Therapy
It’s Time for Psychology to Lead, Not Follow
Psychotherapy is not a medical treatment.
Updated February 25, 2025 Reviewed by Kaja Perina
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.
For example: When you watch a movie, you are seeing arrangements of pixels. The movie is 100% dependent on pixels and cannot exist apart from them. But knowledge of pixels is irrelevant to understanding the movie. We can know everything about pixeIs and have no concept of Luke Skywalker, Darth Vader, or the battle with 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 ills. 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 even a single person. 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. They are, of course, interrelated—but neither can supplant the other.
NIMH bet the farm on naive biological reductionism—assuming neurobiology would answer questions at the biological and psychological levels both. This assumption was not based on any scientific findings. It was just that—an assumption—reflecting the worldview of a researcher who built his career dissecting rodent brains. It was the equivalent of ignoring movies because engineers are working on cool pixel technology.
A lesson is that psychology must blaze the trail for psychological treatments based on psychological concepts and methods. It cannot play handmaiden to biological medicine or ape its concepts and research methods.
It is an intellectual, scientific, and clinical dead-end when psychology seeks to be “like” medicine, or like any other discipline. Psychology should be like psychology. We contribute most to understanding and treating mental suffering by being first-rate psychologists, not aspiring to be second-rate physicians.
This is one reason the 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. These criteria were designed to evaluate biological interventions like medication. Psychotherapy is nothing like medication.
Aping pharmaceutical research methods does not elevate psychology. We should stop misleading the public to think that emotional suffering is like a medical disease and different kinds of psychotherapy are like different medications. The 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 psychotherapy is—because they do not know.
We should study psychotherapy outcomes using 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 outcomes that matter to patients and the psychotherapies that treat them. Meaningful psychotherapy is not about DSM diagnoses and never was. The outcomes of meaningful psychotherapy are not reducible 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 physicians still practiced bloodletting.
For once, can psychology lead, not follow? For once, can our professional organizations stop positioning psychology as handmaid to medicine and second-class citizen of healthcare? Can they stop stooping and groveling and debasing psychology by trying to fit 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 healthcare systems and health insurance companies?
Can we contribute to the world as psychologists with psychological concepts and methods? Can we be proud to study psychology again?
