Sunday, April 25, 2010

Psychiatry and Psychotherapy Today

I hope you do not take my views of the state of psychotherapy today as gospel truth. I don't, so why should you.

However well informed my analysis, it needs to be tested against reality. There it will either rise or fall, be affirmed or be revised.

For this reason I was very interested to read the essay that psychiatrist Daniel Carlat contributed to the New York Times Sunday Magazine today. Link here.

Carlat practices psychiatry. Of late he has grown dissatisfied with the rote nature of his professional activity. As he describes it, psychiatry consists of physicians conducting impersonal interviews, running through a checklist of questions, marking down the answers until they arrive at a diagnosis. Then they write a prescription.

As Carlat explains, he was not trained to establish a dialogue or have a conversation with his patients. They were clusters of symptoms, not people with lives.

In his words: "Psychiatry, for me and many of my colleagues, has become a process of corralling patients' symptoms into labels and finding a drug to match."

He continues: "...psychiatry has been transformed from a profession in which we talk to people and help them understand their problems into one in which we diagnose disorders and medicate them."

In the old days when psychoanalysis ruled the profession, mind was more important than brain. According to Carlat the profession seems to have overcompensated for his love affair with psychoanalysis: now it is brain over mind, often to the exclusion of mind. And also to the exclusion of the person.

And yet, we must note that psychoanalysis is not about establishing dialogues. It is about refusing dialogue. Nor is it about getting to know the person. Psychoanalysis is about treating disembodied minds.

Psychoanalysis insisted that you could solve your problems by understanding them. When I speak of therapy in this blog, especially in its title, I am referring to a form of psychoanalytically influenced treatment that believes the symptoms and other emotional problems are meaningful experiences, expressing unresolved childhood traumas or deficient upbringing.

Given this presupposition, treatment consisted in recovering these past traumas and finding better and more constructive ways to process them mentally and to express them verbally.

It was an interesting theory; it had a compelling narrative structure. Unfortunately, it did not work in practice.

In consequence, I would say, psychiatrists gave up doing therapy and began writing more and more prescriptions. Carlat is acutely aware of the factors influencing this transformation. He counts the perverse incentives that insurance companies create to favor medication. A 20 minute session with a psychiatrist pays about as well as a 50 minute session with a therapist.

If you had the choice, what would you do?

But Carlat also notes that patients have been voting "with their feet" for medication over therapy. It is cheaper, less time consuming, and has become more effective.

The point is worth underscoring, and not merely as a corrective to the kind of paranoid thinking that sees insurance companies conspiring with pharmaceutical firms to push drugs on unsuspecting patients. It may simply be the case that the American public has had enough therapy, and has shifted its trust to medication.

Could this be the reason why psychopharmacologists enjoy a higher status within the mental health profession than therapists?

Carlat makes this point, and it is important to underscore it. Within the mental health profession there is a status hierarchy, with psychiatrists at the top. Psychologists and social workers, the ones who do most of the talk therapy, are of lower status.

In Carlat's words: "The unspoken implication is that therapy is menial work-- tedious and poorly paid." If therapy were effective, would it have been consigned to this demeaned status?

Carlat does not say it, but psychiatry also remains a more male profession, while psychology and social work have more female practitioners.

Nevertheless, Carlat does distinguish one form of therapy for its effectiveness: that being cognitive behavioral treatment. I agree him here, and would emphasize that when I speak about having enough therapy, I am NOT referring to the cognitive behavioral variety, which is, I would say, currently ascendant in the field.

This form of therapy does not see symptoms as meaningful experiences, but sees them as bad habits. Thus, they can be controlled or removed without your needing to find out what they really, really mean or what they really, really say about you. Aristotle would have said that bad habits should be replaced by good ones, and this concept, which is at the basis of cognitive therapy, does not involve dealing with your deeper issues.

To me this means that cognitive therapy is closer to coaching than it is to psychoanalytically inspired talk therapy. And would say the same of what Carlat calls "supportive therapy."

Carlat's article chronicles his movement away from the impersonal check-list way of dealing with patients toward "supportive therapy." He describes it as: "... a technique favored by many therapists and involving basic problem solving and emotional support. It's a bit like what a friend would do for another friend offering advice in time of trouble, but more elaborate and with an accompanying raft of studies showing its effectiveness in psychiatry."

To me this is another term for coaching.

Supportive therapy is distinguished from insight oriented therapy for its emphasis on problem solving. And it is distinct from any therapy inspired by psychoanalysis because it emphasizes giving advice to someone who is being treated as a friend.

So, when Carlat is now working with a woman who was given an impossible assignment by her boss and who was then criticized for failing to get it done, he explains to her that her distress is not a function of an unresolved infantile trauma, but is a normal reaction to her boss's bad behavior.

He does not assign her any fault or blame. He does not attempt to help her get in touch with the guilt that presumably makes her vulnerable. Instead, he offers a series of mental training exercises to perform whenever she is tempted to blame herself for her boss's failings.

When we get into the realm of training exercises we are closer to coaching than to psychoanalysis.

This approach is both constructive and therapeutic. It should not be the end of the story. But it is an excellent way to start. This patient might still need counseling about how to deal with a hostile and incompetent boss... further steps that coaching might provide... but her psychiatrist has set her on the right road.

1 comment:

Anonymous said...

The data continue to pour in that psychotherapy is powerfully effective, regardless of the type of therapy (Wampold 2010). Psychotherapy is increasingly seen to be equally as, or more effective, than medications, with more durable results, lower lifetime costs, and no life-threatening side-effects. Part of the problem with therapy is that nobody actually believes that it works as effectively and efficiently as it does because therapists (and coaches) are too busy arguing with each other about which type of therapy (or coaching) is superior, rather than recognizing that “all have won and all deserve prizes” and rallying around a more unified message, “Therapy Works!” However, the data reveals that some therapists (or coaches) are better than others, regardless of their brand of therapy. The way therapists (or coaches) can truly demonstrate exceptional value in the marketplace is by being transparent about their outcomes and proving their effectiveness, not by simply selling their myths, traditions, and theories. Consumers should therefore shop for empirically validated therapists rather than empirically validated therapies.

Thanks as always for a must-read blog.

Dan B.