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Cognitive Therapy's Faulty Schema

Cognitive Therapy's Faulty Schema

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In the land of psychotherapy for depression, crowned by the research literature, cognitive therapy has long reigned supreme. Is the emperor as fully clothed as everyone seems to think?

Just back from college, a young woman is describing her near-fatal overdose. She is one of those people who ostensibly has everything going for her, yet has been dogged by melancholy for years. Excellent psychiatric treatment at school, including medication, had her feeling "almost well" and succeeding academically by semester's end, but one night, with nothing obvious bothering her, she slowly downed a month's supply of three medications. She doesn't remember any clear intent or intense feeling of despair--just a sort of "absent-minded daze."

Having been found and having survived her coma on an intensive care unit ventilator, she again feels back to normal and is as puzzled as I am over what happened (although I can label it a dissociative episode).

This kind of story is as common as it is baffling. To academics who might object that there could be a comorbidity lurking here, I reply that the real world has no exclusion criteria.

If our trainees are ever in a position to treat a case like this in a role more substantial than medication consultant, they will need a workable theory of mind to approach it. At a minimum, any such theory will have to give them some way to think about unconscious motivation. Instead, training programs are feeding our residents good old American common sense and glorifying it into a theory of mind that is completely inadequate to such everyday tragedies and mysteries. Why? Let's listen to Schuyler (2003), guest editor of the May issue of Primary Psychiatry:

Managed care has stressed cost-effectiveness and a bottom-line related bias for brief therapy. Cognitive therapy fit the bill. Psychotherapy researchers have emphasized 'manualized therapies' to promote standardization to facilitate study. Cognitive therapy fit the bill. Psychodynamics takes a long time to master, with often ponderous readings and substantial irrelevance for the trainee. Trading upon its here-and-now focus, its harnessing of the patient's problem-solving skills, its rejection of the unconscious and transference, the cognitive model can be taught to trainees quickly. Cognitive therapy fits the bill.

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