- Psychiatrist Tom Insel's criticism of traditional psychotherapy is based on outdated prejudices.
- Insel is mistaken when he implies that in-depth psychotherapy lacks the evidence of efficacy that other therapies have.
When one of America’s most prominent psychiatrists expresses deep disdain for depth psychotherapy, especially when that criticism is misinformed and outdated, it should concern all of us.
Dr. Tom Insel directed the National Institute for Mental Health (NIMH) from 2002 to 2015. Formerly a psychiatric researcher “at the cellular level,” he studied medications and neuroscience. Insel admits that under his directorship, the NIMH didn’t improve care for those with serious mental illness:
I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that, I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.
Insel Trades Neuroscience for High-Tech Humanism
After NIMH, Insel led the mental health initiative at Verily, the Google-spawned health science company; co-founded Mindstrong Health, a digital mental health company focused on serious mental illness; launched Humanist Care, a recovery-oriented online therapeutic community; and served as “behavioral health czar” to Governor Gavin Newsom of California.
Even at age 70, Insel apparently hasn’t found a comfortable place to settle down. But having learned a thing or two, he wants everyone to know. Thus his book Healing: Our Path From Mental Illness to Mental Health (Penguin Random House, 2022).
The book’s main message is that we can already help most people with serious mental illness. We “merely” lack the social and political will to make it happen. He downplays these social and political challenges, offering only a roadmap, not policy proposals.
The roadmap, though, is fundamentally sound: comprehensive biopsychosocial care. In other words, the biological treatments Insel knows so well, plus skills training, peer and family support, therapeutic communities, a shift from incarceration to treatment, and so forth. It’s all perfectly sensible, if unsurprising.
An Old Bias Sneaks Through
Unfortunately, there’s a glaring bias in Insel’s narrative. Throughout the book, and confirmed in a recent interview with The New York Times’ Ezra Klein, Insel repeatedly denigrates psychoanalysis, psychodynamic therapy, and all psychotherapy that is not symptom-focused or “skills-based.”
Insel claims such therapies are “eminence-based care” in contrast to “evidence-based” [pg 103], and that psychoanalysis is “not by itself a treatment for mental illness” [pg 51]. He believes that traditional psychotherapy blames parents and families for mental illness and that only by discarding these outmoded approaches, families can now be part of a patient’s support team. He derides analytic therapy as dwelling on childhood, not current life. By contrast, according to Insel, evidence-based therapy focuses on learning skills:
That’s not what you get with talk therapy that’s not focused. It doesn’t have an evidence base. So I’m a huge proponent of psychotherapy, but it has to be psychotherapy that actually involves those kind of skills learning that has a kind of scientific basis to it with people trained to do it in the way that works.
In his book, Insel falsely claims that Victor Frankl developed logotherapy, a type of existential psychotherapy, in reaction “to the introspection and self-absorption of psychoanalysis” [pg 174]. (Logotherapy aims to be more positive than Freudian analysis, not less introspective.) Writing about ELIZA, an early computer program designed to (roughly) mimic client-centered Rogerian therapy, Insel treats ELIZA’s simple algorithmic responses as though they accurately reflected Carl Rogers himself: “Of course, the Rogerian therapist, with this obnoxious reflexive response, was hardly better than a robot and certainly an easy form of ‘natural language’ to automate.” [pg 204] In rushing to condemn such therapy, Insel conflates a primitive computer program with a real therapist who was neither obnoxious nor reflexive.
Finally, Insel praises Woebot, a chatbot that provides a version of CBT. He quotes Woebot (actually, its programmers), apparently sharing their sneering disdain for the “couches” and “childhood stuff” of traditional Freudian analysis, as well as their updated vision of therapy larded with strategies and jokes:
I’m here for you 24/7. No couches, no meds, no childhood stuff. Just strategies to improve your mood. And the occasional dorky joke. [pg 215]
What's Wrong With Insel's Rejection of Traditional Depth Therapy
There’s a lot to look at here. First, mental illness, including serious mental illness, is very heterogeneous. Schizophrenia, bipolar disorder, and OCD count, but by Insel’s reckoning, so do major depression, PTSD, and borderline personality disorder. This broad category obscures a wide variation in the applicability of various psychotherapies.
Most psychiatrists (but not all) agree there is little direct role for insight-oriented, depth psychotherapy in the treatment of schizophrenia, bipolar disorder, or OCD. Nonetheless, even in these conditions, therapies of “depth, insight, and relationship” can help a sufferer come to terms with his or her debilitating condition, reflect on issues of self-identity and life’s meaning, improve treatment adherence, and provide emotional support. In other words, even when such therapy doesn’t treat the problem itself, it can help the patient deal with feelings about the problem. The relationship can be stabilizing and very valuable.
It’s a far different matter when it comes to depression, PTSD, borderline personality, and many other potentially devastating conditions. Here we see much stronger evidence for the benefits of in-depth psychotherapy. Insel is plainly mistaken when he implies that such psychotherapy lacks the evidence of efficacy that other therapies have:
… for many issues (e.g., depression, anxiety, eating disorders, PTSD) there are specific therapies that have been validated empirically—sometimes called empirically supported treatments. [pg 252]
The False Narrative of "Evidence-Based Therapy"
It is a widely held but false belief that only symptom-focused psychotherapy, usually cognitive-behavioral in nature and sometimes manualized or algorithmic, is evidence-based. Insel should know better. There is a large evidence base for analytic, depth therapies, particularly for depression and anxiety. Consequently, he is also mistaken when he declares these therapies are not by themselves “a treatment for mental illness.” They clearly are.
Perhaps worse are the outdated stereotypes he uses to denigrate such therapy. Yes, many decades ago psychoanalysts blamed “refrigerator mothers” for autism and “schizophrenogenic” mothers for schizophrenia. Dismissing current analytic practice for these old errors is just as silly as dismissing modern biological psychiatry for previously using lobotomy.
Contemporary analytic therapy doesn’t blame parents or anyone else, nor is it trapped in an endless rehashing of childhood. It tackles plenty of present-day, pragmatic concerns. But it does so while revealing underlying thoughts, wishes, fears, and more complex emotions, and while closely attending to the relationships the patient forms with the therapist and others. Like everything else, psychoanalysis has evolved in the past 50 years since Insel experienced it. Since he’s an influential speaker and writer, it would be good if his prejudices evolved too.
Depth Therapy Is a Healing Relationship
By far, the most ironic twist is Insel’s newfound emphasis on the importance of people (“people, place, and purpose”) and especially relationships for recovery from serious mental illness. This was his big insight in moving from a strictly biomedical view at NIMH. While peer groups and clubhouses certainly provide support, the healing value of a close relationship with a caring therapist has been well known for at least a century. The therapists Insel belittles have certainly known it all along. His ultimate hypocrisy is complaining about, and failing to take responsibility for, the woeful dearth of research in this area:
Why hasn’t this power been studied sufficiently? Surely, one guilty party is the former director of our premier mental health research agency, the NIMH. The power of connection, experienced as support, attachment, or love, may very well “move the needle in reducing suicide, reducing hospitalizations, [and] improving recovery.” Finding out probably won’t cost anywhere near $20 billion, yet it still awaits serious attention by NIMH.
©2022 Steven Reidbord MD. All rights reserved.
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Page numbers refer to Insel T, Healing: Our Path From Mental Illness to Mental Health, Penguin Random House, 2022, Kindle version.
Quotations without page numbers are from the New York Times interview transcript.