Controversy over DSM-V

This week, I finally got a reprieve from numerous reports and paperwork, so I can dust off the old blog and have some fun again. There is no better place to begin than the controversy over DSM-V.

Background

First, some background. DSM-V stands for Diagnostic and Statistical Manual--Fifth Edition. Of course, in psychiatry, numbers can be misleading. DSM-V will actually be the seventh revision, as DSM-III was revised once (DSM-III-R) and DSM-IV was also revised (DSM-IV-TR. TR stands for "Text Revision.") It's published (and jealously guarded) by the American Psychiatric Association.

When I started out in the 1970's, DSM-II was the manual we used, and it was awful. Definitions were vague, and you could diagnose the same person with anything from depressive neurosis to schizophrenia without much difficulty. DSM-II was generally denounced as irrelevant and unnecessary by behaviorists and humanists. At the time, diagnosis had little to do with treatment, so it really was unnecessary. In hospitals, physicians would argue endlessly about a patient's diagnosis, with no change in treatment after they had differentiated what kind of schizophrenic they were dealing with.

DSM-III changed all that, as diagnoses were made on the basis of behavior. Specific symptoms were identified and you had identify a certain number of symptoms in order to diagnose depression. This was a great advance in two areas. First, research could be focused. If you wanted to research a treatment for depression, there was now a clear operational definition for depression. That means that we could compare different studies without comparing apples and oranges.

Second, DSM-III gave us the ability to communicate what we were treating to third parties. It was published when insurance companies were beginning to pay for psychotherapy. Unfortunately, many therapists didn't know an adjustment disorder from major depression. Consequently, managed care used DSM-III to refuse to pay for many treatments. We had to learn to say, "Here are the symptoms that show the client is depressed and here is the progress I am making on them. Once we learned to do that, managed care stopped refusing psychotherapy and we now generally get as much time to treat clients as we need.

The Controversy

DSM-IV has been a small improvement over DSM-III, but it's still controversial. Now DSM-V is on the horizon and it's generating more heat. A recent article in the New York Times picked up on the controversy. There are a number of points of controversy.

First, there is no real understanding of the causes of mental illness. We're still not even sure if there is such a thing as a mental illness. Psychiatry has been moving toward a neurobiological model of mental illness, but is still far away. If you ask a psychiatrist what causes depression, you'll hear one of two answers. You might hear, "We don't know," which is the honest answer. However, more likely, you will hear some mumbling about serotonin and biochemical imbalances. Those guys are just blowing smoke. Just ask them to define a healthy biochemical balance; their response will be entertaining. Unfortuantely, more than half of the members of the task force writing DSM-V have drug company connections, so you know they will remain committed to a neurobiological model.

Second, diagnoses are often points on a continuum. Consider what is now called Attention Deficit/Hyperactivity Disorder (ADHD). Our ability to pay attention falls along a continuum from fleeting to intense. When we diagnose someone with ADHD we are saying that their attention on the average, falls below some imaginary point on that continuum. That imaginary point is also arbitrary. Do we abandon children who fall just to the normal side of that point? How about children who fall mostly to the average side of that point, but occasionally their attention and concentration crash and burn?

Third, the inclusion of a diagnosis in the manual has always been unsystematic and has many social implications. Why is repetitive handwashing considered obsessive compulsive disorder, while repetitive shopping is not? Is binge eating a disorder, or does the person just need to grow up and get some self control? In DSM-II, homosexuality was considered a diagnosable mental illness. In DSM-III, homosexuality was removed as a diagnosis. There is a straight line from deciding homosexuality is not a mental illness to deciding gays should have the right to marry.

Fourth, how open should the process be? The APA has had the members of the DSM-V task force sign conficentiality agreements. Dr. Robert Spitzer, a member of the APA task force on DSM-V has raised concerns about it. (More about the controversy can be found here.) Given the social implications for some diagnoses, there's a lot at stake here. But, it's difficult to balance the need for open, scholarly discorse, with the risk of being personally attacked by one pressure group or another.

Who gets treatment is affected by diagnosis. When I diagnose a child with autism, that child becomes eligible for a wide range of services that a child with plain old "mental retardation," would not get. Interest groups in a lot of areas would like to see their own diagnoses included, so more services become available. A battle is raging over whether or not transsexuality should be included in DSM-V as a mental illness. Some would like it to be normalized; a person should be able to cross dress if they want to. However, others would like to have insurance cover sexual reassignment surgery. You can't cover a procedure if it isn't treating a diagnosis.

Conclusions

DSM-V will almost certainly move closer to a neurobiological model and away from a psychosocial model. That will lead to less emphasis on psychosocial treatment. I don't hold that against psychiatry; they treat mental illness biologically. However, psychotherapy still has much to offer. Psychotherapy is still the best (or at least a competitive) treatment for personality disorder, post-traumatic stress disorder, and some depressive and anxiety disorders. Generally, psychotherapy reduces the risk of relapse. Yet, if we structure our diagnoses around neurobiolgical models, psychotherapy will be marginalized. Already, family and marital therapies are extremely difficult to justify using DSM-IV. Somehow, diagnoses should also be there to allow for psychosocial treatment and to encourage more research in that area.

Despite these problems, we still need a diagnostic manual. Psychiatric diagnoses, for all their arbitrariness, give us a way of organizing research and communicating therapeutic information. At some point research will give us a handle on the nature of mental illness, and a clear diagnostic system will emerge from that. In the meantime, this is the best we've got, and none of the critics have given us a good alternative to the writing of a new manual.

Questions about Psychotherapy

A recent editorial in the Journal of Psychopharmacology by David J. Nutt and Michael Sharpe raises questions about the efficacy and safety of psychotherapy. It's currently available free of charge, but will be placed behind a pay wall 90 days after initial publication.

Clearly, an editorial in a psychopharmacology journal is not going to be sympathetic to psychotherapy and this article does not disappoint. I'm going to discuss four of their points.

1. Is Psychotherapy Effective?

Nutt and Sharpe begin by questioning the effectiveness of psychotherapy. They say, "few psychotherapy trials have complied with the standard regulations that are required of all drug treatments." This is both true and not true. Psychotherapy cannot be evaluated in the same way as drug therapy. It's a different treatment and there are different issues in evaluating it. Psychotherapy is a procedure, and as such, it is more akin to surgery, than it is to pharmacotherapy.

Nevertheless, psychotherapy has a rich and diverse research base, going back over 50 years. In particular, cognitive behavior therapy (CBT), always grudgingly acknowledged as an empirically based therapy, is based on a large body of literature involving operant conditioning, classical conditioning, rational emotive behavior therapy, self control and self-management. There are large numbers of outcome studies available. While few are large-scale studies, the accumulation of the data through meta analysis still shows fairly robust and positive results.

This research base has given us a good understanding of how CBT works. See the Handbook of Psychotherapy and Behavior Change for some excellent reviews of the research. In fact, we have a better idea of how CBT works than how drug therapy works. We have a pretty good idea about how changing thoughts change mood, and how exposure changes anxiety. In contrast, we still haven't been able to define that "biochemical imbalance" that allegedly causes depression. If you think we have, ask a psychopharmacologist what the balance is, or ask why one SSRI works and another doesn't.

Nutt and Sharpe also raise the issue of whether or not psychotherapy has been evaluated with double blind studies and placebo controls. I'm going to leave that issue for another day. I think they're wrong, but that's going to require more research than I have time for tonight.

Is Psychotherapy Safe?

Nutt and Sharpe question the safety of psychotherapy. They begin by arguing that psychotherapy can, in some cases, worsen outcomes. In particular, they identify suicidal patients and manic patients as being at risk. However, any treatment can cause problems in these patients. We have all heard of the worsening of suicidal ideation in adolescents on SSRI's (Nutt and Sharpe minimize this, but the black box is still there). Less well known is that SSRI's can also cause a manic episode in people with bipolar disorder. One advantage of psychotherapy is that the individual is seen more frequently and can be managed if they deteriorate. In contrast, people receiving drug therapy may not have any contact with their physician for a month or longer.

Another issue they raise involves an old technique called flooding. In exposure therapy, we deliberately expose people to feared stimuli, but in gradual steps. Flooding therapy involves fully immersing the subject in the feared situation all at once. Here is what Nutt and Sharp say about it:

When taken to its logical extreme [exposure therapy] becomes flooding therapy, which was once popular. The anxiety induced by flooding can be extraordinarily distressing and there are well recognised examples of patients escaping in fear from their treatment andrefusing further sessions. David Nutt runs a specialist anxiety disorders clinic in which we have seen a number of patients who could be considered as suffering from a PTSD-like syndrome as a consequence of failed flooding treatment for phobias and OCD. (p.4)

I can believe that a "PTSD-like syndrome" could occur as a result of premature termination of flooding. In fact, I never thought I would have the intestinal fortitude to keep a client in a feared situation long enough to make the procedure work. So, I never did any flooding, and, in fact, I've never met a therapist who ever did any flooding. They must have been out there, but I never traveled in their circles. So, I can't believe it was "popular."

Besides, isn't this an example of the pot calling the kettle black? Shall I now list the now-rejected medical procedures that have hurt people? Ever read the book, The Lobotomist? We who help those in pain often feel the need to "do something," to help people and we often wind up hurting instead of helping.

Nutt and Sharpe then raise the "false memory syndrome" canard. According to advocates of this syndrome, questioning people about past trauma can cause people to develop false memories of events. In reality, experimental evidence for false memory syndrome is weak. Ken Pope has a good discussion of the problems with false memory syndrome here.

Nutt and Sharpe unwittingly provide an excellent example of how badly false memory syndrome is abused. They say:

One young adult patient of David Nutt’s with severe OCD (obsessive-compulsive disorder--F.O.) was quizzed by a therapist about the possibility that she had suffered sexual abuse by family members. This led to her developing chronic ruminations about the possibility that she might have been abused by her father, even though she knew this had not happened. As a consequence for years she was unable to tolerate being in the same room as him, which markedly exacerbated her problems and caused great distress to the family. (emphasis added; p.4)

The section I italicized is the key. The patient knew full well that her father never abused her, so this could never have been an issue of false memories. Instead, this woman was struggling with an obsession. No big surprise. She had OCD. The woman obsessed over the possibility of her father abusing her.

There have clearly been some therapeutic abuses in the name of uncovering a history of trauma. This ain't one of them. A therapist who doesn't consider the possibility of trauma in a severely ill patient isn't doing his or her job.

Are Effective Treatments Withheld?

Moving on, Nutt and Sharpe argue, "Another proven potential risk of psychotherapeutic treatment is that effective drug treatments are withheld either because the therapist does not believe in their efficacy or because the patients are not introduced to the possibility of their being useful in their condition (Klerman, 1991)." True, but this is not a risk of psychotherapy. It's a risk of being a true believer. How many times have patients not been referred to psychotherapists because the physician doesn't believe in it?

Therapist Misconduct

Finally, Nutt and Sharpe bring up the risk of sexual misconduct. They site a 1986 study showing 7% of male psychiatrists and 3% of female psychiatrists have engaged in sexual contact with their patients. I am assuming these are psychiatrists who are providing psychotherapy. But this data is over 20 years old and since then, laws have been enacted, and licensing boards have been aggressive in enforcing a ban on so-called dual relationships. In Pennsylvania, it's a felony to sleep with a client. Yes, I know it still happens. But overall, this isn't a problem with psychotherapy. It's a problem with power relationships. Professors sleep with their students. Business people sleep with their secretaries. This kind of sexual misconduct occurs everywhere there's a power imbalance between men and women. Thankfully, my profession has been aggressive about stopping this.

Conclusions

After all this, I'm not willing to just write off Nutt and Sharpe as a pair of physicians with an axe to grind. I agree that psychotherapy is not as closely regulated as pharmacotherapy and I'd like to see greater quality control over psychotherapeutic services. But like other hands-on treatments, such as surgery, physical therapy, occupational therapy, and others, much of the effectiveness of treatment relies on the skills of the provider. This comes from training. One of the great disappointments to me has been the unwillingness of the leadership in psychology to improve training and accountability.

Psychology defines itself as the science of behavior, and we often research psychotherapy. But, when it comes time to say, "Yes, I believe the data. We should do A and not B to treat depression," we back down and run away. Too many people view any effort to develop treatment guidelines as an attack on psychotherapy. It's a shame that papers like this are so poorly drawn that they reinforce this belief.

In Memory of Albert Ellis

The New York Times reported today that Albert Ellis has died. Ellis is the founder of what he originally called "rational therapy," then called "rational-emotive therapy," and most recently called "rational-emotive behavior therapy," or REBT. He was a tireless lecturer and writer. He was also a shameless self-promoter and total character. He was known as the Lenny Bruce of psychotherapy.

Ellis started writing and lecturing in the 1950's and continued his work until his death. This year, he was giving seminars from his bed in a nursing home. He founded an institute, currently called the Albert Ellis Institute in New York. In many ways, he has been at least as influential as Freud.

Ellis's great contribution was the recognition that our feelings do not come from what happens to us. Instead, our feelings stem from what we tell ourselves about what happens to us. For example. Imagine you get a B on an exam. First, imagine telling yourself, "Oh, God, I'm such a fool! I only got a B. I'll never get into a good school. I'll never accomplish anything. My parents will be disappointed in me!" You can easily see how upset you'll get.

In contrast, imagine yourself saying in response to the B, "Oh, boy. Only a B. I was hoping for an A. What did I do wrong? What can I learn from this?" Here, you might feel disappointed, but not crashingly depressed.

Finally, imagine yourself saying, "Boy am I proud of myself! This was really hard. I didn't think I could do this well!" Then, you feel good.

Ellis's point is that the B didn't make you feel anything. Your thoughts about the B--what you say to yourself--affect your mood. So, you can't tell your spouse, "You made me angry!" That's an unrealistic--Ellis would say irrational--belief. Your spouse may have done something you don't like, and you have every right to object to it, but you made yourself angry.

I saw Ellis speak several times over the years. He always said the same things. Sometimes he would change names, or refine previous ideas, but he never deviated from this basic message. His lectures were always the same. First, he would talk about his approach, then he would demonstrate therapy with volunteers from the audience. He always peppered his speeches with obscenities.

The last time I saw him, he was in his late 70's, still going strong. I often tell my clients about this, because he managed to explain his approach in two words.

After explaining how thoughts affect mood, Ellis began talking about how to change what you tell yourself. He said,

"There are two words you can tell yourself that will get you through any situation, no matter how bad it is."

You can imagine, this whole room, overflowing with clinicians. We all thought to ourselves, "Oh, boy, we're going to get some wisdom from the Master!" We all leaned forward, and Ellis said,

"TOUGH SHIT!"

Broke up the joint.

Ellis's whole life was a tribute to those two words. He started his career at the time that psychoanalysis and humanism were the dominant clinical trends. Everyone thought he was crazy, and the criticism was whithering. Ellis didn't care, basically saying, "They don't like what I'm saying, tough shit. I know I'm right." He outlived all his critics and has been revered as the last of the Grand Old Men of psychology. Today, with variations, an awful lot of us are doing therapy his way.

For about the last 25 years, Ellis was somewhat eclipsed by Aaron Beck's "cognitive therapy." Yet, Beck openly admits that he based his approach on Ellis's ideas. Beck was successful because he was more dignified, if less interesting, than Ellis. He made for a better face for psychotherapy. But, I doubt that cognitive therapy would be where it is today, were it not for Ellis and his willingness to be such a character.

If we live well, we touch the world in some way; we usually don't know how. But Ellis died knowing that the things he believed in were now part of clinical psychology's mainstream. That's an incredible legacy.

Psychoanalysis Evolves: Freudian Dissenters

This is the second post in my series on psychotherapy. I know, I've been gone a long time. My stats show it, too.

When Freud published The Interpretation of Dreams, he became a very controversial figure because of his emphasis on sexuality. He went through a brief period where he worked in isolation, but, by 1902. he began to gather a group of physicians around him. By 1908, the group had grown into the Vienna Psychoanalyic Society. Two early members of the Society eventually split from Freud: Alfred Adler and Carl Jung.

Carl Jung

Jung and Freud were very close and Freud saw Jung as his successor. This relationship soon fell apart, however, as Jung began to diverge from Freud's views. There are many accounts (some of them scandalous) of their final split, which, fortunately, are irrelevant to my goals for this series.

Jung's theory, like Freud's, is extremely complicated. A good summary of his ideas can be found here. Jung became fascinated with symbols, and began to see a cross-cultural pattern in them. He argued that there are "archetypes" among those symbols which relate to common human heritage, not just the individual's experience. Thus, each of us has a set of common symbols within us, which Jung referred to as the collective unconscious. The collective unconscious coexisted with the personal unconscious.

For Jung, neurosis, or mental illness in general, resulted from attempts to cut off elements of both the collective and personal unconscious from the conscious experience of the individual. Humans have an innate need for "self-realization," which involves understanding and integrating all of the material from the collective and personal unconscious. Proceeding with self-realization results in "individuation," the process of becoming a unique and unified individual.

Psychotherapy for Jung was less structured than psychoanalysis. He did not use free-association the same way Freud did. Rather, he relied on the spontaneous discussion of the individual. Like Freud, he analyzed dreams and verbalized symbols. He was less concerned with uncovering trauma and more concerned with tracing the relationships among symbols. He also understood symbols more in terms of common human experience and less in terms of sexuality. Through therapy, individuals become more centered and more comfortable with their own contradictions.

Alfred Adler

An early member of Freud's inner circle, Adler was the first to break with Freud. A good summary of his ideas can be found here and here. Adler anticipated much of modern psychology and psychotherapy. He dispensed with Freud's instinctive psychology and focused instead on the goal-oriented nature of human behavior.

Adler saw individuals first and foremost as social creatures, forming goals and striving to meet them. Where Freud talked about the superego managing our behavior, Adler conceived of the role of values. This is an oversimplification, but essentially Adler saw mental health in terms of (a) having healthy values, which affect what goals we try to achieve, and (b) having both the confidence and the ability to achieve those goals.

This means that analysis was very straightforward. The analyst encourages the patient to overcome feelings of insecurity, develop more rewarding and meaningful relationships, and to pursue healthy life goals. Insight and exploration of the patient's past occur early in the relationship, but later on, there is more emphasis on behavior change.

There were two critical differences between Adler and Freud. First, Adler emphasized the role of empathy in the therapeutic relationship. For Freud, the analyst was supposed to be a blank slate. This encouraged the development of transference. The interpretation of transference was critical for psychoanalysis. In contrast, Adler argued that the analyst should develop an empathic relationship with the patient, stimulating hope and commitment to the process. Second, while Freud encouraged the analyst to be quiet and allow the patient to free associate, Adler encouraged the analyst to engage in Socratic dialogs to help the patient achieve insights.

Conclusions

Jung and Adler are really polar opposites. Adler was much the realist, while Jung was much more mystical. Together, Jung and Adler moved analysis off the couch and put it across the desk. This changed the dynamic between the patient and the analyst, making it possible to create the modern collaborative relationship.

Both Jung and Adler continue to be influential, and there continue to be institutes (e.g., Alfred Adler Institutes and C. G. Jung Institutes) devoted to their ideas. While Jung is better known, it has been Adler whose influence has been most pervasive in modern psychotherapy. He anticipated the more active approaches we use today and was the first analyst to downplay the emphasis on probing the unconscious. We will come back to him briefly when we discuss cognitive-behavior therapy.

A Brief History of Psychotherapy: Freud

When I originally conceived of this series, I thought it would be a brief set posts. I can already see that I was overly optimistic. There's an awful lot of material here. So, at this point, I'm not sure of how many posts it will take to complete this project.

Freud, Charcot, and Hysteria

Most people believe that psychotherapy began with Freud. Actually, Freud himself (Himself?) began as a student of the French neurologist, Charcot, who was investigating the phenomenon of hysteria. In this disorder, patients, mostly women, would manifest symptoms of physical disorders (such as paralysis or blindness) with no known physical causes. (Space prevents me from dealing with the feminist issues here.)

Charcot discovered that hypnotizing his patients and encouraging them to talk about their symptoms would result in their remission. Freud was very impressed with this and began trying Charcot's technique on his own patients. He began a brief collaboration with Josef Breuer, and in 1895, they published Studies on Hysteria, probably the first book ever published on psychotherapy.

Freud apparently was either not a very good hypnotist or not a very enthusiastic hypnotist and soon abandoned hypnotic induction. He kept everything else in place; the patient would lie down on a couch in a dimly lit room and begin talking about her symptoms. There is an apocryphal story that Freud initially used to question his patients to clarify what they were talking about. On at at least one occasion, the patient said, "Don't interrupt me when I'm talking," and Freud learned to be quiet and listen during free association. This is the form of classical psychoanalytic practice: a period of free association followed by interpretation of the material by the analyst.

Freud's initial work led to the publication of The Interpretation of Dreams in 1899. (The publisher later dated the book for 1900, probably to identify it with modernity.) This book, along with his later book, An Outline of Psychoanalysis, (published in 1940) contain the best material on Freudian psychoanalysis.

Personality and Behavior

Psychoanalytic theory is highly complex and was constantly evolving under Freud; I cannot do it justice here. Nevertheless, to understand why Freud did what he did, you have to understand some part of his theory of personality.

For Freud, personality reflected the interaction of forces inside the psyche. These intrapsychic forces interacted and opposed each other. The healthy psyche was one where the forces balanced each other out and energy was expended in rational behavior. These forces interacted within and between three major structures in the psyche: The id, or unconscious mind; the ego, the conscious, rational part of our minds; and the superego, essentially our conscience, although Freud thought of it as the internalized parent.

The id is driven by instincts to either create or destroy. The basic physiological instinct associated with creativity is, of course, sexual reproduction. Aggression is the basic physiological instinct associated with destruction. Because the id is the only source of energy, it is always the central player in our behavior.

The ego and the superego obtain energy from the id through symbolization. The id is unable to tell the difference between reality and the symbol; that is the job of the ego. Hence, the ego would direct the individual to engage in behaviors symbolically related to these instincts. Anything, from playing a musical instrument, to telling a joke to a friend, to doodling on a piece of paper would accomplish this.

It is the job of the superego to control the impulsive, reckless, and immoral behavior of the id. In the healthy individual, the ego is the negotiator between them; in the unhealthy individual, the ego is the battlefield between them. When the superego is in control, the individual is rigid, compulsive, and intolerant. In this three-way interplay, the symptoms of mental illness emerge.

Treatment

It is important to understand that treatment actually evolved before the theory did. Freud thought that his treatment worked. After being analyzed, symptoms of hysteria seemed to go away. Hence, psychoanalysis is really an explanation for why treatment worked.

Treatment, for Freud, was a matter of balancing intrapsychic forces. For doing this, he had three primary tools: Free association, dream interpretation, and analysis of the transference relationship. Free association gives us the classical image of the patient on The Couch.

Free association. Free association, as described above, provided the primary data for analysis. It was assumed that if the patient was talking about it, it was important. The juxtaposition of different ideas gave a clue about unconscious connections between them. Symbolization was manifested both in free association and in dreams, and proper interpretation was crucial to treatment.

Dream interpretation. Freud regarded dreams as the "royal road to the unconscious." He found that patients often discussed dreams during free association and became convinced that dreams represented unconscious processes. By analyzing the dream symbols, the analyst developed insight into the patient's problems.

Transference. Transference refers to the manner in which the patient responds to the analyst. Does the patient idealize the analyst, or does the patient "forget" about appointments? Freud concluded that the patient "transfers" his or her feelings about the parents onto the analyst. This, of course gives clues about early family relationships that are so critical to the development of the individual. To this end, Freud argued that the analyst should be as bland as possible.

Countertransference is the other side of the coin and refers to the feelings of the analyst toward the patient. While this gives insight into the analyst's state of mind, it also helps the analyst understand how the patient affects other people. If, for example, the analyst feels angry at a patient, it may suggest that the patient is behaving in a hostile manner toward the analyst. That provides much data for the analysis.

Analysis. Using these tools, Freud investigated the unconscious life of the individual. By uncovering unconscious conflicts and developing insight, Freud believed that he could strengthen the ego and redirect the emotional energies in a healthier manner. This always involved understanding the internal symbolic world of the individual, and the symptom was always linked symbolically to the underlying trauma. If, for example, a patient complained of hysterical blindness, Freud assumed it was because they had seen something awful. Hence, it was necessary to uncover the traumatic event the patient had seen, to relieve the symptoms. Generally, for Freud, the traumatic event involved childhood trauma.

By developing insight and uncovering repressed trauma, energies attached to inappropriate objects can be released and appropriately redirected by the ego. Freud used the term, catharsis, to refer to re-experiencing the emotions related to the trauma. Release of the tensions associated was called "abreaction."

Conclusions

For those who know something of Freud, you will note that I have said nothing about his theories of development. I have done that deliberately. I am more interested in focusing on psychotherapy than on personality development or psychopathology. I will only say in passing that Freud was very right to observe that a child is not a small adult. His scheme of development was very wrong.

Freud remains a controversial figure today. We continue to argue about his strengths and weaknesses. (A good discussion of the strengths and weaknesses of classical psychoanalytical theory is contained here.) In relation to psychotherapy, I think it is safe to say, he made several significant errors.

First, Peter Kramer, in his book, Freud: Inventor of the Modern Mind, argues that a great error of Freud was his belief that the symptom is a symbol. For Freud, the symptoms were always related to the underlying psychodynamics of the individual. We know now that is not true. Depressed people show similar symptoms regardless of their underlying dynamics. So, for example, if a person experiences panics when out of the house, Freud would have assumed that the person experienced some trauma outside of the house. The goal of treatment would involve uncovering that trauma and unlocking the emotions associated with it.

Freud's second error was that he didn't understand the role of the situation, and saw behavior as a function of the internal dynamics of the individual. Freud did not recognize that individuals acquire maladaptive behavior through experience. A child growing up in an abusive environment learns to be a perfectionist because it helps reduce the abuse. It's not because of a rigid superego.

Third, Freud did not understand the influence of culture. We know that as culture changes, symptoms of mental illness change. Freud saw a lot of hysterical blindness and paralysis. We see almost none of it today. In fact, I have been in practice for over 30 years, and I have yet to see an individual with hysterical blindness. Similarly, Freud saw the role of women as being biologically, not culturally determined. He would be amazed to see women working along side of men, much less fighting in the military.

Finally, Freud hoped that someday psychoanalysis would be subjected to scientific evaluation. But, psychoanalysis is not a scientific theory, especially as science is practiced over 100 years after The Interpretation of Dreams was written. Psychoanalysis is too complex and it makes too many conflicting predictions. There is also a paucity of systematically collected data. But, that does not mean Freud has nothing to offer us.

As I said previously, Freud was a visionary. His ideas are so ingrained in us today, that we cannot conceive of a world without the idea of unconscious motivation. For me, Freud, beginning with almost nothing, made three significant breakthroughs.

First, through his concept of transference, Freud uncovered the therapeutic relationship. Today, we understand that the relationship between the therapist and the patient is the primary vehicle for change. The therapist and the patient must have a relationship of mutual trust and respect if the patient will explore material that is potentially shameful and anxiety-provoking. The modern view of the therapeutic relationship is broader than Freud's, but there is no doubt that he originated the idea.

Second, Freud recognized that something is going on in people's minds that they are unable to talk about. Most modern therapists do not talk about investigating the unconscious, but they do recognize that there are things going on the person's head that are relevant but difficult to identify and change.

Finally, and most importantly, Freud recognized that speech is a very powerful tool. The term, "talking cure" came from one of Freud's patients, and it is a very apt description. Without Freud, there would be no psychotherapy today.

Coming Soon

Today, it is safe to say that there are few orthodox Freudians left. In fact, early in the twentieth century, contemporaries of Freud began to elaborate and diverge from his thinking. By the 1950's psychoanalysis had evolved significantly from it's roots. My next post will trace that change.

A Series of Posts on Psychotherapy

I'm going to begin a series of posts on psychotherapy, which are long overdue. When I started blogging, I anticipated writing a lot about the science of psychotherapy, but I haven't followed through with it; I've been having too much fun with other things.

Two events have come together to get me started. First, at Aardvarchaeology (on ScienceBlogs), there was a recent post entitled, Is Psychotherapy Superstition? in which the author, Dr Martin Rundkvist, seemed to be confused about what psychotherapy is. Furthermore, some of the commenters on the blog seemed totally unaware of the evidence for the effectiveness of psychotherapy.

Second, I put off a post on a story in last week's New York Times Magazine by Bruce Stutz, who decided to withdraw himself from Effexor. Stutz initially went on Effexor after becoming depressed during difficult period in his life. He stayed on the drug for several years, and was advised to stay on it the rest of his life. He decided that he didn't want to and weaned himself off, but experienced severe withdrawal symptoms in the process:

Over the next several days they (low doses of Effexor--F.O.) came in handy, especially at night, when I would wake up feeling dizzy, almost seasick, disoriented and in a heavy sweat, the pillow soaked. One night, awake and not eager to go back to lying restlessly in bed, I went online, typed in “Effexor withdrawal” and found bulletin boards full of pained, plaintive and sometimes angry posters who had quit taking their medication and were suffering a broad but surprisingly consistent range of symptoms: dry mouth, muscle twitching, sleeplessness, fatigue, dizziness, stomach cramps, nightmares, blurred vision, tinnitus, anxiety and, weirdest of all, what were referred to as “brain zaps” or “brain shivers.” While there were those who went off with few or no symptoms at all, others reported taking months to feel physically readjusted.

Stutz eventually did wean himself off Effexor, and has not had a recurrence of depression. He puts his finger on the issue:

If my psychiatrist had told me, “I think you can do this without taking any drugs,” would I have done just as well? If I had been told how difficult it would be to get off the drug, would I have so readily started on it? Even the doctors and researchers who most believe in the effectiveness of antidepressants acknowledge that the “chemical balance” paradigm, the magic-bullet paradigm, makes things seem simpler than they actually are. For some, these drugs may be a lifesaving treatment. But for most of us troubled or even temporarily anguished by life’s difficulties, does our long-term reliance on these drugs become more of a convenience than a cure, allowing us to simply keep going in the midst of very difficult circumstances? And once we start taking them, how do we find the wherewithal to stop?

To make a decision between drugs alone, psychotherapy alone, and both combined, patients need to understand what psychotherapy is. It is not a panacea, as it was once advertised. It's not for all people, or even for all depressed people. Prospective clients of a psychotherapist need to understand what they are getting into. So, there are three topics I want to address in this series.

First, I'll talk about what psychotherapy is and is not. To do that, I have talk about the history of psychotherapy and how we got to where we are today. Next, I'll give a brief description of research in psychotherapy, and finally, I'll talk about how therapy and medication work together in treatment.

I hope this will give readers a better idea of what to expect if they seek psychotherapy and a better ability to understand some of the stories about the effectiveness of therapy that emerge in the press. All treatments for physical and mental illnesses involve decision making. The more you understand the options, the better.

The Tyranny of the Shoulds

I was reading the New York Times, as usual, and stumbled across two articles I knew I should blog about. The first was Bruce Stutz's account of his withdrawal from Effexor, an antidepressant drug. Effexor is a very popular drug, especially among primary care physicians, and it can be very hard to get off. His story is, at points, gruesome. But it speaks for itself, and right now I have nothing to add. I will soon, though, so stay tuned.

The second story is much funnier and more enjoyable. It's an article in the Book Review, entitled, Why Not the Worst? In it, the author, Joe Queenan, writes about his love of bad books and compares himself to others who are obsessed with quality:

Most of us are familiar with people who make a fetish out of quality: They read only good books, they see only good movies, they listen only to good music, they discuss politics only with good people, and they’re not shy about letting you know it. They think this makes them smarter and better than everybody else, but it doesn’t. It makes them mean and overly judgmental and miserly, as if taking 15 minutes to flip through “The Da Vinci Code” is a crime so monstrous, an offense in such flagrant violation of the sacred laws of intellectual time-management, that they will be cast out into the darkness by the Keepers of the Cultural Flame.

Queenan goes on:

Some people would identify a passion for bad books as a guilty pleasure, but I prefer to think of it as a pleasure I do not feel guilty about, even though I probably should. Bad movies, bad hairdos, bad relationships and bad Supreme Court rulings merely make me chuckle. Bad books make me laugh. And if they ever stop writing books with lines like “Being a leader of the Huns is often a lonely job,” I want to stop breathing on the spot.

So, what does this have to do with psychology?

Queenan is attacking what Karen Horney (pronounced HORN-eye), an early neo-analyst, called "the tyranny of the shoulds." In this, Horney anticipated the cognitive-behavioral therapies of Albert Ellis and Aaron Beck.

Horney recognized that we carry around many beliefs about what should or should not be. Some shoulds are about what happen to us. We believe, "I should be successful," or "My spouse should know what I want without my saying so." Unfortunately, that's just not realistic.

We have every reason and right to want things. But, "should-ing" is based on the unrealistic belief that the world must grant us what we want, just because we think we're right. When the world doesn't cooperate with that belief, we get angry or depressed.

Some shoulds address standards for our own behavior. For example, "I should read only good books." These shoulds make us rigid and rob us of our pleasures. Why not enjoy a bad book occasionally? Queenan's observation, "I prefer to think of it as a pleasure I do not feel guilty about," is a wonderful rejection of those shoulds.

When I hear a client bring up their shoulds, it is my job to attack those beliefs and replace them with more flexible beliefs. Some clinicians use Socratic questioning to attack peoples shoulds. For myself, I've found that far too often, Socratic questioning turns into the Possum Lodge Word Game. Instead, I like to hit people between the eyes with a one-liner.

Needless to say, I'm always on the lookout for a good one-liner. Now, I can't wait to say to a client, "Don't think of it as a guilty pleasure, think of it as a pleasure you don't feel guilty about."

Insight and Psychotherapy

Now that Chanukah has passed, my round of parties and events has also passed. Christmas is a pretty boring day for me, so it gives me a chance to catch up on this poor, neglected blog.

There have been several good articles in the New York Times over the last few weeks. This one, entitled, "Sometimes the Why isn't Crucial," caught my attention. The author, Sally Satel, is a psychiatrist. She works in a substance abuse treatment facility and she questions the effectiveness of insight as a psychotherapeutic tool for her. She argues that explaining "why" someone drinks isn't as important as developing resources to resist urges to drink.

Developing insight is the primary vehicle of change for psychoanalysis and related therapies. Freud famously observed, "The child is the father of the man," meaning who we are today comes from our previous experiences. For these insight-based therapies, developing insight means not only explaining why someone has their problem, but also helping them get in touch with the feelings associated with it. Along with the couch, it's a stereotypical view of psychotherapy.

The public is generally unaware that arguments against insight-based therapies dates back many years. Albert Ellis has been arguing this point since the 1950's. In a more recent book titled (as only he can title it), How to Refuse to Make Yourself Miserable about Anything Yes Anything, he says (as only he can say):

Your early childhood experiences and your past conditioning did not originally make you disturbed. You did. (p.70).

Ellis argues that how we think and act in the present is what really matters. He says, speaking of his clients, "Their early thoughts and feelings did not make them anxious today. Rather, their present and continuing dogmas...were really the more direct cause of their current neurosis." (p.70; Emphasis in the the original). So, according to Ellis, we effect emotional and behavioral change by addressing current irrational beliefs, not by uncovering how the beliefs were acquired.

Ellis is not the only one. Behaviorists, such as Joseph Wolpe , also writing in the 1950's, argued that exposure to the feared stimulus was a more effective way of treating phobias than insight-based therapies. Fifty years later, and God knows how many studies, we still treat phobias with exposure-based treatments. The data is conclusive. Insight alone is at best minimally effective in treating phobias or almost any psychological dysfunction.

Satel identifies one reason why insight isn't effective. We have a tendency to distort our memories of life events in an effort to develop a coherent narrative:

What scientists call hindsight bias kicks in when we try to figure out the causal chain of events leading to the current situation. We may well come up with a tidy story but, inevitably, it will contain large swaths of revisionist history. It’s not that we bias ourselves deliberately; it happens because the mind tends to make events in the past appear comprehensible and orderly. We forget the uncertainties that might have beset us as we struggled in real time.

So, how do we develop insight based on "large swaths of revisionist history?" If we're reconstructing our past, an erroneous reconstruction would logically hinder our progress. Is insight important at all?

I think so. Insight has a limited, but important place because it helps us deal with resistance in psychotherapy. To illustrate, here are two vignettes. To guard my clients' privacy, they are composites of several past clients with a little bit of stereotyping mixed in.

First, consider a client who resists going to AA meetings. Normally, the therapist would take this as a sign the client is still denying his alcoholism. Without looking at his past, the therapist's natural tendency would be to confront the client about his denial. However, there is another issue.

The AA meetings remind the client of prayer meetings his family attended while he was a child. The religious sect that sponsored these meetings encouraged physical abuse of children, and the client is still coping with intense feelings of guilt and powerlessness stemming from this. After identifying this source of resistance do you think the client will then jump up and go to AA meetings? Of course not.

Putting the resistance into that context will do two things. It will relieve the client's guilt for not following through with clinical recommendations. Second, giving the client the right to refuse AA and still be respected will help him feel less powerless. Then, the therapist should look for other ways of working on recovery.

The second example involves cognitive therapy for a female client who is unable to trust men. She goes through cycles where she meets a man and falls deeply in love with him. Then, without reason, she becomes extremely jealous. She harasses him, checks on him, and eventually drives him away. She comes into therapy depressed and hopeless about ever having a normal relationship.

Without dealing with this in historical context, cognitive therapy would focus on changing the dysfunctional cognitions the client has about men. The therapist would probably identify the thought, "If my boyfriend were to cheat on me, it would be so awful, I couldn't survive it." Then, the therapist would challenge (a) the probability of cheating; and (b) whether or not her boyfriend's cheating would be survivable. However, each effort to challenge her beliefs is met by "Yes, but...." It is classic resistance behavior.

The "yes, but..." indicates the therapist is arousing anxiety which is itself interfering with therapy. A review of the client's history indicates she grew up in a family where the father had frequent affairs. There were chaotic arguments between the parents each time an affair was uncovered. The mother became increasingly depressed and spent most of her time in bed. After years of chaos, in which the client wound up being a parent to both her mother and her younger siblings, her parents finally divorced. Her mother remained angry and embittered for the rest of her life, insisting that all men are worthless.

So, the client's belief is closer to this: "All men are cheaters and when (not if) my boyfriend cheats on me, it will be awful! I'll turn into my mother and the rest of my life will be ruined." With this historical context, the therapist and client understand the "why" of her behavior. Without that understanding, there is no way to help the client will take the risk of changing her beliefs. The anxiety engendered by being reminded of her childhood is too great. Still, for change to happen, she needs to know that, in the present, she has the resources to deal with loss, rejection, and betrayal, without turning into her mother. Then, she can say, "It would be bad if my boyfriend cheated on me, but I can survive it. The risk is worth it, because it gives me a chance to have a happy, rewarding relationship."

In conclusion, explaining "why" has its place in therapy, but is useless by itself. Good therapy stays in the present, but uses the past as context. Even if the story is distorted, it still has value, providing meaning and motivation for change.

A New/Old Look at Psychoanalysis

The New York Times has an interview with Owen Renik, a psychoanalyst who has just written a book entitled, Practical Psychoanalysis for Therapists and Patients. It controls this wonderful interchange:

Q. You place great emphasis in the book on symptom relief as the central measure of the effectiveness of therapy. Shouldn't that be obvious?

A. Not necessarily. There is a tendency among psychoanalysts to pursue self-awareness as a goal in itself, rather than a means to an end. Originally, the idea was that the self-understanding that arose as a result of psychoanalysis was unique and impressive and valid because it afforded relief from symptoms that were otherwise impossible to treat.

If you don’t require that self-awareness be validated by symptom relief, there are two destructive consequences. The first is scientific. You have no independent variable to track; you set up a circular situation in which it’s the analyst’s theory that determines what is found in analysis. Many critics of psychoanalysis have recognized this.

But an equally important consequence is that you relieve the analyst of any accountability. The process can go on forever, and there are all kinds of temptations to extend it, including the therapist’s vanity, his inability to admit failure, his narcissism — and nobody likes lost income. The therapy then becomes an esoteric practice of proselytizing, rather than a discipline, and the proof of that is everywhere in the world, where fewer and fewer people go to analysis at all. If the therapy worked, people would be going.

This issue actually goes back to 1952 when H. J. Eysenck had argued that psychotherapy was ineffective (a 1957 paper is available here). At the time, psychoanalysis was the dominant form of psychotherapy. Although deficiencies with his research have been well documented, his paper touched off the field of psychotherapy research, and such studies continue to this day. Generally, it has been concluded that certain forms of problem-oriented psychotherapy (e.g., cognitive therapy, behavior therapy, and interpersonal therapy) are effective for treatment of anxiety, depression, and other specific psychological problems. Psychoanalysis, and other psychodynamic therapies have not fared so well, although I have seen a few positive studies in the past.

The issue is not just whether or not psychotherapy "works;" it's also whether or not this particular client is benefiting from a particular therapy, from this particular therapist. This is what we call accountability, and psychologists have not taken it seriously enough. I'm particularly impressed with Renik's eloquent comments about the dangers of not addressing symptom relief in therapy, i.e., not being accountable.

Today, it is becoming more common for therapists to begin sessions with a fairly straightforward questioning of a client about his or her level of symptoms. A quick minute of asking about mood, sleep, appetite, frustration tolerance, and so forth can provide adequate data for accountability. It also helps discourage the conduct of endless, directionless therapy, whose sole hallmark is to keep the client coming back for another fully paid session.

More Complaining about Evidence-Based Treatment

The most recent edition of the National Psychologist contains two articles concerning evidence-based treatment. Unfortunately, the online edition hasn't been updated yet and the articles are only out in hard copy.

For those of you who are not of the cognoscenti, evidence-based treatment is simply treatment with a clear research base. The research establishes that certain procedures are helpful for certain types of problems. My previous post describes an evidence-based treatment for OCD.

The first article, by Thomas Habib, opens with a bizarre story. Apparently a managed care network, Managed Health Network, wants to establish a category of, what Habib calls, an "elite clinician." I'm not sure if it's Habib's words or theirs'; I couldn't find it on their web site. Essentially, this elite clinician would be someone who has been trained in and practices evidence-based treatment. I assume that these elite clinicians would be given priority in referrals.

Habib is worried about the perceived deadly combination of managed care and evidence-based treatment. He states,

No one is against evidenced based practices. As mentioned above, how this goal was pursued and the disregard of how this might strait jacket psychology and be misused by mangled care is the problem.

"Mangled care" is an obvious shot at managed care. Certainly somewhat deserved, but then, our hands aren't entirely clean, either. There have been far too many clinicians who weren't good at getting change, but were very good at keeping clients in therapy for extended periods of time.

Managed care credentialing for clinicians doing evidence-based treatment is silly. From experience, I know this will fail, because it won't save MHN any money. Back in the 1980's, when managed care blew into Pennsylvania, I spent an incredible amount of time on the phone with "care managers," who would authorize treatment for my clients. Once I learned what they wanted to hear, it was no problem to get sessions authorized. I got to know a lot of care managers by name and we'd chat about our families before getting down to business. But, eventually, telephone authorizations became too expensive, and most of my telephone friends had to get other jobs. Now, my secretary fills out a page, I add the diagnosis, and sign it. Bingo! Another 10 sessions.

So, let me assure you, Dr. Habib. This will end with a whimper, and you'll be left with a mild bit of bureaucracy. Nothing to get excited about. Managed care isn't going to hurt you with evidence-based treatment requirements because it's too expensive to do so.

But, is evidence-based treatment a "strait jacket?" Absolutely not, and the second article illustrates my point clearly. Surprisingly the author, Frank Dattilio, also thinks he's attacking evidence-based treatment. He should really know better, as he has extensive training and publication in cognitive-behavior therapy. In his article, he tells the story of Corey, a young psychiatrist completing his fellowship. Corey brought him a tape of a therapy session, of which he was very proud. Dattilio viewed the tape and said,

Much to my dismay, the same things kept cropping up repeatedly during the course of the session--a dry, robotic type of interaction that almost appeared as though it was scripted.

At the end, Corey said to me, "So what do you think?" I was speechless. Before I had a chance to say anything, he interrupted me by saying, "I think it's classic cognitive-behavior therapy. I don't believe I left one thing out."

"Well, there is one thing that is missing," I replied. Corey looked at me perplexed, "What did I forget?" "You!" I exclaimed, "You, the therapist is missing."

It's a wonderful story, and a great cautionary tale to young therapists, who, unsure of themselves, want to retreat into "techniques." Since the 1950's, we've known the quality of the therapeutic relationship has a strong effect on therapeutic outcomes. Wampold (2001) has a good review of the data. Maintaining a good relationship with the client, being empathic and supportive, is part of any evidence-based treatment. Just look at Beck, Rush, Shaw, and Emery (1979).

The sad thing is that we continue to argue about evidence-based treatment even though we consider psychology to be a science. If psychology is a science, we believe the data. If psychology is a science, we opt first for treatments that the data shows are worthwhile. No one expects us to give up our clinical judgment and our empathy in the process. Being empathic and supportive is just another evidence-based therapy.

All psychotherapies are like seeds. They cannot grow into a beautiful flower without the fertile soil that the humanity of a good therapist provides. Clinicians do not need to fear evidence-based therapies.

References

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.

Dattilio, F. M. (2006). Evidence based treatment may be too confining. National Psychologist, 15(5), 23.

Habib, T. A. (2006). A profession in search of legitimacy. National Psychologist, 15(5), 14.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Earlbaum Associates.

Obsessive-Compulsive Disorder

A good summary of psychotherapy for OCD, written by Bradley Riemann, appeared in the Psychiatric Times last month. The article opens with this observation:

Obsessive-compulsive disorder (OCD) is a common and debilitating condition. In many cases, it can come to dominate a person's behavior and cognitive processes, creating great anxiety. It typically affects all aspects of an individual's life, including school performance, occupational responsibilities, and family and social interactions.

Although the television show "Monk" strives for laughs about it, there is no humor OCD. It can be absolutely debilitating. The worst thing about it is that the client knows his or her behavior is irrational, but can't stop doing it.

The heart of treatment for OCD is exposure and ritual prevention. There is typically a feared situation, which is followed by some form of ritual to reduce the fear. For example, a client may go to the bathroom and then compulsively wash his hands for the next 20 minutes. Treatment is straightforward.

First, the client begins with a mildly anxiety-provoking response. For example, he might go into a public bathroom and touch the sink. This exposure creates anxiety. Normally, the client would reduce the anxiety by hand washing. Instead, the handwashing response is prevented. The client waits for the anxiety to drop, which it always does. The procedure is repeated until there is no more anxiety. Then, the client moves on to a more anxiety-producing stimulus, such as a toilet seat.

This procedure has two effects. First, the anxiety is extinguished by a process called habituation. Recall learning to drive. At first, you were quite anxious. As you drove repeatedly, you became less anxious. Through repeated exposure, you habituated to driving.

Second, the client learns an important lesson. Anxiety always goes away. If you tolerate anxiety for a period of time, it always goes away. This gives the client tools for dealing with other compulsive behaviors.

Psychotherapy for OCD is critical. Riemann cites research indicating that antidepressant medications can reduce symptoms of OCD by about 1/3, so medication alone won't provide full relief. Unfortunately, our office procedures are not always sufficient for good treatment. For exposure and response prevention to be truly effective, a person with OCD needs intensive treatment, usually outside the office. Treatment centers are being established in order to meet this need.