The Corpus Callosum

What Ever Happened to Psychotherapy?

Or rather, what is happening to psychotherapy?

Here, I am picking up on a  comment thread at Mad
Melancholic Feminista
, under href="http://melancholicfeminista.blogspot.com/2006/06/prozac-doesnt-get-anorexics-eating.html">the
post that Aspazia did about href="http://scienceblogs.com/corpuscallosum/2006/06/drug_treatment_of_anorexia.php">my
post on pharmacotherapy of href="http://en.wikipedia.org/wiki/Anorexia_Nervosa" rel="tag">Anorexia
Nervosa
.  

The question is one that comes up a lot, and the answers, by SteveR (no
URL given) are fairly common as well.  But they deserve some
additional consideration.

” What ever happened to helping people work their
problems out so they could deal?”

Continue readng below the fold…

1. Pharmaceutical companies wanting to make money.

2. Insurance companies not wanting to pay money for extended therapy (
drug them up, get them out therapy )

3. The human trait prevalent in America of wanting instant answer

Combine all 3 and we have what you call “prozac nation”.

I still believe that taking care of yourself physically, talking out
your problems, working on changing them and changing your attitudes
when you can’t is enough for mental health when more serious problems
are not involved.

It seems like everyone I meet is on some sort of prescription drug. How
did our ancestors hack out life?

1. There is a strong and highly prevalent influence from the
pharmaceutical companies.  Until recently, the most profitable
companies in the world were pharmaceutical companies.  (Now,
 the most profitable companies are oil companies.)  I
can’t think of any way to have that much money change hands, without
there being some kind of inappropriate influence.  

Another factor here is the way the US title="Food and Drug Administration">FDA
regulates drugs.  In order for a drug to get approved, it has
to be approved for a specific condition (called the indication).
 That seems reasonable, and may in fact be necessary.
 However, it has an unintended consequence, specifically in
the area of psychopharmacology.  That is, it requires that
persons with psychiatric conditions be given medical diagnoses.
 It also requires that those diagnoses be established
according to the href="http://en.wikipedia.org/wiki/Medical_model" rel="tag">medical
model
.  

To the psychiatric practitioner, this is unfortunate.  It is
fairly well accepted that a full description of a person’s problems can
only be given using the href="http://en.wikipedia.org/wiki/Biopsychosocial_model"
rel="tag">biopsychosocial model

(Some might argue that the href="http://en.wikipedia.org/wiki/Holistic_health" rel="tag">holistic
model
is better, but I will leave that discussion
for another time.  See href="http://www.surgeongeneral.gov/library/mentalhealth/chapter2/sec3.html#biosocial">this
page for discussion of some of these concepts.)
 Thus, the system of href="http://www.fda.gov/" rel="tag">FDA
regulations has the effect of influencing practitioners to discard
two-thirds of their information (the psychosocial parts).
 Furthermore, the medical model is deficit-oriented.
 That is, it accounts only for problems; it ignores whatever
strengths or idiosyncrasies a person may have that are pertinent to a
full understanding of their condition.  

Anorexia Nervosa is arguably the one psychiatric condition for which
the full biopsychosocial model is most needed.  It simply
cannot be understood without a full accounting of all three domains.
 When you consider that all thee domains can be described only
dimensionally (as opposed to categorically), it is apparent that a full
description requires a model of prodigious complexity.  It is
particularly foolish to think that it could be categorized adequately
with a single five-digit number (as is done with title="Wikipedia link"
href="http://en.wikipedia.org/wiki/DSM-IV" rel="tag">DSM-IV
diagnoses.  There simply aren’t enough bits in five base-ten
numbers to contain all the information required.

If I may wax philosophical for a moment, I would say that description
is the root of all information in the practice of medicine, and
oversimplification is the root of all evil.  Yet, the
structure of our health-care system more or less forces its
practitioners to oversimplify everything.  

The pharmaceutical companies are not to blame for all of this, but we
can’t ignore the simple fact that they are a powerful force, simply
because of how much money they handle.  Furthermore, the
system works well for them as it is; they have no incentive to promote
any kind of reform.  Neither does the FDA.  

2. Insurance companies are not as profitable as drug companies.
 Even so, they do exert a powerful influence.  As
Steve implied, they do have an incentive to promote the use of the
medical model, and to promote reliance on pharmacotherapy.
 Even though psychiatrists are more expensive that
psychotherapists, on a per-patient basis, it is a lot cheaper to pay
for a 15-minute med review every two months, that a 50-minute therapy
session every week.  This is true even when the cost of
medication is factored in.  

Another factor is the mechanization of medical reimbursement.
 Insurance companies manage payments electronically.
 Because five-digit codes are easy to put into a computer, and
multi-paragraph text is not easily analyzed by machines, they want to
handle everything by the numbers.  Rather than try to take
into account the inevitable complexity of psychiatric diagnosis, they
simply ignore the complexity.  

3. Yes, people want instant results.  I sometimes point out
that, 100 years ago, people went to a doctor hoping
that the doctor could help.  Now, some go, not only expecting
to be helped, but expecting to be completely fixed.  A
substantial minority expect to be fixed without putting in much effort
themselves.  That is a gross oversimplification, but I think
it conveys the idea.  

In saying that, I don’t mean to imply that there are no thoughful or
realistic patients.  Probably, most don’t really fit the
description above.  But I can’t help but think there is a
trend in that direction, fueled in part by over-optimistic media
reports.  

I still believe that taking care of yourself
physically, talking out your problems, working on changing them and
changing your attitudes when you can’t is enough for mental health when
more serious problems are not involved.

That is true.  But it is not for a surprisingly large
minority, more than 20 percent of the population will at some point
find that lifestyle changes are not sufficient.  Notice that I
am talking about href="http://www.nimh.nih.gov/healthinformation/qanda_ncs-r.cfm#q3">lifetime
prevalence, not point prevalence.  Also note that I
am being
conservative
here.  

How did our ancestors hack out life?

Historically, the average lifespan of a human was something like 40
years.  So the answer is: not very well.  To be more
elaborate, though, I would say this: If you define stress
as a change in the environment that requires some kind of adaptive
response, there is a lot more stress now that ever before.
 That is a necessary consequence of the fact that there are a
lot more changes now, and the changes are occurring faster.
 If we could slow down the rate and magnitude of change, we
would not be so stressed.  But how do we do that? And, is it
really what we want to do?

Increasing the availability of psychotherapy might help.  It
would not have to be long-term or intensive therapy, necessarily.
 A lot of studies have shown that short-term problem-focused
therapy can be effective for most people.   But even that is
under fire from incessant cuts by insurance companies.

Comments

  1. #1 Hyperion
    June 17, 2006

    There is also a problem with the starting premise: that medication and therapy are an either/or proposition. That pharmacotherapy is increasing in prevalence (due in part to pharmaceutical companies, but also due to an increased understanding of how superficially psychosocial problems have a deep neurological and sometimes genetic basis) does not have to be the cause of a decline in psychotherapy.

    I would argue that the largest reason for a decline in psychotherapy (preuming that such a decline exists – source?) is that Americans simply don’t have the time. As the Altie quacks unfortunately show, Americans will pay any cost, even without insurance reimbursement, if it promises a cure for what ails them, so I don’t think that the added expense of uninsured psychotherapy is a large barrier. I think that taking an hour out of the day to sit and talk through problems is simply more than many Americans are willing to do.

    That being said, pharmacotherapy is more likely to increase the number of patients seeking help (since pharmaceutical ads increase awareness of the condition), and some of these patients may still utilize psychotherapy (or behavioral therapy for some conditions).

    And of course, while psychotherapy may be all that is necessary for many people with comparatively mild problems, pharmacotherapy is often a necessity for many serious neuropsychiatric conditions (ie schizophrenia, bipolar disorder, severe clinical depression).

  2. #2 Leon Suskin LCSW
    June 17, 2006

    “To the psychiatric practitioner, this is unfortunate. It is fairly well accepted that a full description of a person’s problems can only be given using the biopsychosocial model. (Some might argue that the holistic model is better, but I will leave that discussion for another time. See this page for discussion of some of these concepts.) Thus, the system of FDA regulations has the effect of influencing practitioners to discard two-thirds of their information (the psychosocial parts). Furthermore, the medical model is deficit-oriented. That is, it accounts only for problems; it ignores whatever strengths or idiosyncrasies a person may have that are pertinent to a full understanding of their condition.”

    A multidimensional biopsychosocial coding system is available now. It is,

    Person-in-Environment System
    The PIE Classification System for Social Functioning Problems

    James M. Karls and Karin E. Wandrei, Editors

    Book—ISBN: 0-87101-240-5, 1994
    Manual—ISBN: 0-87101-254-5, 1994

    I have used it extensively in a several practice settings. Unfortunately it is a “social worker” system, slightly more time consuming than the DSM, and not perfect.

    Leon Suskin LCSW

  3. #3 Chris Bell
    April 14, 2007

    My comment has nothing to do with science, but I just wanted to point out that your side quip about oil companies being the most profitable companies in world is misleading and overly political.

    People like to jump on oil companies, and Congress-people introduce popular bills to tax their profits, but the truth is that they just aren’t that successful.

    Let me explain.

    Let’s say Guy1 goes to a poker tournament with $100,000. He walks out at the end with $110,000. He made 10% profit, but $10,000 absolute dollars.

    Now say Guy2 goes to the tournament with $1,000,000. He walks out with $1,050,000. He made 5% profit, but $50,000 absolute dollars.

    Now you are an investor, and you want to give one of these two players $1,000,000 of your own dollars to go play with, and you get a cut of the profit. Who do you give it to? You give it to the first guy!

    When people say that oil companies are the most profitable companies in the world, they mean that they make the most ABSOLUTE profits. As a percentage of their investments, however, oil companies do a mediocre job and are not popular on the stock market. Because it takes HUGE amounts of money to invest in a world-wide infrastructure of drilling, recovering, and shipping, oil companies deal with a lot of money. ANY profits are going to sound big.

    But you never see politicians on CNN railing about hedge funds, which tend to make between 50% and 100% profit….

  4. #4 #~%^
    April 14, 2007

    You might find this interesting: According to John Horgan in The Undiscovered Mind: How the Human Brain Defies Replication, Medication, and Explanation, the different talk therapies are all equally effective, as effective as a placebo, and less effective than religion.

  5. #5 Caledonian
    April 14, 2007

    Psychotherapy is also a very broad term, and it includes treatment methods that have proven effectiveness (like Cognitive-Behavioral therapy) as well as methods that have been solidly demonstrated to be ineffective (psychoanalysis).

    Part of the reason psychotherapy is so underutilized is that it was caught in the backlash against useless and harmful ideas that were rightly jettisoned.

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