Steve, you make an excellent point: “The voice of the oppressed can be harsh, especially toward the perceived authorities, but that is a function of the trauma they have experienced and their righteous rage, not necessarily any reflection on you and your contributions to the movement.” I completely agree, and also agree with the value of hearing behind the anger. You excel at this, as do Richard and Sandy. I think I find it difficult to do this as well as you all when my character is being repeatedly insulted. Anyway, the dealing with a harsh (often aggressively so) environment here seems to be the price mental health professionals can expect to pay when they engage in this community. So far, perhaps a few dozen professionals have been consistently willing to do so, but that’s it. I’d like to see a few hundred professionals here. I’d encourage MIA to think about whether this kind of environment, whatever the reasons for its existence, is conducive to achieving success with respect to its mission.
I belong to a professional organization with over 5000 members. Most members are psychologists and are united by their interest in cognitive-behavioral therapy, science, and improving the human condition. I have worked hard in recent years to raise awareness of issues related to MIA’s mission. I commissioned a journal special issue that featured an article by Robert Whitaker. I organized the 2015 annual convention with 3000+ attendees and invited Bob to be one of the 4 keynote speakers. I served on a panel discussion criticizing the biomedical model with Bob and several colleagues that was presented to a standing-room-only audience of 400+ people. At last year’s convention, I presented a workshop with Stanton Peele on how to disconnect psychological therapy from the biomedical model. My impression is that there is considerable interest among my colleagues in issues relevant to MIA’s mission and I have done what I can to encourage that interest. Yet to my knowledge, I am the only person in this 5000+ member organization who has ever engaged with this community in any way. I am not sure exactly why more of my colleagues have not become active here, but since 2015 I can rule out lack of awareness of MIA and Robert Whitaker’s work.
I do not know if the culture here is a barrier to more professionals engaging with MIA, but I think it is possible. Speaking for myself, the hostility and condescension evident in this discussion is a barrier to further engagement here. There are other aspects of the culture here (e.g., biases against science, MH professionals and professions) that further discourage my participation. I had intended to author some blog posts here in the near future but after further consideration of the issues raised by the present situation I have decided to direct my efforts elsewhere. I am aware that some other professionals like Joanna Moncrieff do not find the culture here to be a barrier and I’m sure my reaction to this discussion is influenced by the person I am (e.g., I don’t like it when people attack my character and competence, I don’t support the abolition of MH professions). But I also think there are lots of other people like me, who support MIA’s mission but who are hesitant to engage with this community because of its culture. And also, perhaps, because they are more interested in discussing certain issues with their peers than with a general audience.
In any case, I wish you all well, and I wish MIA the best. Thanks for the opportunity to be a part of this community.
I would like to take this opportunity to comment one last time on this thread. James, I was glad to read your response. Among the good points you made, I noticed you mentioned the reality that as a busy person with a family, career, etc., you have a finite amount of time available. You naturally wish to use that time in a manner that seems productive and consistent with your values. I assume writing this blog post fit that bill. But given the direction in which the comments went, you had to assess whether it was a good use of your precious time to defend yourself from criticisms of your character and beliefs, defend the notion that reality exists, push back against the notion that all mental health professions and those who work within them are insensitive and harmful, and so on, when much of this conversation likely diverged from the conversation you perhaps hoped to initiate with your post. Some commentators here obviously have the time and interest necessary to deeply engage in these sorts of discussions. But I don’t fault you for not doing so; your time is very limited and you need to invest it wisely. As you noted, the kind of culture MIA is developing, as evidenced by the discussion in response to your blog post, can be hostile enough to discourage all but the most thick-skinned and dedicated professionals from choosing to invest their available time here.
Personally, I’m not interested in rehashing the conversation that took place in this discussion, or defending my responses to it, for 2 reasons: (1) I have a limited amount of time and I’d rather spend it doing something more productive and conducive to happiness and vitality, and (2) I am confident that the most respectful, self-effacing, and introspective response I could offer would be met with further criticism, which would make me frustrated, want to respond, and spend more time and mental energy devoted to this situation than I want, which would inevitably take time and mental energy from other more healthy and productive pursuits. I can’t speak for James but I wouldn’t be surprised if he entertained a similar train of thought as this discussion unfolded.
In my view, several themes are consistently evident in discussions of MIA posts authored by professionals, beyond the expected themes of opposition to the biomedical paradigm of care. These include a bias against science (all science, not just poor science); a bias against all mental health professionals regardless of their profession or opinions or track record of work on behalf of MIA’s mission; the perception that a professional who expresses an opinion on any topic with any degree of conviction is arrogant, dangerous, and likely to harm clients; and swift and cutting attacks on any professional who attempts to argue against any of the above. It’s not my intent here to comment on whether these themes are justified, just to observe that their consistent presence here over the years makes them a central part of the culture that has developed in comments sections at MIA.
Accordingly, I welcome efforts for MIA to consider what effect this culture has on its ability to succeed with respect to its mission. The new option of turning off comments for blog posts seems reasonable to me; it’s an obviously imperfect compromise that may be welcome to some who wish to post here. Another option would be to consider an “MIA for professionals” site. I suspect there are many people in my profession who would welcome a MIA-style resource for news, blogs, and discussion about issues related to MIA’s mission, where they could discuss and debate important issues among fellow professionals who generally share their values without having to spend their time arguing with those who want to abolish all mental health professions, regard science as worthless, and so on. Practically speaking, a MIA-like site with a culture that welcomes participation by mental health professionals could go a long way toward promoting MIA’s mission. To be clear, I’m not dismissing the valuable dialogue that takes place between service users, professionals, and other groups here, nor am I suggesting it’s not sometimes important to critique science and so on. Rather, I am approaching this situation from a practical lens. In my view, the reality is that absent a cultural shift at MIA, the vast majority of mental health professionals will remain uninvolved both here and with respect to MIA’s mission. An attitude of “if they can’t stand the heat, they should stay out of the kitchen,” however gratifying to purists, seems like cutting off the nose to spite the face. Personally, I will continue to work hard within my profession in pursuit of MIA’s mission and read what is posted on this site. I hope that someday the culture here will allow me to confidently recommend that kindred spirits in my profession become actively involved. MIA has a long way to go before that can happen.
I must respectfully disengage from this conversation. The last thing I will say is to ask MIA to consider that the environment here is not conductive to the participation of well-meaning people within the mental health system who share MIA’s mission. This has huge implications for the ability of MIA to achieve its mission, and saddens and frustrates me because of how important MIA’s mission is to me. I would like to see more people in my profession become active here and support the cause, but I can’t see that happening given the current environment here. Goodbye.
Do the laws of physics exist?
I had decided to leave this alone and deleted my response. But given that you copied and pasted it and wrote a response to it, knowing I deleted it, I feel obligated to respond. A few things. First, I stand by what I wrote, every word. Second, I read your comments as a personal attack, a perception that is now validated by your second post. Third, I’ve done more to try to change the system than 99% of the people in know in my profession. I would provide evidence to support that assertion but that’s not why I’m here. I don’t have to justify my credibility or competency to you, and given your comments I doubt you’d care anyway. Fourth, some beliefs are in fact delusional because reality exists. If there is no objective reality, we may as well abandon all scientific inquiry, and all technologies produced by scientific discovery, because it’s all based on a lie. Fifth, the fact that some beliefs are not consistent with reality not at all mean a clinician has to demand a client yield to their authority (as you falsely and offensively suggested I do). I agree with Steve’s post a few up that it is “possible to influence someone’s views while still being totally validating of their viewpoint.” Sixth, before you (the pot) call me (the kettle) black for “lashing out,” have a read of your two posts. Finally, I noticed you ignored the central point of my last post, which was the central point of my posts above that. I guess you had other priorities in responding.
My first thought is that lumping psychology in with psychiatry obscures important differences between them related to this conversation. My second though is that whatever MIA might organize has no realistic chance of competing with and replacing established professions. I suspect MIA’s best chance to influence matters related to its mission is through a combination of educating the public and policy makers, but mostly through changing the hearts and minds of people of influence within mental health professions (who influence the public and policy makers). Which brings me back to my initial point, which has since been reinforced by some of the comments on this thread.
Uprising, those are excellent questions and I’m not sure about the answers. I am fairly certain that in my professional neck of the woods – scientifically-oriented clinical psychology – those who might otherwise be sympathetic to MIA’s mission would likely be turned off from engaging with this site or possible MIA initiatives because of the tendency of some here to demonize them, fairly or not. It takes not only dedication to MIA’s mission but unusually thick skin to post what James did here, knowing commenters will question his judgment, morality, and sanity, even when making a point that would seem fairly evident (i.e., sometimes it can be helpful to know what reality is rather than hold beliefs that are objectively delusional).
I suppose MIA is a big tent and represents many perspectives. Most here are united in their stand against the current dominant model of psychiatric care. But beyond that, it’s not clear to me that a consensus exists in terms of what people stand for. When someone sticks his/her neck out and offers a solution that involves working within the mental health system, it’s often the case that person is vilified. And so we end up tearing down those who offer potential solutions, and creating an environment that probably precludes the participation of many influential people in the system who might work to change it.
As a practicing psychologist, my caseload includes clients who (for example) believe the body sensations they experience during a panic attack will result in imminent death, or that merely thinking about something bad happening to another person means it will actually happen. These individuals are operating on a false premise and their lives have suffered mightily for it. There is a mountain of evidence attesting to the power of therapy that involves helping these individuals come to a new understanding of reality, not by me authoritatively persuading them that my way of thinking is right and theirs is wrong, but by encouraging them to change their behavior to learn for themselves what the nature of reality is. By facing rather than avoiding feared situations and finding that feared outcomes rarely happen and that distress is tolerable, belief change naturally occurs, and life change follows.
According to some comments here, it is morally wrong for a therapist to work with a client to explore the possibility their beliefs might be maladaptive or irrational and that coming to see the world in a new life could be more adaptive and conductive to living a valued life. The entire profession of psychology should be abolished along with that of psychiatry. All who work in them, even thoughtful people like James who are keenly aware of and respectful toward issues that matter here at MIA, are crazy and harmful. Any mention by a therapist of the potential value of a strategy that suggests clients change anything – potentially problematic thoughts, behaviors, and so on – is dismissed out of hand as Orwellian social control.
I have read every article on this site for years and understand well the terrible experiences some people have had in the healthcare system, and it’s clear that sometimes “mental health treatment” can be an exercise in pathologizing normality and crushing individuality. But sometimes it is not, especially I would guess when provided by someone like James. At some point, if MIA is serious about influencing those who work within the system to see the light, it will have to wrestle with the conflicting motives of those who wish to reform it vs. those who wish to blow it up and demonize all who work within it.
Rob, I couldn’t agree more with your comments. Walkup’s use of the term “failed trial” concerns me greatly. This term appears synonymous with the discredited notion of “assay sensitivity,” and scientifically speaking both terms are highly problematic. Walkup is basically saying that we should disregard results from many “antidepressant” trials in which the drug failed to outperform placebo. Antidepressants work, he assumes, so therefore clinical trials that do not show this are “failed” and their results can be ignored. Instead, we’re meant to only consider findings from a few positive trials. Such “counting the hits and forgetting the misses” is a cardinal feature of pseudoscience and a recipe for obscuring the truth.
Walkup is certainly correct that most drug trials for pediatric depression are conducted by drug companies and have all manner of design and reporting biases that favor the drug over placebo. Given how much the deck is stacked in their favor in such trials, I find it remarkable that “antidepressants” consistently perform so poorly. Rather than being uninformative, I think such outcomes speak volumes about the effectiveness of these drugs in young people.
If we’re meant to focus our analysis of “antidepressants” on just a few trials, principally the TADS study, then let’s have an honest conversation about the findings. For example, in the TADS study, CBT was as effective as Prozac at 18 weeks and during the year-long follow-up period. Suicidal events occurred in a whopping 16.7% of clients taking Prozac, compared to 3.6% of those who did not take Prozac. When comparing outcomes directly between the Prozac and placebo conditions, the rate of suicidal ideation and attempts was 11.2% higher among youth on Prozac. Walkup did not mention these findings in his paper, and instead characterised the results as demonstrating “good efficacy for antidepressant medications in pediatric depression.”
It’s nice to see the scientific community working in earnest on alternatives to the DSM. However, I see some of the same assumptions that underline the DSM’s biomedical view in the psychologists’ Hierarchical Taxonomy of Psychopathology proposal (https://www.ncbi.nlm.nih.gov/pubmed/28333488). Thoughts, feelings, and behaviors are regarded as “symptoms” (i.e., pathological expressions of a disease). Problems of thinking, feeling, and behaving constitute “psychopathology”; people with multiple such problems have “comorbidity.” The authors promote their DSM alternative as useful in understanding topics such as “pathophysiology” and “illness course.” Aside from dropping the DSM’s categorical diagnostic system, and replacing DSM diagnostic labels with different diagnostic labels, I’m not sure the proposed alternative is really that different from what we have now. People struggling with psychological problems will still be given diagnostic labels based on the presumption that they are mentally ill. And it is this philosophical paradigm, not the particular names or scientific basis of DSM diagnoses, that is the real problem.