Is Psychotherapy Outdated?

[CitoPsych]

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According to Yale psychologist Dr. Alan Kazdin, yes it is. According to Dr. Kazdin

"The problem is that these evidence-based therapies aren't getting to the people who need them. Nearly 50% of the American population will suffer some kind of mental illness at least once in their lifetimes, but the mental health field, which relies largely on individual psychotherapy to deliver care, isn't equipped to help the vast majority of patients."

This conversation made me wonder, where is psychotherapy heading in the next 5,10, 20 years? Where do psychologists and mental health providers fit in the big picture? Is our profession becoming "outdated?" If so, how do we stay current? I was curious to hear everyone's thoughts on this matter. Here is the link:

http://healthland.time.com/2011/09/...alls-for-the-end-of-individual-psychotherapy/

 

[roubs]

For the non-checkout aisle fluff version for what this psychologist is actually saying: http://pps.sagepub.com/content/6/1/21.full

 

[erg923]

For the non-checkout aisle fluff version for what this psychologist is actually saying: http://pps.sagepub.com/content/6/1/21.full

Agreed. Read the actual article. As many of us here would agree, in community practice, there is a often a relative lack of, and sometime reistance to, using treatments that have been proven to work best (ie., utilizing science and research in practice). This is not new news.

However, I will say Im not too big a fan of perpetuating the steretype (as the article appears to), that older practioners are more out of touch. Maybe. maybe not. I dont know. I think you need a pretty large practice survey to make that generalization/insinuation. I'm sure all of us have met psychologists in their 60s and 70s who are way out of the loop, as well as ones who explifiy what it means to be a true "scientist-practitioner." Similary, we have all probably met mudleheads with recent training who love to do everything the way Jung did and have little interest in looking into what the literature says and/or what is considered best practice in today's healthcare market.

 

[CitoPsych]

For the non-checkout aisle fluff version for what this psychologist is actually saying: http://pps.sagepub.com/content/6/1/21.full

Thanks Roubs for the link! After reading the entire article, it certainly does not read like that Time article.

I do agree with his premise that "a central thesis of this article is that, despite advances in research, mental health professionals may have little success in decreasing the prevalence and incidence of mental illness without a major shift and expansion of intervention research and clinical practice." I wholeheartedly agree with this. It doesn't seem however, that programs that educate practitioners are up to pace with this mode of thinking as the article discusses, so where are we left now? How do we expand our service models without diluting the field? Thanks for the full context!

 

[Therapist4Chnge]

"...mental health professionals may have little success in decreasing the prevalence and incidence of mental illness without a major shift and expansion of intervention research and clinical practice."

I'm not sure we can directly impact prevelance, but I think we can impact quality of life for individuals who have been diagnosed with a MH-related condition. Psychotherapy does work for many different disorders, but good luck getting patients to be compliant, insurance companies to reimburse fair rates, and undertrained/untrained clinicians from encroaching on the field of psychology.

The research side of the house needs to be directly imbedded into the healthcare system. Most research populations are scrubbed clean of realistic patient profiles. Show me efficacy with a real population, not just in a lab. I think great things have come from clinical research (PE, CPT, CBT for Pain Management, DBT, etc), but much of it included narrow patient profiles.

 

[aequitasveritas]

Most research populations are scrubbed clean of realistic patient profiles. Show me efficacy with a real population, not just in a lab. I think great things have come from clinical research (PE, CPT, CBT for Pain Management, DBT, etc), but much of it included narrow patient profiles.

THANK YOU!

I'm glad this knowledge of flawed "evidence-based" research is gaining traction.

 

[Ollie123]

Well I don't think there's really any question that we don't exactly have high standards for practice in this field. It doesn't mean there aren't good practitioners out there, but I've seen tons of "supportive therapy" masquerading as EBTs, people doing off-the-wall things, and patients in therapy for years and years without getting anything approximating the standard of care in say, a university clinic.

There's really two major points - whether people are using effective interventions and "reach". Whether traditional 1x/week hour-long therapy sessions are sustainable is a valid question - there's no question that it can work, but there does need to be some consideration of cost.

RE: EBT research - this has been discussed in the literature for years now, and is certainly changing, but like many things in psychology it is moving like molasses. Efficacy research has its place, but effectiveness studies are becoming more common. More and more research is either including co-morbid conditions, or sometimes studying them explicitly. That said, I'd still trust an RCT with extraordinarily rigid exclusion criteria over the "gut instinct/I do what seems right based on some loose philosophy I came up with after reading a few case studies 20 years ago" approach that seems disturbingly common. The hallmark of the evidence-based practitioner is not blind faith in RCTs, but having good enough research training to judge all available evidence, gather more when necessary, and use it to select a treatment approach.

 

[DrGachet]

The research side of the house needs to be directly imbedded into the healthcare system. Most research populations are scrubbed clean of realistic patient profiles. Show me efficacy with a real population, not just in a lab. I think great things have come from clinical research (PE, CPT, CBT for Pain Management, DBT, etc), but much of it included narrow patient profiles.

As my behaviorist prof would say, Why assume that "real population" is any different. The only way we would know is by doing research on them of course; but as long as we have not, we can not simply guess and we should rely on whatever findings we have based on research population. Anything more is mere speculation and guesswork and seriously discouraged.

I don't share his radical view. Yes, we all need to have faith in something, nothing is 100%. But to treat someone with five different problems in a way that completely ignores the other four problems mainly because good research has been done only on problem D, is nonsense. Research findings are important; but so is improving our critical thinking such as trying to falsify our hypotheses as opposed to validate them, and when to rely exclusively on research and when not.

 

[FadedC]

. Show me efficacy with a real population, not just in a lab.

That's one thing I find interesting about research in school psychology, is that it tends to primarily take place with "real" populations. Of course studies in schools have their own issues, headaches and limitations, but they do have the major benefit that your subjects are about as real as it gets.

There are actually now federal laws that require us to us to use evidence based interventions when dealing with a child who has a problem causing them to struggle in class. It's not well implemented everywhere yet, but it does create a lot more emphasis on evidence based work.

 

[roubs]

I think Ollie has it spot on with this

That said, I'd still trust an RCT with extraordinarily rigid exclusion criteria over the "gut instinct/I do what seems right based on some loose philosophy I came up with after reading a few case studies 20 years ago" approach that seems disturbingly common. The hallmark of the evidence-based practitioner is not blind faith in RCTs, but having good enough research training to judge all available evidence, gather more when necessary, and use it to select a treatment approach.

I don't share his radical view. Yes, we all need to have faith in something, nothing is 100%. But to treat someone with five different problems in a way that completely ignores the other four problems mainly because good research has been done only on problem D, is nonsense. Research findings are important; but so is improving our critical thinking such as trying to falsify our hypotheses as opposed to validate them, and when to rely exclusively on research and when not.

The only thing worse would be pursuing a treatment that purports to treat the whole client through intuition but actually avoids using anything that works in any of the five problems.

 

[2012PhD]

Individual psychotherapy is just as effective for many psychological problems as medication (particulary for many forms of anxiety and depression), but with a much smaller risk of relapse. The problem is that we need better advocacy in our field and greater visibility to reach the public and to get $ from congress.

Funding for mental health, particulalry therapy is practically non-existent these days. Hospitals and clinics are providing group therapy, meds, and case management and very little individual therapy. This will just continue to get worse with the great recession. Most have long wait lists. Psychologists have huge case loads and are not able to see clients often in many hospital settings. Many hospitals also hire untrained people to run large groups so they can cut costs. Most people are not getting any care or inadequate care.

There is no shortage of psychologists who can deliver EST and are well-trained from what i've seen. The problem is that hospitals and clinics don't want to pay for quality or expert treatment. They care about low cost treatments, meds and mega groups. Many prefer to hire a social worker for 30-40K as opposed to a psychologist for 80K. The experts who practice EST are going into private practice/research/institutes/academia. Private practices are only serving the ultra rich generally speaking and only the best can survive.

 

[BuckeyeAlum]

I read this paper when it first came out, and it had a big effect on me. However, I think I look at it a bit differently...

I think Kazdin (and Blase) are right in saying that plain old psychotherapy should not be the only option available to the public. It definitely has utility and should exist as a major service of our mental health field. However, there are other treatment modalities that await us thanks to technology (like it or not, it's not going away...). As a field, we need to capitalize on these new forms of communication and therapy. How should we do this? We need to translate EBTs to other treatment modalities.

I know there a bunch of you out there who are thinking, "I hate the idea of technology replacing face-to-face therapy. It will never be as good as the real thing." Well, you may be right. However, getting a less-effective therapy is probably better than getting none at all. By using new methods, we may be able to reach clients who previously could not participate in therapy for any number of reasons (unreliable transportation, rural locations, disability/poor physical health, etc.). This may help to lessen the burden highlighted by Kazdin.

 

[roubs]

I read this paper when it first came out, and it had a big effect on me. However, I think I look at it a bit differently...

I think Kazdin (and Blase) are right in saying that plain old psychotherapy should not be the only option available to the public. It definitely has utility and should exist as a major service of our mental health field. However, there are other treatment modalities that await us thanks to technology (like it or not, it's not going away...). As a field, we need to capitalize on these new forms of communication and therapy. How should we do this? We need to translate EBTs to other treatment modalities.

I know there a bunch of you out there who are thinking, "I hate the idea of technology replacing face-to-face therapy. It will never be as good as the real thing." Well, you may be right. However, getting a less-effective therapy is probably better than getting none at all. By using new methods, we may be able to reach clients who previously could not participate in therapy for any number of reasons (unreliable transportation, rural locations, disability/poor physical health, etc.). This may help to lessen the burden highlighted by Kazdin.

And really, Skype kinda is face to face...right? 🙂

 

[BuckeyeAlum]

And really, Skype kinda is face to face...right? 🙂

Actually, there has been some work on this! Dr. Michael Harris, a peds psychologist in Oregon, presented at the Nat'l Conference in Ped Psych about his project delivering services via Skype. It seemed promising and kind of cool...

 

[roubs]

Actually, there has been some work on this! Dr. Michael Harris, a peds psychologist in Oregon, presented at the Nat'l Conference in Ped Psych about his project delivering services via Skype. It seemed promising and kind of cool...

An agoraphobes dream....but at what stage would we be enabling? 😛

 

[futurepsydoc]

As I reflected upon what's been said, I think considering Meehl's work on actuarial prediction is critical. Randomized controlled trials (RCTs) provide actuarial data that can guide treatment planning for practitioners in the field. However, as many point out, these data are not enough on their own. RCTs have inherent limitations that cannot be overlooked and it would be wise not to forget that.

Along these lines, advancing programs research to include effectiveness studies conducted in community settings seems warranted. While this occurring more often, there is not enough data being generated. By transporting empirically supported treatments (ESTs) to real world settings and disseminating these findings to directors in community mental health centers (CMHCs), provides the best route to get wide scale practitioner "buy in." There just is not enough of this research being conducted, at least being conducted in a rigorous fashion, to make such a concerted push in the right direction.

Nexy, I think we also need to reconsider how ESTs are actually disseminated, with respect to training and oversight. When any of us go to conferences, we all see practitioners attending workshops and gaining CE credits for learning different treatment approaches. I often wonder to myself how many of the attendees walk away thinking "I can do this now." Competently delivering an EST with no further training and supervision seems quite unrealistic to say the least. While I am sure that some well educated therapists can integrate interventions and perhaps deliver the treatment techniques they learn without further education, I would bet that the overwhelming majority cannot. This is clearly an empirical question that deserves investigation.

Finally, how many workshop attendees subsequently claim to offer that EST to patients. Develop quality control standards that prevent people from misidentifying the services they provide to consumers seems paramount to the integrity of field, especially since we cannot be sure if work as a primary means of dissemination (i.e., lack of data). If the development of standards and a method for overseeing them is unfeasible, which is likely given the financial and logistical requirements that would be required oversight, creating educational initiatives to aid the public in identifying what specific ESTs look like would likely be helpful and the least we could do.