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 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.