Evil Deeds

A forensic psychologist on anger, madness and destructive behavior.

The Death and Rebirth of Psychotherapy

Second posting in series of five celebrating National Psychotherapy Day

Tuesday, September 25th, marks the first celebration of National Psychotherapy Day. National Psychotherapy Day is the brainchild of PT blogger and clinical psychologist Dr. Ryan Howes, who deserves credit and congratulations for conceiving of, organizing, and getting it off the ground.

In honor of National Psychotherapy Day, I will be posting a series of my previously published pieces on the practice of psychotherapy. A different posting each day this week, Monday through Friday. In effect, extending National Psychotherapy Day into National Psychotherapy Week here at Psychology Today. Hope you enjoy!


image Psychotherapy is dying. The truth hurts. Denial, as psychotherapists know, can be a maladaptive and dangerous defense mechanism. Psychotherapy today is on its death bed, beset by hostility from all sides: a victim of aging, managed care, "New Age" spirituality, life-coaching, psychics, exorcists, economics, poor public relations, internecine sniping, and especially, the ascent of neurobiological psychiatry and psychopharmacology. We are at a precarious crossroads in the history of psychotherapy, a quite literal battle for the hearts, minds and souls of the public--both the "consumers" of mental health services and its practitioners. If this pitched public battle is lost, the psychotherapy depicted here will likely go the way of the dodo. Psychotherapy's slow, insidious descent toward extinction is well under way.

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The public is disenchanted with and misinformed about psychotherapy. This negative attitude has been exacerbated by the predominance of Cognitive Behavioral Therapy (CBT), which is spuriously touted by its frequently fiscally motivated supporters as superior to other kinds of psychotherapy in both efficacy and brevity. Psychotherapists in training—psychiatric residents, clinical psychology, counseling and social work interns too are taught the same misleading party line. The sad result has been a gradual mechanization, dehumanization and reductionistic de-souling of psychotherapy.

An estimated ninety percent of psychiatrists no longer practice psychotherapy much at all, relying heavily instead on pharmacotherapy. According to a Los Angeles Times article (August 5, 2008) about psychiatry, "Wider use of antidepressants and other prescription medications has reduced the role of psychotherapy, once the defining characteristic of psychiatric care...The percentage of patients who received psychotherapy fell to 28.9 percent in 2004-05 from 44.4 percent in 1996-97." The vast majority of psychiatrists today receive only minimal training in providing psychotherapy.

Ironically, the aforementioned mounting crisis within the psychotherapy world parallels a growing crisis in public mental health. The public's need for psychotherapy is clearly greater than ever. Serious mental disorders are epidemic. More than one in four American adults (almost 60 million) has received mental health treatment in the past two years, according to Therapy in America 2004, a new Harris Interactive poll. In a recent American Psychological Association survey (2004), 54 percent of Americans are seriously concerned about the level of stress in their daily lives. And according to the National Institutes of Mental Health, more than 44 million Americans suffer from some mental disorder. Sixty-one percent of men and 51 percent of women have experienced psychological traumas related to post-traumatic stress disorder (National Comorbidity Survey). Approximately 18.8 million adults suffer from clinical depression, and bipolar disorder affects about 2.3 million annually (National Institutes of Mental Health). Almost 20 million American adults suffer from some diagnosable anxiety disorder: more than 3 million meet diagnostic criteria for obsessive-compulsive disorder; 3.2 million experience panic attacks and agoraphobia; and 5.3 million American adults ages 18 to 54 suffer from social phobia (National Institutes of Mental Health). 2.2 million Americans are incapacitated by schizophrenia (National Institutes of Mental Health).

Real psychotherapy is becoming more and more scarce. But this is precisely what is needed. Most people suffering from emotional disturbance who have at least several sessions of psychotherapy are far better off than untreated individuals. And 50 percent of patients noticeably improved after eight therapy sessions, while 75 percent of individuals in psychotherapy progressed by the end of six months (APA, How to Find Help Through Psychotherapy, 1998). Research suggests that psychotherapy is frequently at least as effective as medication, and that the benefits are more enduring. Other studies support a combination of both psychotherapy and psychopharmacology as the most efficacious treatment of serious depression and other debilitating mental disorders.

Here in America, and around the world, we desperately need more—not less—psychotherapy to address this raging mental health epidemic. According to the Surgeon General's Report on Mental Health (1999), untreated mental health disorders cost American businesses seventy-nine billion dollars in lost productivity each year.

But meanwhile, the very soul of psychotherapy is being lost. Even the American Psychological Association does little to combat this unfortunate trend. Indeed, in America, there is a growing movement, already established in some states, to grant psychologists the right to prescribe psychiatric medications. This is, in my view, yet another nail in psychotherapy's coffin. It would be far more convenient and financially rewarding for psychologists to forego providing psychotherapy altogether, relying instead, like most psychiatrists today, on prescribing drugs. Patients have already come to depend heavily on pharmaceutical support, concurrent to but often in lieu of psychotherapy.

The truth is, most psychotherapy patients need far more than what pharmaceutical intervention and/or cognitive restructuring—the two most popular "evidence-based" modalities today—can provide. As does every person seeking meaning and peace of mind. They need and deserve support and accompaniment through their painful, frightening, perilous spiritual or existential crises, their "dark night of the soul." They need a psychologically meaningful method to confront their metaphorical devils and demons, their repressed anger or rage, and the existential reality of evil. They need access to a psychotherapy willing to ask the right questions, and not afraid to embrace spirituality. They need a psychotherapy that restores their soul.

For more than a century now, the Greek word psyche has been misinterpreted by psychiatry and psychology to merely mean "mind." Consequently, psychiatry, psychology and psychotherapy--the study and healing of psyche—have become almost exclusively concerned with the mind (including cognitions or thoughts, perception, memory, imagination, will and emotions) and human behavior. But the classical term psyche, archetypally symbolized by the ethereal butterfly, literally means life, spirit, self or soul. What mental health consumers need now is real psychotherapy.

In its heyday, during the mid-to-late twentieth century, psychotherapy was touted by some as "religion for the previously irreligious." What happened? Psychotherapy slowly had much of its spiritual heritage and soul sucked right out of it. Ironically, the field of psychotherapy faces this life-threatening identity crisis at the precise moment that consumers of mental health services—the general public—most need what psychotherapy can provide: Some way of discovering meaning, discerning and fulfilling our destinies, nurturing our souls.

The fundamental task of psychotherapy is to redeem (rather than cast out or exorcise) our emotional devils. It is inevitably both a psychological and spiritual venture. Bravely voicing our inner  "demons"—symbolizing those unconscious tendencies we most fear, flee from, and hence, are obsessed or haunted by—transmutes them into helpful spiritual allies. During this alchemical process, the esoteric secret that many artists and spiritual savants share is revealed: That same demon so righteously run from and rejected paradoxically becomes the redemptive source of vitality, creativity  and authentic spirituality.

In the final analysis, the kind of resurrected and renewed psychotherapy celebrated here does not mark a reactionary movement back to the supremacy of Sigmund Freud’s psychoanalysis during the first half of the twentieth century. Rather, it represents a revolutionary twenty-first century movement within a profession in which the pendulum swing toward pharmacological and cognitive-behavioral treatment of mental disorders and away from psychodynamic psychotherapy (depth psychology) has gone too far for too long. Sadly, “psychotherapy”continues to be seen by most today as, in the case of CBT, some predetermined, mechanistic cookbook recipe of rote techniques robotically applied to rapidly suppress certain troublesome psychiatric symptoms or behaviors. Patients receiving this sort of superficial, severely curtailed treatment are being tragically deprived of a much-needed opportunity to consciously wrestle with what existential theologian Paul Tillich called life's "ultimate concerns." And with what Rollo May (1969) called the “daimonic.” We forget that the founders of psychotherapy—Freud, Jung, Adler, Rank—saw themselves as healers of the soul, psyche, or spirit. Not of the brain. Not as mechanics of the mind. Men of medical science, to be sure. Yet more like midwives, priests, rabbis, shamans or exorcists. (See my prior post.)  If practitioners and patients can recognize the therapeutic value, power, and psychospiritual significance of subjects such as beauty, God, death (see first post in series), evil, creativity, love, anger, rage, and the innate “will to meaning” (Frankl)—even in brief, intensive treatment—then maybe, just maybe, psychotherapy has some small chance of surviving for another century.

Can psychotherapy survive? The outcome of this historic conflict is undecided and unpredictable. Still, there are signs of a coming rebirth or renascence of psychotherapy in the air. The winds of change are blowing. But this revival will happen only if we—as clinicians and consumers—are willing to stand up right now and fight passionately and aggressively for its future against those who would happily do away with it. And let the world know that psychotherapy—and its cumulative treasure trove of precious healing wisdom—is still very much alive, evolving, valuable, desperately needed, and eminently worth practicing.

Stephen Diamond, Ph.D., is a clinical and forensic psychologist in LA and the author of Anger, Madness, and the Daimonic: The Psychological Genesis of Violence, Evil, and Creativity.

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