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 the
post that Aspazia did about my
post on pharmacotherapy of 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 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 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 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.  

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 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 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.