The apex and decline of evidence-based psychotherapy and psychiatry

By Brent Potter, PhD

I am grateful to be alive during to see the apex and decline of evidence-based psychotherapy and psychiatry. Honestly, I didn’t think that I’d see anything like it in my lifetime. It was looking pretty daunting for a while, but we’re not only making substantial progress, but winning.

Please don’t mistake me—we have plenty more to do. We’re not in the clear yet, but we’re light years ahead of where we were roughly 20 years ago. Last week, I had breakfast with a physician who was interested in meeting with me. He has some ideas about how to bring focused psychoeducational courses to children and teens in public schools. A friend suggested we meet and all he knew about me was that I had some experience with these sorts of programs. In any event, during the course of the conversation he asked, “How do you feel about psychiatric medications?” I told him. Perhaps it was the coffee, but I was feeling especially open and even expressed that I didn’t think psychotherapy was always the best or highest intervention. After offering my critiques of medications and psychotherapy, he sat silent for a minute, apparently thinking. He finally smiled, looked up, and responded, “I agree with 95% of what you’re saying.” The conversation continued along very productive, positive lines.

This event doesn’t prove anything, of course. I offer it as one example of the kind of interaction that is far more common these days. Those of you who have been a part of the recovery / critical psychiatry / anti-psychiatry (whatever title you prefer) movement will recall that, in the past, any critique of the psychiatry-psychotherapy juggernaut was heresy. I thought it may be helpful and/or useful to offer a few reflections here on what’s going on. The recovery perspective, psychology and history remain passions of mine. Some of what follows is from my newest book, Elements of Reparation: Truth, Faith, and Transformation in the Works of Heidegger, Bion, and Beyond (Karnac, 2015).

STEM is an acronym that stands for Science, Technology, Engineering and Mathematics. STEM represents, of course, the fields outlined by the acronym but the word is used descriptively as a kind of standard of validity of what a given field (e.g. psychology) should be. STEM can be used synonymously with the phrase ‘natural science’. STEM psychology today focuses on research and what is deemed as natural scientific clinical tools of assessment, diagnosis and treatment. This includes so-called evidence-based approaches, such as cognitive behavioral therapy (CBT) and similar manualized approaches, such as dialectical behavioral therapy (DBT). As with psychiatry and the DSM, STEM approaches have been the object of grave criticism. Jonathan Shedler’s (2010) seminal research clearly demonstrates that psychodynamic therapy is more effective than cognitive-behavioral therapy (CBT) / manualized approaches to mental health treatment as well as these modalities utilized in combination with medication management.

As if this were not enough, Shedler (2013a) writes, “One piece of news is that NIHM just dissed the newly-released DSM-5, and dissed it in a big way. Insel’s [NIMH director] post basically says that DSM is useless for understanding mental health problems and that its fundamental premise—that mental health conditions can be classified meaningfully on the basis of overt symptoms—is flat out wrong. NIMH will no longer fund research based on DSM diagnosis.” And Shedler is correct, the federal funding source of the DSM, NIHM, has pulled its funding. Insel (2013) is taking a hard right STEM turn, seeking a “new nosology” based on the following:

A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
Each level of analysis needs to be understood across a dimension of function,
Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.

It may strike some that those adhering to non-STEM disciplines and approaches applaud NIHM’s maneuver. In fact, many, if not most, non-STEM professionals do applaud it, as it represents an awareness that the DSM is highly flawed in a variety of different ways and since they do not believe that NIHM, nor anyone else, is going to find the biomarkers they are seeking. Decades of dedicated research, countless dollars and cutting-edge technology have thus wielded nothing, probably because varieties of human distress are not solely reducible to biological causal agents. To date, there is no blood test, mouth swab, spinal tap, organ biopsy, hair sample, nor any other medical means of assessing a supposed psychiatric disease. In fact, as I will show, there is a mounting body of epigenetic research clearly demonstrating where distress, chemical abuse / dependency and a host of physical ailments come from.

Concerning so-called evidence-based therapies, Shedler (2013b) reviews the literature and finds that academic researchers have “usurped and appropriated the terms ‘evidence based’ to refer to a group of therapies conducted according to step-by-step instruction manuals…The other things these therapies have in common are that they are typically brief, highly scripted, and almost exclusively identified with CBT.” He goes on, “The term ‘evidence-based therapy’ is also de facto, a code word for ‘not psychodynamic’.” Basically, it is not the case that CBT and similar approaches are more effective, they were simply studied more in research settings. By way of absurd example, this is tantamount to me developing a ‘Brent’ therapy, only conducting research on the ‘Brent’ approach to therapy, praising the outcomes of the research only investigating the ‘Brent’ approach, branding it as evidence-based and prescribing it as the best modality of treatment. As Shedler also points out, devotees of evidence-based approaches go so far as to admonish other approaches (e.g. psychodynamic) as being unethical for not practicing CBT or something similar. Shedler (2013c) concludes:

Claims that “evidence-based” therapy is more effective than real-world therapy lack scientific basis. Academic researchers have been selling a myth—one that enhances the careers and reputations of academic researchers, but not necessarily the well-being of patients.

It is not just my conclusion that the therapies promoted and marketed as “evidence based” confer no special benefits. It is the official scientific conclusion of the American Psychological Association, based on a comprehensive review of psychotherapy research by a blue-ribbon expert panel.

All of the aforementioned issues are addressed succulently and cleverly by my friend, Loren Mosher in his resignation letter to the American Psychiatric Association. Briefly, Mosher, who passed away in 2004, was a psychiatrist, clinical professor of psychiatry and chief of the Center for Studies of Schizophrenia at NIHM from 1968-1980. Following the ideas of Laing, he Mosher was made famous for his establishment of therapeutic households for persons suffering from emotional distress. From 1970-1992, Mosher was research director of the Soteria Project. Soteria, by the way, was the Greek goddess of protection and deliverance. The Soteria Project sought to provide progressive, non-drug, non-hospital, residential facility support for people going through their own metanoia. One can think of the Soteria House and other associated residential sanctuaries as the American equivalent, in many ways, to the residences of the Philadelphia Association that Laing helped establish in 1965. The history of Soteria, including many remarkable successes, is outlined in Mosher and Hendrix (2004), Soteria: Through Madness to Deliverance. Mosher is considered something of a hero in the recovery community. In a letter he penned on December, 4, 1998 to then then-president of the American Psychiatric Association, he wrote:

Dear Rod,

After nearly three decades as a member it is with a mixture of pleasure and disappointment that I submit this letter of resignation from the American Psychiatric Association. The major reason for the action is my belief that I am actually resigning from the American psychopharmacological Association. Luckily, the organization’s true identity requires no change in the acronym.

Unfortunately, APA reflects, and reinforces, in word and deed, out drug dependent society. Yet it helps wage war on “drugs”. “Dual diagnosis” clients are a major problem for the field but not because of the “good” drugs we prescribe. “Bad” ones are those that are obtained mostly without a prescription. A Marxist would observe that being a good capitalist organization, APA likes only those drugs from which it can derive a profit – directly or indirectly. This is not a group for me. At this point in history, in my view, psychiatry has been almost completely bought out by the drug companies. The APA could not continue without the pharmaceutical company support of meetings, symposia, workshops, journal advertising, grand rounds, luncheons, unrestricted education grants, etc. etc. Psychiatrists have become the minions of drug company promotions. APA, of course, maintains that its independence and autonomy are not compromised in this enmeshed situation. Anyone with the least bit of common sense attending the annual meeting would observe how the drug company exhibits and “industry sponsored symposia” draw crowds with their carious enticements, while the serious scientific sessions are barely attended. Psychiatric training reflects their influence as well: the most important part of a resident’s curriculum is the art and quasi-science of dealing drugs, i.e., prescription writing.

These psychopharmacological limitations on our abilities to be complete physicians also limit our intellectual horizons. No longer do we seek to understand whole persons in their social contexts – rather we are there to realign our patient’s neurotransmitters. The problem is that it is very difficult to have a relationship with a neurotransmitter – whatever its configuration. So, our guild organization provides a rationale, by its neurobiological tunnel vision, for keeping our distance from the molecule conglomerates we have come to define as patients. We condone and promote the widespread use of misuse of toxic chemicals that we know have serious long term effects – tardive dyskinesia, tardive dementia and serious withdrawal syndromes. So, do I want to be a drug company patsy who treats molecules with their formulary? No, thank you very much. It saddens me that after 35 years as a psychiatrist I look forward to being dissociated from such an organization. In no way does it represent my interests. It is not within my capacities to buy into the current biomedical-reductionistic model heralded by the psychiatric leadership as once again marrying us to somatic medicine. This is a matter of fashion, politics and, like the pharmaceutical house connection, money.

In addition, APA has entered into an unholy alliance with NAMI (I don’t remember the members being asked if they supported such an association) such that the two organizations have adopted similar public belief systems about the nature of madness. While professing itself the “champion of their clients” the APA is supporting non-clients, the parents, in their wishes to be in control, via legally enforced dependency, of their mad/bad offspring: NAMI with tacit APA approval, has set out a pro-neuroleptic drug and easy commitment-institutionalization agenda that violates the civil rights of their offspring. For the most part we stand by and allow this fascistic agenda to move forward. Their psychiatric god, Dr. E. Fuller Torrey, is allowed to diagnose and recommend treatment to those in the NAMI organization with whom he disagrees. Clearly, a violation of medical ethics. Does APA protest? Of course not, because he is speaking what APA agrees with, but can’t explicitly espouse. He is allowed to be a foil; after all – he is no longer a member of APA. (Slick work APA!) The shortsightedness of this marriage of convenience between APA NAMI, and the drug companies (who gleefully support both groups because of their shared pro-drug stance) is an abomination. I want no part of a psychiatry of oppression and social control.

“Biologically based brain diseases” are certainly convenient for families and practitioners alike. It is no-fault insurance against personal responsibility. We are all just helplessly caught up in a swirl of brain pathology for which no one, except DNA, is responsible. Now, to begin with, anything that has an anatomically defined specific brain pathology becomes the province of neurology (syphilis is an excellent example). So, to be consistent with this “brain disease” view, all the major psychiatric disorders would become the territory of our neurologic colleagues. Without having surveyed them I believe they would eschew responsibility for these problematic individuals. However, consistency would demand our giving over “biologic brain diseases” to them. The fact that there is no evidence confirming the brain disease attribution is, at this point, irrelevant. What we are dealing with here is fashion, politics and money. This level of intellectual /scientific dishonesty is just too egregious for me to continue to support by my membership.

I view with no surprise that psychiatric training is being systematically disavowed by American medical school graduates. This must give us cause for concern about the state of today’s psychiatry. It must mean – at least in part that they view psychiatry as being very limited and unchallenging. To me it seems clear that we are headed toward a situation in which, except for academics, most psychiatric practitioners will have no real, relationships – so vital to the healing process – with the disturbed and disturbing persons they treat. Their sole role will be that of prescription writers – ciphers in the guise of being “helpers”.

Finally, why must the APA pretend to know more than it does? DSM IV is the fabrication upon which psychiatry seeks acceptance by medicine in general. Insiders know it is more a political than scientific document. To its credit it says so – although its brief apologia is rarely noted. DSM IV has become a bible and a money-making best seller – its major failings notwithstanding. It confines and defines practice, some take it seriously, others more realistically. It is the way to get paid. Diagnostic reliability is easy to attain for research projects. The issue is what do the categories tell us? Do they in fact accurately represent the person with a problem? They don’t, and can’t, because there are no external validating criteria for psychiatric diagnoses. There is neither a blood test nor specific anatomic lesions for any major psychiatric disorder. So, where are we? APA as an organization has implicitly (sometimes explicitly as well) bought into a theoretical hoax. Is psychiatry a hoax – as practiced today? Unfortunate, the answer is yes.

What do I recommend to the organization upon leaving after experiencing three decades of its history?

To begin with, let us be ourselves. Stop taking on unholy alliances without the members’ permission.

Get real about science, politics and money. Label each for what it is – that is, be honest.

Get out of bed with NAMI and the drug companies. APA should align itself, if one believes its rhetoric, with the true consumer groups, i.e., the ex-patients, psychiatric survivors etc.

Talk to the membership – I can’t be alone in my views.

We seem to have forgotten a basic principle – the need to be patient/client/consumer satisfaction oriented. I always remember Manfred Bleuler’s wisdom: “Loren, you must never forget that you are your patient’s employee.” In the end they will determine whether or not psychiatry survives in the service marketplace.

While all of the aforementioned items are indeed true, it is also true that I do not deny that people suffer, sometimes terribly, from emotional and psychological states of mind. I also acknowledge that these forms of distress tend to fall along typical, archetypal lines. There is no doubt that people report feeling depressed, anxious, experiencing unusual states of consciousness, etc. Mercifully, today we know the causes of these forms of distress which also contribute to a host of physical ailments. As promised earlier, I will address this topic.

We don’t need a stitch more research…This stuff is painful and therefore we dare not look at it in ourselves and therefore we don’t open to its existence in others and then we have to look for all kinds of other reasons. If you deny pain, going to early experience and early loss and early trauma, then the world becomes very complicated and justifies all kind of complicated explanations. Yet if we see that a child has certain needs and, if you meet those needs, that child will be just fine and, if you don’t, he’ll have to adapt somehow and those adaptations are the basis of dysfunction late on. That’s really simple. They call it simplistic. It’s not simplistic, it’s simple. The world is really very simple. We make it complicated because of our denial…

We have the evidence. It’s just that the evidence is not incorporated. So when they talk about evidence-based practice, they are looking at a very specific kind of a very narrowly defined sense of evidence. If you actually look at the science–it’s not that the science doesn’t exist—we know how the children’s brains develop, we know how the chemistry of the brain develops, we know how behaviors occur as a response to either nurturing or emotionally impoverished environments. We don’t need more research. (Mate, 2012)

The question naturally arises as to where distress arises from, if they are not brain diseases. The answer, as succinctly put by Mate, is clear: developmental stress and trauma. The word ‘trauma’ comes from the ancient Greek τραῦμα (wound, damage), which is akin to θραύω (to break, break in pieces, shatter, smite through). As previously mentioned, trauma is inherent in life. It and its outcomes vary in degree, but not kind, from those labelled as insane and everyone else. Epstein (2013) in his The Trauma of Everyday Life, aptly points out that it is impossible to avoid trauma. No matter how well-intentioned, well-resourced, educated or any other positive attribute one may have, he or she will invariably experience stress, loss, grief, sickness or hardship of one kind or another. No one is spared from trauma, to a greater or lesser degree. Imagine, if you will, one such event in your life. Now imagine if the felt sense of that event were multiplied exponentially or if there were a series of such events. It is not at all difficult to imagine the some of the impacts this would have. For some, stress and trauma are normative. When this happens, especially during formative developmental years, the result is often something that will likely be labeled as mental illness and/or substance abuse or dependence in adulthood.

The recovery movement is a ‘sibling’ of contemporary existential-humanistic and contemporary psychoanalytic schools of thought that are emerging as psychiatry and STEM psychology fade. In mental health recovery, often referred to as wellness programs, individuals who have successfully recovered aid those who are early in recovery. These people, often professionals are often referred to as peer bridgers or simply peer support specialists. Both groups tend to see human distress as a normal part of life, rather than as a disease or something to be moralized or pathologies in any way. Forms of distress are simply seen as an organic part of living. The goal of recovery support, is to partner with the client and develop an individualized recovery plan. Nothing is forced upon an individual or even suggested. The idea is to join with the client in his or her process and to utilize his or her strengths to aid in the process of recovery. Often, if the client desires it, family and other community supports are utilized. There is no cookie-cutter process in recovery; from their perspective, each recovery is unique and intensely personal to the individual and his or her life context.

Recovery, seen as an organic process, experienced some setbacks during the 1940s and 1950s in the US, as the predominant way of contending with psychological distress was institutionalization. Even during the deinstitutionalization, beginning in the 1970s, it was assumed that recovery was not possible from so-called psychiatric diseases. We still see some of this today, unfortunately. Nonetheless, the recovery movement persevered, refusing to adopt the limiting and errant beliefs of the psychiatric establishment. Laing and his colleagues made substantial headway in establishing therapeutic household that still remain today, such as the Philadelphia Association in the UK. Following Laing, Mosher, as already mentioned, was successful in his work at Soteria House. To this day, Soteria houses still exist in various locations. In a similar vein, the consumer and psychiatric survivor movements began taking hold in the 1980s and 1990s and are still quite active to this day. By 2002, the President’s New Freedom Commission on Mental Health solidified a way for a system wide paradigm shift.

Of note, in the recovery movement, is the well-resourced and expanding organization, Recovery Innovations. The organization constellated around the notion of recovery, from its entry level employees to its administration. Their international expansion is testimony to the efficacy of its educational, clinical and peer support programs. With this organization, having a recovery story, of some kind, is considered a strength, not a detriment. Their states mission: “To create opportunities and environments that empower people to recovery, to succeed in accomplishing their goals, and to reconnect to themselves, others, and to meaning and purpose in life.” Their service values are hope, empowerment, wellness, personal responsibility, community focus and connectedness. Their organizational values include quality, creativity, friendliness, quality team, cultural competence and financial stability. Impressively, their entire international business operates on a non-hierarchical fashion. They go so far as to have what they call “wellness cities” where all supports are offered in a single setting. The services offered include, but are not limited to, peer support, education, medical services, mental health services, employment and crisis services. The vision of the business “was a transformation in the service delivery system grounded in the belief that people with mental health and substance abuse challenges do recover and move on with their life.” The domains deemed critical to recovery are represented in the services provided: “The principle ingredients of this transformation include hope, education, employment, peer support and self-help” (Recovery Innovations, 2008). I present Recovery Innovations, since it is remarkably effective in regards to supporting people through recovery and also being fiscally sound. There are other organizations such as MindFreedom International, The Icarus Project and PsychRights that also participate in and support the recovery movement.

Dr. Brent Potter is a psychotherapist and wellness specialist with 20 years of direct clinical service. He is the Director for the Society for Laingian Studies. Brent is the author of numerous articles whose topics include: innovative and effective mental healthcare models, analytical psychology, humanistic psychology, existential-phenomenology, psychoanalysis, the psychotic register of the mind, character and personality disorders, chemical dependency and child / adolescent mental health concerns.

More by Brent Potter on Beyond Meds:

Books by Dr Brent Potter:

References:

Epstein, M. (2013). The Trauma of Everyday Life. New York: The Penguin Press.

Insel, T. (2013). Director’s blog: Transforming diagnosis. National Institute of Mental Health. [On-line] Available: http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

Irvine, C. (2009). Men Lie Twice as Much as Women. The Telegraph [On-line.] Available: http://www.telegraph.co.uk/news/uknews/6186358/Men-lie-twice-as-much-as-women.html

Mate, G. (2012). Gabor Mate, M.D.: Attachment = wholeness and health or disease,

ADD, addiction, violence. Retrieved 2/28/14 from http://vimeo.com/5541641

Mosher, L. (1998). Letter of Resignation from the American Psychiatric Association. {On-line] Available: http://www.moshersoteria.com/articles/resignation-from-apa/

Mosher, L. & Hendrix, V. (2004). Soteria: Through Madness to Deliverance. Bloomington, IN: Xlibris LLC.

Potter, B. (2015). Elements of Reparation: Truth, Faith, and Transformation in the Works of Heidegger, Bion, and Beyond.

Recovery Innovations. (2008). History. [On-line] Available: http://recoveryinnovations.org/history.html

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, (65)2, pp. 98-109.

Shedler, J. (2013a). Is NIHM brilliant, stupid, or both? Psychology Today, Oct. 13, 2013. [On-line] Available: http://www.psychologytoday.com/blog/psychologically-minded/201310/is-nimh-brilliant-stupid-or-both

Shedler, J. (2013b). Where is the evidence for evidence-based therapies? Psychology Today, Oct. 02, 2013. [On-line] Available: http://www.psychologytoday.com/blog/psychologically-minded/201310/bamboozled-bad-science

Shedler, J. (2013c) Bamboozled by bad science. Psychology Today, Oct. 31, 2013. [On-line] Available: http://www.psychologytoday.com/blog/psychologically-minded/201310