Therapy

It’s Time for Psychology to Lead, Not Follow

Psychotherapy is not a medical treatment.

Posted Oct 27, 2019

One of the most powerful constructs I know is called supervenience. It helps us understand why knowledge at one level of analysis can be irrelevant at another.

Ptmoney/Used with Permission
Mind or Brain?
Source: Ptmoney/Used with Permission

For example: When you watch a movie on a screen, you are seeing arrangements of pixels. The movie is 100 percent dependent on pixels and cannot exist apart from them. But knowledge of pixels is irrelevant to understanding the movie. We could know everything there is to know about pixeIs and have no concept of Luke Skywalker, Darth Vader, or the battle for the empire.

Movie supervenes on pixels.

Likewise, mind supervenes on brain. Mind depends on brain and cannot exist apart from it. But knowledge of brain is not knowledge of mental life. They are different levels of analysis requiring different concepts and methods.

The National Institute of Mental Health (NIMH), under the direction of Tom Insel, made the assumption that mental health problems are “brain disease” and neurobiology would unlock the cure for all manner of mental and emotional suffering. NIMH bet the farm and failed spectacularly.

Now Insel says, “I spent 13 years at NIMH really pushing on neuroscience… and when I look back on that I realize that while I think I succeeded in getting lots of 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. I hold myself accountable for that.”

No, they did not move the needle. That $20 billion gamble with taxpayer money did not improve the mental health of one single person. Not one. Despite endless promises, there is no biological test for any mental health condition. There are no new or better treatments. But, hey, what’s $20 billion among friends?

Neurobiology is one level of analysis, mental life is another. Thoughts and feelings must be studied at their own level of analysis. The brain is the subject matter of neurobiology and mental life is the subject matter of psychology. There are, of course, areas of intersection and overlap, but neither can supplant the other.

NIMH bet the farm on naive biological reductionism—assuming neurobiology would answer the important questions at the biological and psychological levels both. The assumption did not follow from scientific findings. It was an a priori assumption reflecting the world view of a researcher who built his career dissecting rodent brains. It was the equivalent of abolishing film studies because engineers are working on visual display technologies.

Twenty billion reasons say they were wrong.

The lesson is that psychology must blaze the trail for psychological treatments using psychological concepts and methods. It must not play handmaiden to medicine or ape its concepts and methods.

It is an intellectual, scientific, and clinical dead-end when psychology seeks to be “like” medicine or like any other discipline. Psychology should not be more like medicine. Psychology should be like psychology. Psychologists contribute most to understanding and treating mental suffering by being first-rate psychologists, not aspiring to be second-rate medical doctors.

This is one reason why the new clinical practice guidelines issued by the American Psychological Association, which evaluate and recommend psychotherapies based on Institute of Medicine (IOM) criteria, are a tragic mistake. The criteria were designed to evaluate biological interventions like medication. Psychotherapy is nothing like medication.

Aping the methods of pharmaceutical research does not elevate psychology. We should not mislead the public to think emotional suffering is like medical disease, or different kinds of psychotherapy are like different medications. These assumptions are false at every level. Psychotherapy is not like medication, psychotherapy is like psychotherapy. And we should help the public, policymakers, and fellow healthcare professionals understand what good therapy means—because they do not know.

We should study the outcomes of psychotherapy using our own psychological concepts and methods. We should study how people change and how lives change, not diagnostic categories from the Diagnostic and Statistical Manual of Mental Disorders (DSM). We should study the outcomes that matter to patients and the therapists who treat them. Real psychotherapy is not about DSM diagnoses and never was. Real psychotherapy outcomes cannot be reduced to DSM symptom lists. There is no excuse for debasing psychotherapy by forcing it into a medical Procrustean bed.

Psychology has its own concepts and methods. Wilhelm Wundt established the first experimental psychology laboratory in 1879, studying mental life scientifically at a time when bloodletting was still common medical practice.

Just once, can psychology lead, not follow? Just once, can our professional organizations stop positioning psychology as handmaid to medicine and second-class citizen of healthcare? Just once, can our professional organizations stop stooping and groveling and devaluing psychology by trying to shove the round peg of psychology into the square hole of a broken healthcare system?

Can psychology define for itself what we treat and how we treat it, instead of forcing ourselves into misshapen slots defined for us by medical researchers, healthcare systems, and health insurance companies?

Can we contribute to the world as psychologists using psychological concepts and methods? Can we be proud to be psychologists again?