But cognitive therapy does not fit the bill for the case of my college student. The problem to be solved is not clear and didn't seem to be in the here-and-now when she overdosed; there-and-then elements are likely to be relevant. It may take more than a brief effort to bring them to light, and I won't have the option of rejecting the Unconscious in that effort.
Reject the Unconscious! One might as well try to reject the air. Any psychiatric training worthy of the name will have to include a psychodynamic psychotherapy modality that "takes a long time to master." Some difficult reading may indeed be necessary! Psychiatry is, after all, a medical specialty. You don't see nephrologists deciding to "reject the glomerulus" as a shortcut to learning dialysis.
Call the Unconscious a construct if you will, but this will not help my patient. Like many other deeper realities in science-the continental drift, the evolution of species, the gravitational bending of space--the Unconscious must be inferred from more tangible and observable realities. It can't be seen like a glomerulus can (though brain structures important to its functioning certainly can--see below), and there may be better ways to think about it (e.g., multiple "coconscious modules" of mental functioning). But one thing is certain: my patient and I are stuck with the Unconscious whether it is rejected or not.
This kind of situation leads many an experienced clinician to echo Beiber (2003) in a recent review examining the evidence-based mandate for cognitive therapy:
I remain ambivalent. On the one hand I see results with some patients, but I also see failures with other patients, who react to this form of therapy as a naive view of the world. The idea that depression is based on cognitive interpretation and that this interpretation can be modified can be experienced by the patient as a large empathic failure.
Evidence-based medicine is both a set of statistical techniques and a fashionable movement in internal medicine. An explanation of why its methodology misses some of the most important aspects of psychiatric treatment is beyond my scope here, and I refer the reader to the paper by Williams and Garner (2002). For the purposes of this essay, I am willing to grant that cognitive therapy is helpful for many patients, much of the time. However, the questions of why it works and what it really is need to be answered before we let it replace psychodynamics as psychiatry's workaday theory of mind and therapeutic interaction.
What may be good for a subgroup of patients may nonetheless be bad for psychiatry if we elevate it to the dominant worldview of our profession and our major training modality for psychotherapy. Here are some of the reasons why, which I will discuss: