Is Psychotherapy Dead?

August 26, 2011 By scottdm 1 Comment

“AMERICANS PREFER DRUGS” screams the headline posted by the Reuters news service and attributed to Consumer Reports–one of the most respected periodical for the average American reader. “NEARLY 80 PERCENT TAKE A PILL FOR DEPRESSION,” the article continues. Read a little further and do some searching around on the internet and a different story emerges. Americans it turns out don’t necessarily prefer drugs but rather, “78 percent of those seeking treatment for depression or anxiety were prescribed antidepressants.”

With respected news agencies advertizing for the pharaceutical companies, is it any wonder why the practice of “talk therapy” is suffering? AA’s Executive Director for Professional Practice, Dr. Kaherine Nordal, in a recent editorial asked, “Where has all the psychotherapy gone?” The percentage of Americans who receive outpatinet mental health care has remained unchanged over the last several decades. Moreover, as Dr. Mark Hubble and I point out in the lead article in the May-June issue of the Psychotherapy Networker, “median incomes for psychologists, both applied and academic, have dropped between 17 and 33 percent at the same time that workloads have increaed, profssional autonomy has been subverted, and funding for public behavioral healthcare has all but disappeared.”

In a recent, highly publicized exchange on psychotherapy that appeared on Medscape: Psychiatry and Health, panel participants (all psychiatrists) repeated the same, old, tired argument about the field. To wit, “the research base is insufficient.” How such statements can be made with a straight face, much less by mental health professionals, on a public website, defies explanation. The truth is, the evidence-base for psychological treatments is as large and robust as any. What’s more, seeing a talk therapist does not require invasive surgery or a black box warning. Clearly, the issue is not research. It is about awareness.

The members and associates of the International Center for Clinical Excellence (ICCE) are working diligently to raise consciousness among the public and policy makers. Every day, 1000’s of professionals connect to, learn from, and share with colleagues around the world. The mission of the organization? To use community to improve the quality and outcome of behavioral health services. On the ICCE web-based community, clinicians share experiences and real world data regarding the effectiveness of talk therapy. For example, ICCE associate Dan Buccino shared outcomes from a 7 year project aimed at “promoting recovery and accountability.” Using the Outcome and Session Ratings Scales, Dan documented effectiveness levels that far exceeded national benchmarks for clinical practice. Why not email him for a copy of the report? Meanwhile, providers serving US Airforce personnel began using the same measures in early 2010 and have reported very similar findings. Finally, to date, more than a dozen randomized clinical trials, involving thousands of clients and numerous therapists, have established that using feedback to inform services increases effectiveness of individual practitioners three fold, cuts dropout rates by 50 percent, reduces the rate of deterioration by 33 percent, and speeds recovery by 66 percent, while simultaensouly improving client satisfaction and reducing the cost of care.

To paraphrase Mark Twain, the rumored death of psychotherapy has been greatly exaggerated. Now is not the time, however, to merely hope for a better future. Join the discussion taking place on ICCE right now. Membership is free and a strong, supportive community just a few clicks away.

Cha-cha-cha-changes on a Grand Scale: Think Tank Meets in Chicago

November 11, 2010 By scottdm Leave a Comment

David Mee-Lee, MD Bill Miller, Ph.D. Scott D. Miller, Ph.D.

Jim Prochaska, Ph.D. Don Kuhl, CEO

Whether in the United States or Europe, Asia or Australia, the field of behavioral health is undergoing a period of dramatic change–some would say, “transformation.” At least that’s the verdict of the group bought together by the CEO of The Change Companies, Don Kuhl, who brought together some of the leading figures in behavioral health for two days of discussion and brainstorming last week in Chicago.

Chief on the list of issues to be discussed was bringing “scale” to the provision of mental health and substance abuse services. Let’s face it, the current service provision model is broken: many people in need of help, do not get it. The care that is provided is often limited in scope and does not address the “whole person.” And finally, healthcare costs are soaring–particularly among those with longstanding, chronic problems requiring ongoing care.

In spite of 40 years of research support, behavioral health–that is, psychological interventions–are losing ground to other approaches to change. Consider the following data published by Katherine Nordal: “the percentage of Americans who receive outpatient mental health care…is very similar to the proportion of those receiving such treatment in 1998.”

Let’s see, that’s two decades of no growth! None. Zero. Zip. Nada.

Dr. Nordal continues, “Overall, there has been a decrease in the use of psychotherapy, a decrease in the use of psychotherapy in conjunction with medication and a big increase in the use of medication only.” The question that begs to be answered is why, especially when one considers that psychological intervention (whether face to face, on the phone, in a book or together with peers in a group) has a side effect profile that is the envy of the pharmaceutical industry: no weight gain, no sexual dysfunction, no sleep disturbance or dry mouth.

Many factors are, of course, responsible for the demise of behavioral health (By the way, have you noticed the size of the psychology section of your local bookstore. Its miniscule compared to what it was a decade ago, and the majority of the titles that are available praise neuroscience over human connection, and drugs over talk). Dr. Nordal cites the rise of managed care and gargantuan advertizing budgets of the pharmaceutical industry. Others cite cultural changes including a “short-term fix” mentality and the increasingly frenetic pace of life.

Whatever the cause, the problem is not the lack of effective psychological treatments. Rather, the issue is that more people need to be helped, more quickly and efficiently. “Helping people make behavioral change,” Dr. Jim Prochaska argued, “is at the center of healthcare reform.” Bringing scale to behavioral health, the group agreed, requires a radical revision of the current service delivery model.

In truth, many of the ideas discussed are already underway, including the move toward “integrated care” and ongoing measurement and use of feedback to improve the quality and outcome of treatment. Other ideas discussed included methods for putting the principles of behavior change directly into the hands of the consumer. But there’s more. Stay tuned. The group has big plans. Announcements will soon be made right here on the “Top Performance” blog.

Hope Transcends: Learning from our Clients

July 30, 2010 By scottdm Leave a Comment

“Hope Transcends” was the theme of the 39th Annual Summer Institute on Substance Abuse and Mental Health held in Newark, Delaware this last week. I had the honor of working with 60+ clinicians, agency managers, peer supports, and consumers of mental health services presenting a two-day, intensive training on “feedback-informed clinical work.” I met so many talented and dedicated people over the two days and even had a chance to reconnect with a number of folks I’d met at previous trainings– both at the Institute and elsewhere.

One person I knew but never had the privilege of meeting before was psychologist Ronald Bassman. A few years back, he’d written a chapter that was included in my book, The Heroic Client. His topic at the Summer Institute was similar to what he’d written for the book: harmful treatment. Research dating back decades documents that approximately 10% of people deteriorate while in psychotherapy. The same body of evidence shows that clinicians are not adept at identifying: (a) people who are likely to drop out of care; or (b) people who are deteriorating while in care.

Anyway, you can read about Ron on his website or pick up his gripping book A Fight to Be. Briefly, at age 22 Ron was committed to a psychiatric hospital. Over the next several years, he was diagnosed with paranoid schizophrenia and forcefully subjected to a series of humiliating, painful, degrading and ultimately unhelpful “treatments.” Eventually, he escaped his own and the systems’ madness and became a passionate advocate for improving mental health services. His message is simple: “we can and must do better.” And, he argues persuasively, the process begins with building better partnerships with consumers.

One way to build bridges with consumers is routinely seeking their feedback regarding the status of the therapeutic relationship and progress of any services offered. Indeed, the definition of “evidence-based practice” formally adopted by the American Psychological Association mandates that the clinician “monitor…progress…[and] If progress is not proceeding adequately…alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or the implementation of the goals of treatment)” (pp. 276-277, APA, 2006). Research reviewed in detail on this blog documents significant improvement in both retention and outcome when clinicians use the Outcome and Session Rating Scales to solicit feedback from consumers. Hope really does transcend. Thank you Ron and thank you clinicians and organizers at the Institute.

And now, just for fun. Check out these two new videos: