Call to Action: Save Talk Therapy!

In January 2017, the Chicago Center for Psychoanalysis held a conference, Advancing Psychotherapy for the Next Generation: Rehumanizing Mental Health in Policy and Practice.

Psychotherapy Action Network (www.psian.org) was born of the angst and inspiration of that conference. Our hope was to become an umbrella organization for individuals and organizations concerned with protecting relationally based psychotherapies from the pressures of professional and research biases, insurance interests, and public misperceptions. Our mission is to promote talk therapy in policy, education and practice as an essential mental health treatment.

Since the original seventy-some conference attendees who stuck it out through the last day and joined us immediately, our numbers have swelled to well over 500 individuals and more than 25 strategic partners. Our membership is mostly American at this point, and we’re addressing most particularly the current state of the American mental health system, but our concerns touch the way treatment is thought about and conducted internationally. Our efforts are multiple, directed at

• challenging the current narrative about what treatments are evidence-based;
• training programs that increasingly limit the teaching of all treatments but cognitive behavioural;
• accreditation monopolies that reinforce the stance that psychoanalytic and humanistic therapies are not evidence-based and therefore should not be taught;
• policies that fail to protect or provide adequate services for people suffering from emotional distress;
• commercially driven online asynchronous texting “therapy” services like TalkSpace that function without regulation and use marketing to claim equal status with embodied, regulated treatments;
• the public understanding of what psychotherapy actually is, how it works, what it can accomplish.

What follows describes one of these initiatives, placing it in a social, professional, and conceptual context so you can get a feel for what we do. We have an ulterior motive: that you, as a reader, are inspired to join us in our advocacy efforts.

Underlying many of the problems our profession faces is the woeful state of research into psychotherapy outcomes, particularly conclusions drawn and the policy that follows. Robert Whitaker (Anatomy of an Epidemic, 2010) and Jonathan Shedler (The Efficacy of Psychodynamic Psychotherapy 2010) gave keynote addresses at our conference, delineating the ways in which psychotherapy research findings have been biased by influences both calculated and inadvertent that shape what is studied and how. The tangible evidence of these biases appeared in the nature of the treatment Guidelines for PTSD and depression published by the American Psychological Association over the last year. In the PTSD Guideline (https://www.apa.org/ptsd-guideline/ptsd.pdf), the research base was limited to studies using randomized control trials, and therefore almost exclusively to the sorts of treatments readily studied in this way—short-term, manualized—with subjects whose psychological picture wasn’t complex (e.g., dual diagnoses were typically excluded). This meant that virtually all psychoanalytic psychotherapy outcome research was excluded from consideration. Moreover, the extensive input of psychoanalytic practitioners offered during the Guideline comment period was largely ignored. PsiAN joined the battle to get APA to address these objections before publishing the Guideline and to reconsider its whole approach to treatment guidelines. As part of this effort, we started a petition describing the problem and seeking support. Within the week, we had more than 4000 signatures of clinicians. When we went to the public with the petition, those numbers exceeded 57,000.

Find the petition here: https://www.thepetitionsite.com/takeaction/480/492/776/?cid=headerClick

While there was no formal change in APA’s policy, there were two things that did change. First, APA did indeed make some changes in what research they used and how they reported it in the subsequent Depression Guideline (still in draft form). The complete text of that guideline actually quite fully articulates the major problems in the field of outcome research—we give it credit as a worthwhile guide to researchers. Second, after a discussion with Blue Cross Blue Shield about our concerns that their posting the PTSD Guideline on their website could mislead consumers, they removed it.

What didn’t change? The depression guideline still makes recommendations of treatments that have a poor evidence base over others that are more difficult to study by RCTs. The rich, honest discussion of how little we have been able to identify of what helps depressed people through these research methods isn’t evident in the conclusions, which still highly recommend certain treatments over others based on admittedly poor evidence. Moreover, even though the Guideline states that insurance companies shouldn’t use it to establish standards of care, that’s exactly what happens when guidelines are made with the authority of the largest psychological association in the country behind it.

This misuse of evidence has tremendous social consequences in the long run—it’s a problem not limited to the field of mental health but it’s particularly insidious for us. When we adopt RCTs as the gold standard for the study of the treatment of human suffering, it’s a bit like the man in the old joke who drops his keys on a dark street but searches for them under the streetlamp where the light is better. What turns up under the street lamp isn’t keys, but when it’s announced to the public that it is, the interests of the people developing, researching, and promoting the techniques studied are served, as is an insurance industry seeking ways to contain costs. But the people being told their problems should be cured in 6-12 sessions are not served. They may only come to see themselves as failing or blame the whole enterprise of psychotherapy as a waste of time. In countries like Great Britain and Sweden, the results of policy decisions to widely implement CBT because of its “evidence base” have been disappointing, to say the least. Farhad Dalal, in CBT: The Cognitive Behavioural Tsunami (Routledge, 2018), captures the way a dominant narrative, based in misreported, misunderstood, or biased research, can with breathtaking speed overtake the public and political idea of what helps people, and why, and persist in spite of evidence to the contrary.

The marginalization of treatments of depth and relationship has occurred at least in part because people and corporations accrue power and make money off the treatment of human suffering. Our field has not engaged the battle of marketing talk therapy—perhaps we’re too isolated in our offices, perhaps too confident in the value of what we’re doing to believe it could be overlooked, perhaps too busy with our individual conversations, and too helpless in our silos as the perception of the value of what we do has eroded. I think the battle for public understanding, so much of which occurs through PR and marketing, is distasteful to many of us. I also think that by continuing to avoid facing our loss of influence, we cause harm to those we mean to help. The dominant narratives as sold to and heard by the public, of biologically based disorders that can be treated with medication, on the one hand, and of cognitive definitions of emotional problems which can be resolved by changing thinking patterns, on the other, too often leave real people with complex problems stigmatized for their inability to fit their real selves and real experience into these boxes. Both forms of treatment have a place of value, but what’s essential to being human isn’t captured by medication or CBT paradigms. We need to see ourselves as responsible, within the larger field of mental health, for holding the centre of humanness, its relationally-based nature, as we practice the relationally-based alleviation of suffering.

We invite you and your professional or social justice organization to join us! Go to our website, www.psian.org , see what we’re doing, and click on the “join us” button to be added to our google group. If you’re interested in getting actively involved, email from our website, and we’ll be in touch to set up a conversation.

References:

APA Post-Traumatic Stress Disorder Clinical Guideline,

https://www.apa.org/ptsd-guideline/ptsd.pdf

Dalal, Fahrad, CBT: The Cognitive Behavioural Tsunami, Routledge, 2018

Shedler, Jonathan, The Efficacy of Psychodynamic Psychotherapy, 2010

https://www.apa.org/pubs/journals/releases/amp-65-2-98.pdf

Whitaker, Robert, Anatomy of an Epidemic, Crown Publishing Group, 2010