Psychology's Escalating Civil War: How Do We Understand, Diagnose and Treat Mental Disorders?
In defense of psychotherapy
Posted Nov 25, 2011
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 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."
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.)
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.
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.