Is this the End of Individual Psychotherapy?
The first thing we do, let’s kill all the therapists.
Posted Sep 16, 2011
Time magazine recently published an interview with Yale psychologist Alan Kazdin (among other things, a former president of the American Psychological Association and author of influential textbooks on clinical psychology research) titled: Q&A: A Yale Psychologist Calls for the End of Individual Psychotherapy. "Is individual therapy overrated and outdated?" the article asks, "Yes, says [Kazdin]". Wait, what?
In the academic journal article on which the interview is based, Kazdin (and his colleague Stacey Blase), write: "Our comments are not a criticism of the model of individual therapy. One-to-one therapy will always have a place; individual crises and challenges in life are invariably at that level."
Yet the Time interview reads just like that, a criticism of individual therapy as "way outdated" and telling people "don't come [to therapy] for anxiety or depression". Kazdin calls eclectic therapy approaches "a red herring", and that there's "no real evidence" for one of the most robust and replicated findings in both medical and psychotherapy research (that the therapeutic relationship with a practitioner is a powerful and significant factor for treatments that work). He goes on to say that we should have guidelines that "offend the profession", be "proselytizing" for online and self-help treatments, and be "taking the moral high ground" (although in this case, it sounds like taking the moral high ground means that therapists should all take a jump off the nearest cliff).
Here are some major things I find wrong with the interview:
1. Therapy does work. It works for a great majority of people and for a range of conditions like anxiety and depression. And a good therapeutic relationship is a key factor in those improvements.
2. Therapy isn't stagnant and outdated, it's a constantly evolving field, bustling and growing with new treatment practices, new clinicians, and new challenges to face.
3. Even though we don't know the best ways of tailoring individual treatment to individual patients, eclectic therapists are not offering a "red herring". Therapists who are flexible and receptive to client feedback do better than those that are over-rigid and dogmatically adhere to standardized treatment manuals.
4. According to Kazdin, most therapists "don't know how to monitor your progress". He says, "think about if you went to your physician and had a blood test, but they never read the results. They don't have any idea if you're getting better. It's ridiculous." The only thing ridiculous is that statement. I agree that more therapists should routinely monitor their patients' progress, and I do it in my own practice (evidence suggests such monitoring improves outcomes). On the other hand, there are plenty of ways other than questionnaires or blood tests to know if your patient is feeling better (gee, I don't know, like you could ask them how they're doing). I've never had a blood test when my allergies act up or I've come down with the flu, but my doctor and I can tell when I'm feeling better.
5. At one point in the article, the interviewer says: "In Manhattan, which has no shortage of therapists, I've asked for referrals for evidence-based treatments like cognitive behavioral therapy [CBT] and several times had high-level professionals be unable to provide one." First, most people have a misguided notion that CBT is the only "evidence-based treatment", but there are plenty of other evidence-based therapies, too (like short-term dynamic therapy, interpersonal therapy, acceptance and commitment therapy, just to name a few.) The APA itself defines evidence-based practice as: "...the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences." Second, if you can't find a CBT therapy in Manhattan (home of the Albert Ellis Institute, among other things), then you aren't looking very hard.
All that being said, there are some other important things in the interview (though mostly in the academic article) worth considering:
1. Too few people are getting adequate mental health treatment. (Not enough people are getting good health care, either, but that doesn't mean you shouldn't go see a doctor if you're sick). As Kazdin and Blase write, "Interventions are needed that can reach many more people, but also with particular attention to select subpopulations."
2. Psychotherapy doesn't work for everyone. There are still many people who don't see benefits from individual therapy and it isn't a cure for all that ails you. But let's not throw out the therapist with the used couch. Let's find ways to improve practice for a broader range of people.
3. Many people presenting to general medical practitioners are actually dealing with mental health symptoms, and we need more effective ways to get them referred for services. (See my article here about a novel approach to this issue from Dutch researchers).
4. We need to adapt the profession to embrace and promote novel approaches and new technologies. (See my article here about telephone and internet approaches to treating depression).
5. As Kazdin says, "We should unite in some way to try to bring together a critical mass of people who would have a voice to educate the public and serve at least as triage." I wholeheartedly agree, and that's why it's such a shame that the Time interview is so sectarian and misleading.
By Jared DeFife, Ph.D.
© September 16, 2011 (article link: http://tinyurl.com/3hmjbjw)
For more information about research, speaking, and Atlanta-based private practice, visit www.psychsystems.net/DeFife