PhD/PsyD Do psychologists have a distorted or exaggerated view of psychotherapy

[Nahsil]

Mixed feelings on the article. Some points are excellent, some are distorted and some are simply incorrect.

This is a big interest of mine, but have a grant due soon so didn't have as much time to go through as I'd like. Nonetheless, some point-by-point thoughts:
1) Freudian psychoanalysis does not equal short-term psychodynamic treatments. They screw this up left and right in the article.
2) True CBT is more insight-oriented than I think many realize. Automatic thoughts are superficial. Schemas and core beliefs are where much of the long-standing work happens. The two treatments have more in common than many realize - largely at that level.
3) They mention a meta-regression showing the efficacy of CBT shows a downward trend over time. The author seems to think this is evidence that CBT doesn't work as well as it used to. They fail to mention this is true of a huge number of findings that have an adequate literature base to draw on sufficient power to show the effect. Some may be a publication bias effect. It has always seemed a huge leap to me to think it disproves the original effect. Its meta-analysis people - we're collapsing studies together and losing information about individual ones. It certainly has merits, but you can't ignore the methodology. I think an easier explanation is that it is a function of study design. Initially, we set up studies to show something works at all (high effect size). Eventually, we push the bounds of what it can do more and more (different populations it wasn't designed for, more active control groups, messier settings and designs). Covariates are rarely used in such analyses (they are a PITA to implement in meta-analysis). Of course...we can't see the effect for psychoanalysis because there aren't enough well-designed studies to even attempt something like that.
4) Author logic: CBT effect size is overrated. In some cases it is only slightly better than psychodynamic treatments. Therefore Psychoanalysis is more effective in the long-run (unless I'm mistaken, that actually seems to be the argument at one point).
5) Depression is not the only mental illness that exists. What about OCD? What about panic disorder?
6) Not a fan of ad hominem, but if we are going to paint Shedler as a savior doing cutting edge science showing the efficacy of analysis...let's look a little deeper at that. He's never held an NIH grant per Reporter. In the last 3 years, it looks like he's published a bunch of personality structure work (some of which is pretty good), but otherwise his contributions seem to be mostly narrative critiques of the CBT literature. It ain't perfect. Its miles ahead of what the dynamic literature has at the moment. He has a habit of doing this, but showing that someone else's point is weaker is not the same thing as proving that your point is stronger. This is really what the EBP crowd has been saying all along. If it works, prove it. We're trying to prove our points. Not every execution is perfect, but we're trying. Why aren't you?
7) Anyone can pick out a poorly designed study (the reference to grad students with 2 days training in the therapy). If I find a poem a patient wrote about how much analysis helped them - does that tell us anything about how strong the evidence is for analysis?
8) Does anyone know a researcher developing treatments who only has 10 hours of therapy experience? Public health folks do some evaluations of it. Obviously some folks get to a point they no longer actively practice. My experience is that the vast majority on that side are actively practicing or at least have extensive practice experience.
9) Symptom relief shouldn't be the only outcome of interest. Agreed, I'm down. Do we have strong evidence that analysis improves other outcomes (functioning across a variety of settings, interpersonal relationships, etc.)? Nope. Actually, there is more for CBT.

Phew...5 minutes reading and 15 minutes typing. I'm a little harsh above, but don't take this to mean analysis doesn't work. I don't even take the stance that it shouldn't be used. I do think it makes way more sense to try a treatment that has been known to work first, before trying something that is 1) Less cost effective and 2) There is less evidence to suggest will be efficacious. "This is my therapeutic orientation" is never a good reason to do anything...whether that is CBT, psychoanalysis or anything else. Think more and think better.

Think more and think better - agreed. Which is why I think there's some ignored problems here with what can be measured through quantitative analysis, how things are potentially poorly operationalized, how they change as they're turned into objective "data points," how we may not even have a firm enough foundation on "the good life" to really say whether something is effective (seems like symptom management is pretty huge, which does indeed often fail to consider the larger picture), how even things like functioning across a variety of settings may not be big enough - is therapy purely a method for getting people to fit in? Are cultural contexts always to be supported, such that fitting in is always desirable? Is there a place for more political, societal-structures thinking in this stuff?

Just some issues to consider, imo, that often fly under the radar.

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[WisNeuro]

- is therapy purely a method for getting people to fit in? Are cultural contexts always to be supported, such that fitting in is always desirable? Is there a place for more political, societal-structures thinking in this stuff?

Just some issues to consider, imo, that often fly under the radar.

Based on the therapy RCT's that I have served on, and on many studies I have reviewed over the years, I hardly see this as the "downfall" of the outcome literature. Nearly every outcome balances looking at symptoms, along with how they impair individuals in several domains (social, occupational, academic, interpersonal), as well as subjective distress. There is usually a lot of focus on the individuals' perception of their well-being and impairment, in addition to more objective measures. Could you clarify your critique there?

 

[smalltownpsych]

Think more and think better - agreed. Which is why I think there's some ignored problems here with what can be measured through quantitative analysis, how things are potentially poorly operationalized, how they change as they're turned into objective "data points," how we may not even have a firm enough foundation on "the good life" to really say whether something is effective (seems like symptom management is pretty huge, which does indeed often fail to consider the larger picture), how even things like functioning across a variety of settings may not be big enough - is therapy purely a method for getting people to fit in? Are cultural contexts always to be supported, such that fitting in is always desirable? Is there a place for more political, societal-structures thinking in this stuff?

Just some issues to consider, imo, that often fly under the radar.

Most, if not all, of my patients want two things: reduction in symptoms and improved function. Number one priority for me is identify what patients want and then assist them in accomplishing that. They decide what that means for them, not me.

 

[Nahsil]

Basically I think it's naive not to pay attention to how psychology is situated in a broader sociopolitical and historical context. People like Foucault and more recently Nikolas Rose, Derek Hook etc examine the institution of psychology and the recursive effect that it has on people...more than the simple claim that it's just helping people be happier or whatever, they argue that it serves a political/governmental function, related to individualism and normalization (the reduction of desire/idiosyncrasy/the range of human experience in order to promote good functioning subjects, a la the kind of subject that capitalism requires). The narrative therapy folks, as one instance of an alternative, work off of these critiques and try to create a less individualistic modality of therapy that includes the social, cultural, political, etc contexts into mental illness etiology rather than "putting everything into people's heads" like a lot of psychology tends to do...I know there's a move to the biopsychosocial, but it's still missing a lot and still seems to be more lip service when it comes down to actual therapeutic practice and even a lot of theoretical thinking (although I'm also aware that a lot of people here are more on the "cutting edge" than a lot of people I've seen or had as peers for instance).

I'm also aware that this post is probably going to do nothing in the way of convincing anyone, although I think there's an ethical responsibility to be aware of these arguments and give them due attention, even if you ultimately disagree or don't find them convincing.

 

[Ollie123]

Think more and think better - agreed. Which is why I think there's some ignored problems here with what can be measured through quantitative analysis, how things are potentially poorly operationalized, how they change as they're turned into objective "data points," how we may not even have a firm enough foundation on "the good life" to really say whether something is effective (seems like symptom management is pretty huge, which does indeed often fail to consider the larger picture), how even things like functioning across a variety of settings may not be big enough - is therapy purely a method for getting people to fit in? Are cultural contexts always to be supported, such that fitting in is always desirable? Is there a place for more political, societal-structures thinking in this stuff?

Just some issues to consider, imo, that often fly under the radar.

Believe it or not, I actually fully agree with pretty much everything you have listed there (suspect we'd differ on some of the nuance). My concern is more what people tend to do with those concerns. Concerns about how things are operationalized? Great! Discuss it or even better, run a replication with different outcomes/operationalizations/etc. Something can't be measured quantitatively? Most of the time when I hear that criticism, people really mean it isn't easy/convenient/no one has made a measure for it yet and factor analysis is scary/etc. That said, there are certainly plenty of things that are better assessed qualitatively and even when not, qualitative work can provide important insights that quantitative work can easily miss.

My issue is one of baby-bathwater. Shedler (and many many others) have made some incredibly valid criticisms of the CBT literature. I'm fully on board with the fact the science may be weaker than many would have you believe. Though as I said above though - poking holes in the CBT literature does nothing to provide support for psychoanalysis. One must (convincingly) demonstrate these issues are overcome in other literature and that the strengths outweigh the weaknesses. Like I said previously, they tend to stop with the criticisms. "See, the CBT literature isn't perfect! Therefore...psychoanalysis" is kindergarten logic. I have profound respect for those who can say "I'm not sure X can really be quantified" and then go on to explain why, how else it could be studied, what other methods would allow us to converge on a solution. I have profound concerns for the folks who say "Oh, I don't think you can quantify it" and when pressed will start to stammer, fall back on vague statements ("The human experience is too rich!") and tautologies (you can't meaningfully assign numbers to it!), and can't take it a lick beyond that level of discourse. Sadly, that is the modal individual in my experience.

(Note that none of this is directed at you specifically, nor do I think you are making these arguments as from everything I've seen you do seem to one of those who knows better. ).

 

[smalltownpsych]

Basically I think it's naive not to pay attention to how psychology is situated in a broader sociopolitical and historical context. People like Foucault and more recently Nikolas Rose, Derek Hook etc examine the institution of psychology and the recursive effect that it has on people...more than the simple claim that it's just helping people be happier or whatever, they argue that it serves a political/governmental function, related to individualism and normalization (the reduction of desire/idiosyncrasy/the range of human experience in order to promote good functioning subjects, a la the kind of subject that capitalism requires). The narrative therapy folks, as one instance of an alternative, work off of these critiques and try to create a less individualistic modality of therapy that includes the social, cultural, political, etc contexts into mental illness etiology rather than "putting everything into people's heads" like a lot of psychology tends to do...I know there's a move to the biopsychosocial, but it's still missing a lot and still seems to be more lip service when it comes down to actual therapeutic practice and even a lot of theoretical thinking (although I'm also aware that a lot of people here are more on the "cutting edge" than a lot of people I've seen or had as peers for instance).

I'm also aware that this post is probably going to do nothing in the way of convincing anyone, although I think there's an ethical responsibility to be aware of these arguments and give them due attention, even if you ultimately disagree or don't find them convincing.

I think you need to be more specific because it sounds a little too brave new world for me. I see lots of problems with our society that psychology just goes along with to an extent. The best example is the educational system and philosophy. I had a discussion yesterday with the parent of a kindergartener with some severe emotional regulation difficulties on how to get him to do his hour or so of homework. WTF? Maybe we just need to up his seroquel and concerta. I was clinical director of a program that was able to improve academic and social functioning of kids on these medications and in over 90 percent decrease medications and in half d/c altogether and our outcome measures were phenomenal.

The problems with community mental health and its huge focus on medications is another big problem. Combine this with reinforcement of disability and what do you get?

I could go on and on with various problems, don't get me started, I just think the above stuff is a bit too vague to be useful and neglects the fact that psychology is probably the best hope for help with the problems.

edited to fix the errors from typing on my phone.

 

[Nahsil]

Yeah it is vague, it's a whole big edifice of an argument so it's kinda hard to sum up, but I'll try to give a little bit more detail later on.

and yeah Ollie, I'd never advocate a return to Freud or whatever. I don't think very highly of psychoanalysis personally, although it may have some useful conceptual tools (transference/countertransference, some of the ego defenses etc).

 

[Nahsil]

I can't do a full detailed summary, but the guy who started a lot of this, Foucault, does a historical analysis of for instance the function of the "birth of the clinic" in the 18th/19th century...which was to begin to categorize individuals in order to know "where to put them" - asylums and stuff. In some older communities, like indigenous communities, people with psychotic symptoms were a valuable part of the community - they'd frequently receive the support of the other community members (perhaps similar to some of the more progressive models for treating schizophrenia in Finland I think?) and many times (allegedly) they would "come out of the other side" with some new insight or psychological abilities, e.g. in Jungian terms the ability to sort of have a closer connection to the unconscious, so they'd serve as sort of guides for a community that helped people with psychological sorts of problems, because they understood the psyche in a different way than most people. Little bit of a tangent, but anyway, that changed in the West and we started to cordon off psychotics because they disrupted our social environments according to the functionality we were trying to achieve - needing to fit into a social structure in terms of being able to go to work every day in a prescribed, rigid fashion. We needed people like that to run factories and other socioeconomic institutions.

according to Foucault, fast forward to the 20th century and you have less of this external control of people, dividing them up and keeping them separate, and with the advent of psychology more of an internal form of control, where people are taught to control themselves in order to fit into the sociopolitical scene. Obviously not everybody can do this on their own, so you get psychologists, who through absolutely good intentions become sort of "doctors of subjectivity" able to help people fit into these structures. It's not a conspiracy like BNW because nobody was at the top thinking "we've got to find a way to control people!" It happened as a series of local solutions to problems in the sociopolitical realm, business owners and government folks needing to figure out how to get the kind of workers or political subjects they needed.

obviously there's nothing wrong with wanting to help people and wanting to make their lives less stressful/overwhelming/despairing/etc, but this line of thinking argues that a lot of the social structures are in the first place creating the conditions for a lot of mental problems, e.g. requiring people to work menial slave labor jobs in a culture where money and materialism take precedence over more "nourishing" forms of value and activity. In my mind, this focus on the individual as the seat of control and change has the effect of taking the focus away from the social structures that may be causing people problems and telling the individuals themselves "it's your problem, now do your best (perhaps with the aid of a psychologist) to fix yourself and adapt yourself to our ****ty conditions".

again, this may not sound very convincing laid out like this, but I think people should be looking at these issues and potential alternatives for psychology to take that avoid some of these issues (if you buy into it after looking into it). I really like the Narrative Therapy people - who try to show that "your problems" are involved in a whole social network of demands for what you should be doing, how you should be acting, how you shouldn't be acting, etc - and there's some others as well, some of the family systems people of the past few decades have taken these critiques into account and tried to be more holistic and anti-individualistic in their assessment of mental health.

 

[deleted343839]

In my mind, this focus on the individual as the seat of control and change has the effect of taking the focus away from the social structures that may be causing people problems and telling the individuals themselves "it's your problem, now do your best (perhaps with the aid of a psychologist) to fix yourself and adapt yourself to our ****ty conditions".

The main concern I have with your analysis is the assumption that this is what psychotherapy is about. It sounds like you are equating therapy with gaslighting - I would be alarmed too if this were my understanding of therapy.

Has it never occurred to you that sometimes a goal of therapy is to acknowledge the role of these larger factors you are describing? There are entire lines of research suggesting that it is adaptive to be aware of structural/cultural barriers AND have some sense of personal efficacy within realistic limits. This is especially true for marginalized populations. You are confusing the modality of treatment - usually individual - with the presumed cause and solution to the problem from the psychologist's perspective.

Let's use the example of psychotherapy for a person who has been marginalized by his community for his sexual orientation and is struggling with depression. Does the therapist say, "You're just being overly sensitive. Here are some ways to fit in better and talk yourself out of thinking this is a big deal." Well, maybe a really bad therapist would do that. But a reasonable therapist would normalize and validate the person's experience, acknowledge homophobia, help connect them to resources or communities that offer a differ perspective, and help them take meaningful steps toward forming a positive identity as a person with a same-sex orientation. One would ALSO use time-honored strategies for addressing depression in general, because there are few cases in which the problem boils down neatly to a single issue (another attractive though usually inadequate explanation).

Really, a surprising amount of what I do is normalizing feelings and behaviors that are actually someone else's problem and helping people figure out how to address their concerns in a way that is both adaptive and authentic for them. This does not fit with your narrative. I also acknowledge that I am not a community organizer, policymaker, or activist. I can only offer one set of tools. (And for the record, I consider myself primarily cognitive-behavioral in orientation.)

 

[Nahsil]

I'm glad that you do that, and I'm not saying therapy never does it, but I still think it doesn't do it to a great enough extent...maybe particularly with depression, anxiety, schizophrenia, etc (which are very often conceived of as "internal" problems rather than problems situated in a wider context), rather than LGBT type issues. I'd certainly hope if a therapist plans to address those types of issues that s/he has an understanding of them as cultural phenomena, but that's just the tip of the iceberg related to a whole set of theoretical and praxis related things that don't take into account things like social discourses and demands.

 

[deleted343839]

I'm glad that you do that, and I'm not saying therapy never does it, but I still think it doesn't do it to a great enough extent...maybe particularly with depression, anxiety, schizophrenia, etc (which are very often conceived of as "internal" problems rather than problems situated in a wider context), rather than LGBT type issues.

But... the example I gave was referring to depression as the presenting problem. You split it off as "LGBT type issues," which surprised me since I thought this was a good (if obvious) example of the type of conceptualization you're advocating. Did I just fail to properly refer back to Capital?

If you're referring to serious mental illnesses like schizophrenia, severe affective disorders, etc... well, you're going to need more than Foucault.

 

[smalltownpsych]

I can't do a full detailed summary, but the guy who started a lot of this, Foucault, does a historical analysis of for instance the function of the "birth of the clinic" in the 18th/19th century...which was to begin to categorize individuals in order to know "where to put them" - asylums and stuff. In some older communities, like indigenous communities, people with psychotic symptoms were a valuable part of the community - they'd frequently receive the support of the other community members (perhaps similar to some of the more progressive models for treating schizophrenia in Finland I think?) and many times (allegedly) they would "come out of the other side" with some new insight or psychological abilities, e.g. in Jungian terms the ability to sort of have a closer connection to the unconscious, so they'd serve as sort of guides for a community that helped people with psychological sorts of problems, because they understood the psyche in a different way than most people. Little bit of a tangent, but anyway, that changed in the West and we started to cordon off psychotics because they disrupted our social environments according to the functionality we were trying to achieve - needing to fit into a social structure in terms of being able to go to work every day in a prescribed, rigid fashion. We needed people like that to run factories and other socioeconomic institutions.

according to Foucault, fast forward to the 20th century and you have less of this external control of people, dividing them up and keeping them separate, and with the advent of psychology more of an internal form of control, where people are taught to control themselves in order to fit into the sociopolitical scene. Obviously not everybody can do this on their own, so you get psychologists, who through absolutely good intentions become sort of "doctors of subjectivity" able to help people fit into these structures. It's not a conspiracy like BNW because nobody was at the top thinking "we've got to find a way to control people!" It happened as a series of local solutions to problems in the sociopolitical realm, business owners and government folks needing to figure out how to get the kind of workers or political subjects they needed.

obviously there's nothing wrong with wanting to help people and wanting to make their lives less stressful/overwhelming/despairing/etc, but this line of thinking argues that a lot of the social structures are in the first place creating the conditions for a lot of mental problems, e.g. requiring people to work menial slave labor jobs in a culture where money and materialism take precedence over more "nourishing" forms of value and activity. In my mind, this focus on the individual as the seat of control and change has the effect of taking the focus away from the social structures that may be causing people problems and telling the individuals themselves "it's your problem, now do your best (perhaps with the aid of a psychologist) to fix yourself and adapt yourself to our ****ty conditions".

again, this may not sound very convincing laid out like this, but I think people should be looking at these issues and potential alternatives for psychology to take that avoid some of these issues (if you buy into it after looking into it). I really like the Narrative Therapy people - who try to show that "your problems" are involved in a whole social network of demands for what you should be doing, how you should be acting, how you shouldn't be acting, etc - and there's some others as well, some of the family systems people of the past few decades have taken these critiques into account and tried to be more holistic and anti-individualistic in their assessment of mental health.

A big part of my current clinical population are indigenous people and they tend to have a completely different world view that embraces psychotic disorders, non-sequential reasoning, and contrarianism. There are some great strengths within this and things that we should bring to western culture. I also agree with some of what you are saying and much of my work with patients is helping them to see the dysfunction in society, as well. However, I think you are being selective in your focus. Western culture and psychology is not all bad and the other is not all good, but that is how this type of presentation tends to come across. I agree that our conceptualization and treatment of severe mental illness sucks, to be blunt, and that other countries and cultures can do better. We, as psychologists, should all know that because the statistics are pretty clear. I also think that cherry picking certain aspects where other cultures have better outcomes isn't always helpful. It is like my patients who only see the positives in others and negatives in themselves or vice versa. The reason I say that is because I would imagine that much of the treatment of the mentally ill throughout history is not as rosy as some might like to paint it.

 

[psych844]

To add a bit to what MamaPhd said. I have a pretty good sexology example.
Obviously our beliefs about sex have a lot to do with the culture/society we live in, so it's very relevant to what we're talking about. Sexologists often see women that complain about anxiety/feeling abnormal because they feel sexually aroused in their day to day life... their feelings are a result of a culture/society that thinks that's unnatural in women. (thank you Victorian era!) The research on the other hand shows that there is very little or no difference between men and women when it comes to sexual arousal. And the only reason that many women appear less sexual is that most of them fear harsh judgement.

The point is, one of the main jobs of a good Psychologist is to try to see the world for what it really is, (the impact of society on the person, other individuals, etc) as a lot of people's problems (especially the less serious ones) are about the person feeling abnormal/not good enough..because others have told them that who they are is somehow not right.

 

[smalltownpsych]

To add a bit to what MamaPhd said. I have a pretty good sexology example.
Obviously our beliefs about sex have a lot to do with the culture/society we live in, so it's very relevant to what we're talking about.
Sexologists often see women that complain about anxiety/feeling abnormal because they are sexually aroused all the time... their culture/society teaches them that it's abnormal for women to feel that way. (thank you Victorian era!) The research on the other hand shows that there is very little or no difference between men and women when it comes to sexual arousal. And the only reason that many women appear less sexual is that most of them fear harsh judgement.

The point is, one of the main jobs of a good Psychologist is to try to see the world for what it really is, (the impact of society on the person, other individuals, etc) as a lot of people's problems (especially the less serious ones) are about the person feeling abnormal/not good enough..because others have told them that who they are is somehow not right.

I think that being sexually aroused all the time might just be abnormal for men and women.
Seriously though, that is a good description of how I help my patients by examining their beliefs and where they come from. Whether it is society or their family or even the internet doesn't matter that much to me or to them. I tend to just ask a lot of questions that help them to think about these things. I will also provide them with the information that we have from psychological science as well. I also emphasize that there is no real normal for many of these concepts. Sexual desire is a great example of that. It is just another standard distribution and does it really matter where a person falls on the distribution? It does tend to matter more to both the individual and society when they get to the tails, but it is the same with height or weight or mathematical ability or even ability to sing or dance. The biggest problem I see with differences in sexual desire is when couples are far apart in that area. Of course, often both individuals will think their amount of sexual desire is normal and they want me to fix the other partner.

All of my psychological training and the instructors who I have had since being an undergrad psych major have emphasized a broadening of perspective and an emphasis on the importance of cultural and historical and oppressive factors along with an understanding of the science of psychology. I just don't see this movement in the field that wants to align themselves with an imposition of conformity and so it appears to be a bit quixotic when I hear it.

 

[Nahsil]

But... the example I gave was referring to depression as the presenting problem. You split it off as "LGBT type issues," which surprised me since I thought this was a good (if obvious) example of the type of conceptualization you're advocating. Did I just fail to properly refer back to Capital?

If you're referring to serious mental illnesses like schizophrenia, severe affective disorders, etc... well, you're going to need more than Foucault.

Yes you mentioned depression within the context of LGBT, which is typically acknowledged as a cultural issue, rather than say depression within the context of your everyday neurotic family circumstances, which is not typically acknowledged as a cultural issue, though it is often acknowledged as a family one.

Foucault's first book is called Madness and Civilization, and a great deal of his work is about schizophrenia, so I'd wager you haven't read him? At any rate he's not trying to propose therapeutic alternatives, so of course I "need more than Foucault," he's one of a number of people I like. All he's doing is a "history of the present" and trying to show how psychology fits into the modern sociopolitical realm. Other people luckily have taken up the charge and tried to look at therapeutic alternatives, as I've mentioned.

At any rate pointing out an example of something that's known to tie into cultural issues, as proof that psychology is culturally-minded, is missing the point, although I'm definitely glad there are exceptions/frontiers in new directions! The issue has more to do with how individuals are conceptualized according to psychological theory and practices than it does whether therapists sometimes recognize the importance of culture. I should probably just stop while I'm ahead and say that if this has piqued anyone's interest, I really encourage you to take a look into some of the resources I've mentioned. Narrative Therapy by Stephen Madigan would be a good, concise, well-written introduction.

that's cool smalltown, it sounds like you've had a pretty progressive education. Maybe with the increased cultural focus on social justice things are shifting. I know multicultural psychology is getting to be a big thing. That doesn't fully negate some of the complaints I'm making, but it does seem like a step in the right direction. Conformity is part of it, but it's also just about how people think of themselves and others...as individuals who sort of "possess" their experience. What Edward Sampson refers to as "possessive individualism," which I'm going to be doing some qualitative research on this semester. Maybe I'll post it here if I put it up somewhere.

 

[Ollie123]

Generally agree with what others above have said. Contextual factors (including geopolitical climate, etc.) are crucial to consider for any therapist. Heck even radical behaviorists I've worked with frequently draw on this in conceptualization and treatment planning. Societal and geopolitical pressures frequently contribute heavily to mental health (however defined) and I'm actually not sure I've ever heard anyone say otherwise. The question of what to do about it is a complicated one. My approaches have run the gambit from helping folks change themselves to better "fit in", activists who accept and embrace their role on the fringe and draw strength in fighting for increased acceptance and folks who make a decision to largely withdraw from society to the degree possible because of their beliefs. The latter is rare, but I have occasionally supported folks in taking that path. All of these are largely determined by the patient, with some restrictions based on what is ethical/safe/possible (i.e. no conversion therapy).

All of this is somewhat tangential to our original discussion though. Importantly, I haven't heard even a glimpse of a single thing in this discussion that can't be operationalized, quantified, measured, studied empirically, etc. Perhaps for some the literature is not yet developed enough and is better suited to exploratory work right now, but I don't seen any impossibilities. Narrative therapy is an excellent example. Do we think it helps more than other approaches? What is the end goal (symptom reduction? geopolitical acculturation? rejection of imposed societal standards? general life satisfaction?). We could find all of those out easily enough. Do we think it works through different mechanisms that have advantages over other approaches? Somewhat more complicated and typically entails slightly weaker designs, but we can certainly figure that out too.

 

[Nahsil]

The critique is more radical than including culture in dialogues about individuals...it's about seeing how individuals are prominently constructed by cultures, that our sense of self is particular to our culture, and how that itself tends to create a lot of mental illness (because of things like the social constraints of normalization), rather than much on the part of the individual. It's a different conceptual focus/lens/resolution, premised on the idea that the rise of individualism (that level of focus) is a parallel development tied into the rise of capitalism, and both are problematic for people's mental health, so the necessary remedy is more radical. But of course not everybody is into being radical, so I just figured I'd throw this out there and anyone interested can pick it up if they'd like.

I'm not sure how you'd quantify something as subtle and nuanced as one's sense of self according to culture, or if many psychologists would entertain the idea that you're describing anything worth describing that's why I'm probably going to do a discourse analysis for my research, or some other form of qualitative analysis.

 

[deleted343839]

Foucault's first book is called Madness and Civilization, and a great deal of his work is about schizophrenia, so I'd wager you haven't read him?

I've read a lot of things, including Foucault. And I'm married to someone with graduate training in philosophy who has also read Foucault. Foucault has a warm, happy home on our bookshelf. But we are not Foucault fundamentalists nor do we grant Foucault some privileged frame of reference for conceptualizing mental illness. Sorry.

It is also true that I have witnessed a family member's onset of schizophrenia and the tragic consequences it held for himself and his loved ones. Suffice it to say there was no silver lining in this transformation. I'd wager you haven't known many people with schizophrenia?

 

[Ollie123]

I'm not sure how you'd quantify something as subtle and nuanced as one's sense of self according to culture, or if many psychologists would entertain the idea that you're describing anything worth describing that's why I'm probably going to do a discourse analysis for my research, or some other form of qualitative analysis.

Probably difficult to quantify precisely what it is, but I don't think impossible to quantify changes in it (presuming conscious awareness of the construct anyways). I agree that is something probably best suited to qualitative research at this juncture, but I'm not convinced that always need to be the case.

That said - I'm still unclear how things like this tie into our previous conversation. Is the argument that narrative therapy is more effective for enhancing sense of self according to culture? And that this is a more important/relevant outcome than symptom relief for an individual presenting to a clinic with depression (or any other concern for that matter)? I'm all for studying it and think its hugely important for our broader understanding of mental health and long-term thinking about how to shape our society. However, I agree with MamaPHD that often times these things provide little guidance on what to do clinically. I imagine if I told most of my patients "You'll still be sad, crying all the time and unable to leave your house, but will have a better understanding of your place in the world and what led you here at the end of treatment" somewhere between 99 and 100% would walk out the door and never come back. And of course, societal pressures would likely contribute to that decision as well - which may be the point. Of course, these alternative interventions could well provide sufficient symptom relief too (which could well be mediated by something like sense of self - this sounds like the framework posited for most insight-oriented approaches) - so why not find out?

I guess my question is this. Is the argument that sense of self according to culture (or pick any other construct where this applies if not that one) is more likely to lead to long-term life satisfaction through intervention? That emphasis on symptom relief is likely to cause long-term harm? That sense of self is more amenable to intervention? That its a more potent mediator of behavioral change? That emphasizing individual change ultimately proves detrimental to society and our role as psychologists should be to foster acknowledgement of this rather than encourage change? I'm open-minded to discussion about any of these (though would obviously debate them), I just never find anyone actually willing to lay out arguments for these alternative treatments in a cogent way. Its like arguing against involuntary commitment, but not positing alternative solutions and balking at the idea that we'd let someone walk out the door and hurt themselves (or someone else) without stopping them (this description fits several groups I know).

 

[erg923]

Why is psychotherapy that aims to have individuals become functional members of whatever society they are in a bad thing? Of course psychotherapy is affected by the culture, duh. And I fail to see why this a bad thing, as long as the patient is the one who dedicates treatment goals. Most people I encounter/treat want to "fit into a social structure in terms of being able to go to work every day." That's the whole reason they come to my office, right? Their emotional state or stressors are affecting this. Are we suggesting its more ethical and more "sensitive" to advise them on how the Finnsih handle that?!

 

[smalltownpsych]

Why is psychotherapy that aims to have individuals become functional members of whatever society they are in a bad thing? Of course psychotherapy is affected by the culture, duh. And I fail to see why this a bad thing, as long as the patient is the one who dedicates treatment goals. Most people I encounter/treat want to "fit into a social structure in terms of being able to go to work every day." That's the whole reason they come to my office, right? Their emotional state or stressors are affecting this. Are we suggesting its more ethical and more "sensitive" to advise them on how the Finnsih handle that?!

Agreed and I also help patients accept and cope with and even celebrate the fact that they don't or can't "fit in"to society. At the same time I can work toward improving our culture and systems by advocating for changes that are supported by research. I just see that as what a good psychologist does everyday.

On the other hand, It does become problematic when working in an unhealthy system as to how best to help your patient. I can justify that I am helping patients within the system, but I do believe that at the same time I am supporting the unhealthy system.

 

[erg923]

To redirect this hot garbage fire of boring nonsense, I think that I will add that since I have been doing some work with VISN2 MIRREC and the Center for Integrated Care, we have been talking alot about this, as a large focus of PCMHI is on clearing up access for the larger general mental health service. There are increasing discussions of shared medical appts in the place of a tradition brief 6-8 session of behavioral-oriented interventions. I have done about 3 this past month, and fee like this is working quite well and more efficiently than simply collaborating after the fact whilst and plodding on with an individual is only half heatedly engaged in therapy. I would really like to see this trend continue. The interesting things is, there is also talk of expanding what PCMHI is treating and taking on, which I actually think may be the wrong direction to go at this time. Sometimes less is more, which hearkens back to the question posed by this thread to begin with.

Mod note: Edited to remove quote of deleted post

 

[Therapist4Chnge]

There are increasing discussions of shared medical appts in the place of a tradition brief 6-8 session of behavioral-oriented interventions. I have done about 3 this past month, and fee like this is working quite well and more efficiently than simply collaborating after the fact whilst and ploding on with an individual is only half heatedly engaged in therapy.

That model makes a lot of sense.

I would really like to see this trend continue. The interesting things is, I there is also talk of expanding what PCMHI is treating and taking on, which i actually think may be the wrong direction to go.

why is that?

 

[erg923]

That model makes a lot of sense.


why is that?

The more I do primary care, the more I find out how limiting the model it is for people unless the presenting concern exists within a life that has minimal other psychosocial stressors and/or dysfunctions. This is NOT most of the people who are consulted to me. Trying to treated heroin addiction in the PCMHI service through collaboration with PCPs is just not good care, IMHO. Yet this was recently proposed