Psychology's Escalating Civil War: How Do We Understand, Diagnose and Treat Mental Disorders?

In defense of psychotherapy

Posted Nov 25, 2011

Psychotherapy is under siege. There is an increasingly hostile war being waged within the mental health field.  A heated battle for the hearts and minds of the profession and public. One which will determine whether we progressively advance as a society in our psychological understanding and treatment of mental disorders or dangerously regress. This war right now is being fought on two major scientific fronts: pharmacological and cognitive-behavioral, both of which together are vying to defeat the forces of Freudian and Jungian depth psychology, the psychodynamic therapies into which they later evolved, and existential psychotherapy's humanistic and philosophical approach to dealing with life's inevitable problems. Are you ready for another revolution?
In a recent Time (September 13, 2011) interview titled "Q&A: A Yale Psychologist Calls for Radical Change in Therapy," clinical child psychologist Dr. Alan Kazdin expresses one polarized side of this contentious clash. He makes several dubious and debatable points. First, he claims that psychotherapy, in general, is, for the most part, outmoded and ineffective, and should be replaced or at least preceded by "more easily disseminable interventions." Next, he suggests that the only efficacious forms of psychotherapy are those that have been scientifically proven to work, so-called evidence-based treatments like Cognitive-Behavioral Therapy. He pretty much dismisses the possibility that any psychodynamically or existentially-oriented psychotherapy could be helpful. Moreover, Dr. Kazdin completely rejects the notion that therapy can or should be tailored to fit each unique case or patient. Finally, he flat out denies that psychotherapy is fundamentally based on the caring and supportive human relationship between patient and therapist, culminating with this telling statement: " If you want to get over an anxiety disorder, do graduated exposure. But sit down and relate to me or love me like your mom and dad? There's no evidence for that." Especially in this last highly prejudicial comment, Dr. Kazdin demonstrates what seems to be a stunning misconception of what modern depth psychology really is and how it really works. In this interview, Kazdin clearly becomes a partisan foot soldier in psychology's internecine struggle, what is fast becoming a pitched civil war, pitting the powerful forces of scientific medicalization of psychology and psychotherapy against those still fighting for the value and utility of a more humanistic, existential, or psychodyanamic approach to treatment. The stakes are high. Make no mistake. The very future of psychotherapy and the quality of mental health care in this country hangs in the balance.

I definitely concur with Kazdin that what we need is "radical change" in how we approach therapeutic treatment. But he and I have radically different, indeed, diametrically opposed ideas about the direction that change should take. So, in rebutting Kazdin's points, let me first take the reader for a very brief, abbreviated and, of necessity, incomplete historical tour of how we arrived where we are now in the evolution (or, more recently, devolution) of psychotherapy.

The revolutionary turning point in psychiatry and clinical psychology came with Viennese physician and neurologist Sigmund Freud's introduction to the world of "psychoanalysis" around 1900. (See my prior post.on A Dangerous Method, David Cronenberg's new film about Freud, Jung and the early years of psychoanalysis.) At that time, psychotherapy, in any formalized sense, did not exist. Psychological problems were traditionally viewed by physicians and, therefore the public, through the lens of biological medicine, and treated accordingly--though psychiatry's biochemical armamentarium was primitive since the specific psychotropic medications so heavily depended upon today had not yet been discovered. Freud's sophisticated theories and therapy revolutionized psychiatry, emphasizing psychology over biology in both etiology and treatment.
Psychoanalysis was founded on Freud's clinical observations of the therapeutic value of catharsis, or what he termed abreaction, in treating trauma. Here is what he wrote in his first book (1895) co-authored by fellow physician Josef Breuer:

"The fading of a memory or the losing of its affect depends on various factors. The most important of them is whether there has been an energetic reaction to the event that provokes an affect. . . . If the reaction is suppressed, the affect remains attached to the memory. . . .  The injured person's reaction to the trauma only exercises a completely ‘cathartic' effect if it is an adequate reaction--as, for instance, revenge. But language serves as a substitute for action; by its help, an affect can be ‘abreacted' almost as effectively."

Somewhere along the way, psychoanalysis lost this crucial affective focus, turning overly intellectual and insight-oriented rather than experiential and abreactive. Though re-introduced during the 1960's and 70's by popular therapies such as psychologist Arthur Janov's  controversial "Primal Therapy," for example, mainstream psychiatry and psychology today eschew the use of abreaction in treatment, believing such affective self-expression to be either ineffective or self-perpetuating, inflammatory and dangerous--especially when treating anger or rage. (See my prior post on anger disorders.)

Consider how we deal with the epidemic problem of anger or rage in treatment today. Basically, we don't. We try to suppress it. To quell it with rationality or medication. To think ourselves out of feeling our fury. And that is part of the problem. The arbitrary use of expressive, ventilationist or cathartic techniques like pillow-pounding, primal-screaming, bed-beating or bataka-bashing and so forth, designed to "drain off" or disperse anger and rage is, in the long run, ineffective, more masturbatory than procreative, and can be clinically counterproductive. But concluding that catharsis can't be therapeutic is incorrect. An excellent example of such controlled and apparently experimentally proven efficacious use of abreaction was recently reported on by psychiatrist Dora Calott Wang, a fellow PT blogger, and demonstrates precisely the direction in which psychotherapy needs to be moving in my view. (See Dr. Wang's welcome post on Intensive Short-term Dynamic Psychotherapy for trauma here.)

The discovery during the 1950s of psychotropic drugs efficacious in reducing the symptoms of many bedeviling psychiatric disorders such as schizophrenia, bipolar disorder, depression and anxiety disorders slowly, insidiously, but surely eroded the practice of psychotherapy in America. Today, the practice of psychotherapy is in steep decline. That would be fine if psychotherapy was no longer needed.  After all, the goal of the psychotherapist is, in a sense, to put him or herself out of business by "curing" whatever ails the suffering patient. The assumption was that since biochemical treatment could impact (but not cure or alleviate) mental illness, it's underlying cause must be biologically based. But this assumption was and still is dead wrong, taking psychiatry and psychology down the utterly wrong path. The prevailing attitude of most mainstream mental health providers--and, without exception, the insurance companies that pay for their services--assumes that the vast majority of mental disorders embody some brain or biochemical imbalance, and will therefore most expediently be ameliorated by medication and, perhaps, as a secondary consideration, some brief cognitive-behavioral therapy. Unfortunately, consumers of mental health services are being misinformed en masse, even duped, about the true causes and best treatment for mental disorders. And, as a result, being short-changed in the therapeutic services they receive. But the public is gradually beginning to figure out that they've been sold a "bill of goods" psychiatrically speaking regarding "broken brains" and "bad biochemistry." And starting to seek out and demand real therapy.
In recent decades, following the "pharmacologcial revolution," there has been an obvious--and ominously regressive--pendulum swing in psychiatry and clinical psychology toward the "organic" or "medical" model of mental disorders. Such a paradigm places excessive emphasis on the neurobiological components of mental illness, thereby minimizing the significance of psychological, existential, spiritual or sociological sources of emotional suffering. Proponents of this materialist model seek, as far as possible, to reduce all so-called "mental disorders"--from schizophrenia, to autism, to attention deficit disorder, to anxiety, to depression, to bipolar disorder--to their neurobiological bases, in hopes of discovering not only their biogenetic causes, but their psychopharmacological or biological cures. This fundamentally flawed neurophysiological view of psychiatric symptoms is profoundly influencing how and what we diagnose, as can be seen in the latest controversy and protests over the forthcoming DSM-V, published by the American Psychiatric Association. (See my prior post.)

Here is an excerpt from a recent statement from the British Psychological Society on the matter of how this regressive and misguided trend is manifesting itself in the diagnosis and treatment of mental disorders today:

We thus believe that a move towards biological theory directly contradicts evidence that psychopathology, unlike medical pathology, cannot be reduced to pathognomonic physiological signs or even multiple biomarkers. Further, growing evidence suggests that though psychotropic medications do not necessarily correct putative chemical imbalances, they do pose substantial iatrogenic hazards. For example, the increasingly popular neuroleptic (antipsychotic) medications, though helpful for many people in the short term, pose the long-term risks of obesity, diabetes, movement disorders, cognitive decline, worsening of psychotic symptoms, reduction in brain volume, and shortened lifespan.

The so-called "cognitive revolution" came into its own by the 1980's, led by clinical psychologist Albert Ellis and psychiatrist and psychoanalyst Aaron Beck, who, frustrated with psychoanalytic therapy, contended that cognitions (thoughts) are to blame for psychiatric conditions such as depression and anxiety. (See PT blogger psychologist Robert Leahy's recent pro-CBT response here.) Borrowing heavily from the ancient philosophy of Epictetus ("Men are not influenced by things but by their thoughts about things.") and joining forces with the behaviorism of Pavlov, Watson and B.F. Skinner, which dominated the field of clinical and academic psychology for decades through the 1960s, cognitive-behavioral therapy has been successful at measuring (and marketing) its efficacy because it does so in very concrete behavioral terms. CBT's orientation is scientific, mechanistic and highly rational, deeming the patient's pathologized "irrationality" the problem to be rooted out and "cognitively restructured." It is rotely technique driven, and therefore, readily repeatable and standardized. CBT tends to be delivered during a relatively short or brief course of treatment, as opposed to, say psychoanalysis or psychodyamic therapy, which traditionally takes years. (Though this doesn't necessarily mean that symptom reduction takes years; only that presenting symptoms tend to be manifestations of broader or deeper underlying issues that need to be more fully addressed.) This comparative brevity made CBT extremely attractive to both consumers and insurers. And, of course, it has come to dominate academic training in graduate programs, where I have had students complain bitterly about the dearth of psychodynamic courses available to them.
But, as time passes, and consumers, graduate students (as well as clinicians) increasingly recognize the serious and very real limitations of CBT and its theory, there is growing disillusionment even with this darling of scientific psychology. (See, for example, the recent critical posting here from psychiatrist David Allen.)  It is becoming clear to many that this once mighty emperor has no clothes. And that working rationally with irrational or distorted cognitions, while helpful, is but one aspect of what any truly healing psychotherapy worth its salt must provide. And not necessarily the most essential aspect. Indeed, I would suggest that directly and experientially addressing powerful, repressed or dissociated affects like anger, rage, sadness or grief is at least as beneficial, if not more so. But this is the opposite of what contemporary psychotherapy is fast becoming, with its emphasis on behavior, rationality and suppressive approach to the so-called irrational or daimonic. The problem is that constantly suppressing the daimonic--psychologically, pharmacologically or utilizing some combination thereof--while in the short-term may be therapeutic and even clinically necessary, ultimately makes it more and not less problematical and potentially dangerous to deal with.

Indeed, we are in the midst of a monumental mental health crisis, and in particular, a runaway rage epidemic here in America, one which has insidiously been spreading across the globe. (See my prior posts.) In my opinion, part of the cause of this crisis is our failure as a society, and, in particular, the failure of psychotherapy, to meaningfully address this profound  frustration, rage and embitterment in our patients.  And I suspect there is some positive correlation between the predominance in recent decades of both the pharmacological and cognitive-behavioral approach to psychiatric treatment and this surging tidal wave of anger, rage, mental illness and violence we are now witnessing.

It is high time for another revolution in the way we view and treat mental health issues. Freud's great contribution, his revolutionary message, has been degraded, adulterated, and all but forgotten. That vital message--that the power of psychology, not only biology (and not just cognition and behavior, but the unconscious, chronically repressed affect, or what I call the daimonic) is at the root of most debilitating mental disorders--must be reintegrated into our current understanding of the psyche to counteract the slippery slope psychotherapy has sadly headed down, leading us back to the dark ages of psychiatry prior to the contributons of Freud, Jung, Rank, Adler et al.

So, let me now counter Dr. Kazdin's points one by one. Though without doubt withering on the vine, psychotherapy is not becoming obsolete. Not by a long shot. As he rightly points out, almost half of all Americans will suffer from some mental disorder during their lifetimes, and will require psychological or psychiatric treatment. Ironically, the aforementioned mounting crisis within the psychotherapy world parallels a growing crisis in public mental health. 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 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. 61 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). We need real psychotherapy now more than ever. By "real psychotherapy," I mean therapy that constructively addresses, rather than rotely ignores, disregards or actively suppresses (psychologically or pharmacologically) the daimonic.

However, real psychotherapy is, in fact, becoming more and more difficult to find. An estimated 90 percent of psychiatrists no longer practice psychotherapy much at all, heavily relying 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% in 2004-05 from 44.4% in 1996-97."  The vast majority of psychiatrists today receive only minimal training in providing psychotherapy of any kind. Yet, this is precisely what is needed.

Studies show that most people suffering from emotional disturbance who have at least several sessions of psychotherapy are 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 scientific studies support a combination of both psychotherapy and psychopharmacology as the most efficacious treatment of serious depression and other debilitating mental disorders.

Indeed, in her own measured official response to former APA President  Dr. Kazdin's remarks, current American Psychological Association President Dr. Melba J.T. Vasquez, had this to say:

"Psychotherapy is a highly effective treatment for many disorders, including anxiety and depression. That's an important and data-based message for health care consumers, which unfortunately was ignored by Maia Szalavitz in her interview with Dr. Alan Kazdin: "Q&A: Yale Psychologist Calls for the End of Individual Psychotherapy" (September 13). Dismissing the value of individual psychotherapy is not supported by the research data and does not help address the access and barriers-to-care issues that many mental health consumers currently experience. . . . Importantly, for some disorders, psychotherapy treatment can be more effective, safer and less expensive in the long-term than drug treatment. Unfortunately, your article may discourage people who could be helped by psychotherapy from seeking such treatment."

Meta-analysis of the available data shows that, despite the exaggerated claims of cognitive-behavioral therapy research, no particular form of psychotherapy, including CBT, is any more effective than any other in general. All psychotherapies statistically work equally well overall. Some studies even suggest psychodynamic psychotherapy can be more effective than CBT and has more enduring benefits. Moreover, the relationship between patient and therapist has been scientifically shown to be the common factor in effective psychotherapeutic treatments, no matter the specific orientation. Dr. Kazdin is, of course, correct that correlation in scientific research is not necessarily causation. But he is incorrect in then asserting that the therapeutic relationship does not contribute to or "cause" treatment efficacy. There is most definitely a strong correlation if not clearly causal connection between the two. Moreover, cognitive-behavioral approaches to anxiety disorders, specifically, are not superior to other treatments. In fact, existential psychotherapy is especially well-suited for addressing anxiety disorders, and has, in the long term, much more to offer patients than either CBT or psychopharmacology. Finally, psychodynamic therapy of anxiety symptoms does not insist, as Kazdin suprisingly claims, that the patient relate to the therapist "like mom or dad." That is absurd, and again, demonstrates a seeming lack of sophistication in understanding what actually happens in contemporary psychodynamic psychotherapy.

One of my former mentors, existential psychoanalyst Rollo May (1909 -1994), passionately argued that real psychotherapy should be less about technique or what he pejoratively called "gimmicks" designed to rapidly subdue symptoms than about enhancing the patient's capacity to feel, experience, create, love, find meaning, and in general become more receptive and accepting to life and love in both their positive and negative aspects. (See my prior post.)  In some ways, this is a radically divergent view on the very nature, meaning and purpose of psychotherapy compared to the conventional, medicalized, behavioral and symptom-centered approach prevalent  today. Suppressing painful, crippling psychiatric symptoms quickly is helpful and sometimes life-saving. But it doesn't faciliate the patient's personal growth or transformation. Instead, it fosters avoidance and further suppression of that which dynamically underlies or drives these symptoms, which include the patient's so-called cognitive distortions. That is to say that irrational or negative cognitions are themselves often symptomatic manifestations of repression, rather than the root cause of the patient's problems as CBT claims. And, as such, they sometimes cannot be successfully "restructured" or countered without dealing with the daimonic directly, e.g., the underlying rage.
May's neo-Freudian, and especially existential attitude toward psychotherapy and his humane emphasis on the healing power of the relationship between patient and therapist over the primacy of technique (as in CBT) is closely related to that of C.G. Jung, who once quipped that psychotherapy "demands all the resources of the doctor's personality and not technical tricks."  This is one reason psychodynamic or existential therapy are so difficult to scientifically standardize, replicate and validate. One size never fits all. Treatment varies considerably from patient to patient. As it should, depending upon the symptoms and circumstance. No two courses of real psychotherapy are exactly the same. And no two psychotherapists are identical in what they do during treatment. But to use the obvious shortcomings of experimental science to deny the validity of any psychotherapy other than one's it can readily figure out how to objectively measure and verify is nonsensical. Science is not the sole arbiter of truth. Empirical experience counts. Subjectivity counts. Common sense counts. There is no substitute for the caring and creativity of the psychotherapist. Clearly, real psychotherapy of any sort depends partly on specific techniques. But the utilization of such techniques is secondary to and can never substitute for the real human relationship between patient and therapist. Especially when patients are struggling with powerful and potentially destructive emotions such as anger or rage, anxiety or despair. (See my prior post.) As May pithily puts it in his foreword to my book: "I do not believe in toning down the daimonic. This gives a sense of false comfort. The real comfort can come only in the relationship of the therapist and the client or patient." This is what makes the so-called therapeutic alliance so crucial in successful psychotherapy. So much so, that, in some studies, it appears to be more important than experience, training, orientation or technique. But instead, clinicians like Kazdin, in the name of supposed "science," today promulgate therapeutic treatments that technically or pharmaceutically suppress the daimonic (especially anger or rage) to provide expedient comfort rather than making use of the therapeutic relationship to empower  the patient's psychological development. The problem with this is that patient's learn to depend on their psychopharmacologist and suppressive drugs rather than on themselves for dealing with their troublesome feelings. Such chronic dependency has also become common in psychoanalytic or psychodynamic psychotherapy, and cited by the opposition in making their case against  "long-term" or "open-ended" treatment. (See my prior post.) But these are two extremes in psychiatric treatment. Ideally, psychotherapy should take whatever time is needed to provide the patient with the skills, insight and freedom to stand on his or her own feet. But, at some point, termination is not only inevitable, but necessary. (See my prior post.) A primary goal of psychotherapy, especially in these tight economic circumstances, must be to get the job done in the briefest possible time at the lowest overall cost to consumer or health insurer. But this goal cannot be permitted to take priority over providing adequate and efficacious treatment. Paradoxically, when this occurs, which is typical today, the long-term duration and cost of psychiatric treatment dramatically increases rather than decreases, due to constant crises, chronic debilitation, and the very expensive "revolving door" of frequent emergency room visits and multiple psychiatric hospitalizations. Penny wise. Pound foolish.
Still, the kind of psychotherapy I am promoting here has less to do with the duration or cost of treatment than with how we view the fundamental nature of symptoms and purpose of treatment itself. Real psychotherapy provides patients adequate opportunity, when needed, to grapple with life's thorny questions and emotions--which are often closely, though unconsciously, related to their presenting problems. The goal of such therapy is to assist patients in developing their own philosophical or spiritual perspective in life, to find some solid psychological ground to stand upon within themselves so as to be able to deal with future issues and stressors from a position of inner strength, autonomy, integrity and stability. To find and fulfill their destiny. Or at least take some tentative steps in that direction. If psychotherapy continues to be perceived as a  predetermined, mechanistic cookbook recipe of rote techniques designed just to rapidly suppress certain troublesome symptoms or behaviors, such treatment goals will increasingly seem moot. Patients receiving this sort of severely curtailed and dogmatic treatment today are being tragically deprived of a much-needed chance to consciously wrestle with what existential theologian Paul Tillich called life's  "ultimate concerns."  We live today in a stifling therapeutic culture that devalues talking or even thinking about such things. But if psychotherapists and patients can recognize and respect the highly pragmatic therapeutic value, power and importance of addressing meaningful subjects such as beauty, God, death, evil and the daimonic, even in brief, intensive treatment--psychodynamically, existentially, cognitively, behaviorally, and, when needed, pharmacologically, since all have their clinical value--then maybe, just maybe,  psychotherapy has some small chance of surviving for another century. But only if we--clinicians and mental health consumers--are willing to stand up right now and fight passionately for its future against those who would do away with it. And let the world know that psychotherapy and its precious healing secrets is still desperately needed and worth saving. Are you ready for the next psychotherapy revolution?