Assessing the State of Psychotherapy

Is Today's Therapy Losing Out to Science and Psychopharmacology?

Mary Sykes Wylie

The bad news was made official in 2010, though everybody in the head-shrink business had long suspected as much: psychotherapy was in decline, or even in freefall. According to a study published in December of that year in the American Journal of Psychiatry, the proportion of people getting only psychotherapy in outpatient mental healthcare facilities had fallen from 15.9 to 10.5 percent between 1998 and 2007---that’s by more than a third---while those receiving both therapy and meds had fallen from 40 to 32.1 percent. Meanwhile, the number of people receiving only meds had increased from 44.1 to 57.4 percent. Even the average number of therapy visits per patient per year had declined, from 9.7 to 7.9 percent. So far, in the succeeding years, there’s been no indication of any uptick; most likely, the numbers have continued to drop.

You might think this trend represents people’s preferences for the quick fix of a pill, rather than a slog through talk therapy, but you’d be wrong: surveys have consistently shown that depressed and/or anxious people and their families would rather talk to a real, live, human therapist than fill a prescription.

Are people being talked out of psychotherapy because a biomedical approach has been proven superior to pokey old talk therapy? Not at all. Psychotherapy isn’t only the treatment preferred by clients, it’s probably the best option, particularly for the commonest complaints, like anxiety and depression. Research shows not only that several major approaches---including cognitive behavioral therapy (CBT); acceptance and commitment therapy; interpersonal, family, and even short-term psychodynamic therapy---are successful stand-alone treatments for depression, anxiety, substance abuse, and other conditions, but that therapy significantly boosts outcomes for clients already taking meds for severe mental illnesses, including bipolar disorder and schizophrenia. Furthermore, therapy appears to provide longer-lasting effects than meds and at lower cost over time (particularly given the vast sums involved in developing drugs), but without the side effects or withdrawal symptoms and relapses associated with going off them.

In fact, the much-vaunted psychotropic revolution seems to have fizzled. Not only does current research suggest that antidepressants work little better than placebo for mild to moderate depression, but medications are often massively overprescribed and widely misprescribed (antipsychotics for anxiety disorders, for example) when milder drugs don’t work. Even the drug companies seem tired: their sales are down, the patents on their great old moneymakers are quickly expiring, and they’re just about out of ideas, with no fabulous new blockbusters in sight.

So in what appears to be the twilight of the psychopharm gods, why aren’t therapy practitioners rising up, throwing off their chains, and reconquering lost mental health territory, not to mention restoring their once-respectable, middle-class incomes? In May 2013, the Clinical Psychology Review devoted an entire issue to the apparent demise of the therapy profession—why it’s happening and what might be done to rescue it. The main culprit, write the editors of the issue, Brown University psychiatrist-professors Brandon Gaudiano and Ivan Miller, is the pervasive medicalization of mental health treatment and the widespread belief that almost all forms of psychological distress are medical/biological problems with medical/biological solutions. And if those solutions haven’t yet been found, they will be, any day now, with the next laboratory breakthrough.

In short, therapists stubbornly persist in clinging to intuition and personal experience as their guiding lights, and ignoring research showing that statistics trump individual clinical judgment. Even worse, these self-willed do-it-yourselfers use the much-ballyhooed meta-analyses showing that all credible therapies produce roughly equivalent results in order to do any damn-fool thing they want---which might include totally unsupported, useless, or even harmful methods. All this seems to suggest that most therapists are just too loosey-goosey about their practice for their clients’ or their own good.

Gaudiano and Miller suggest that unless therapists and their own lobbying organizations get with the program and insist that the profession become more “scientific” (more like the drug industry), therapists will continue to lose out in the popularity sweepstakes.

But barring the odd idea that the public is turning away from therapy because so many practitioners don’t hew to empirically validated methods (do people seeking mental health treatment really pore over academic manuals to learn which methods have the highest evidence-based ratings?), is it appropriate to make such a fetish of science in the field of psychotherapy?

Therapeutic practitioners and practices show far more divergence than is dreamt of in the philosophies of biomedical researchers. Therapists are social workers, pastoral counselors, PhD psychologists, medical doctors, school and prison counselors, business coaches, personal coaches, and even—still—psychoanalysts!

We have more than enough room to wonder whether psychotherapy can or should ever be completely “scientificized” in a me-too attempt to beat psychopharm at its own game. Neither the great pharmaceutical revolution, nor the proliferation of empirically validated methods, has reduced the prevalence and costs of mental disorders.

Never before have young adults been so free to do what they want, but never before has it been so hard for them to find their place in the world, in the face of unprecedented challenges and pressures—economic, relational, sexual, personal—that leave many paralyzed, unable to move forward.

As much as any generation in history, today’s clients need and want guidance, a helpful conversation, and a genuine connection with a mature, wiser adult—somebody who can listen to them with kindly intelligence, fully grasp the nature of their dilemma, and help them discover within themselves what they need to make their way in the world. This, ladies and gentlemen, is the job of a good therapist!

This blog is excerpted from “The State of Our Art." The full version is available in the March/April 2015 issue. To subscribe, click here. >>

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Topic: Business of Therapy | Anxiety/Depression

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1 Comment

Sunday, March 15, 2015 1:52:53 PM | posted by Paula Solon
My training and experience informs my critical thinking and intuitive skills. A parsimonious diagnosis, a sound treatment plan, and watching my client heal over time --these are my guides. Like any responsible person, I willo use any intervention--medical, spiritual, etc., in service to my client. Signed - a psychologist