The state of the art of modern psychiatry
While psychiatry has long been valued as the caretaker of highly prevalent mental disorders, psychiatrists have always been second-class citizens in the “house of medicine.” Psychiatry seems less scientifically grounded than other specialties, although psychiatrists routinely overestimate the validity of what occurs in medicine.1 Medicine has officially embraced evidence-based-medicine standards, and psychiatry has dutifully followed, even though the work typically does not lend itself to the drug/surgery/disease model. In psychiatry, there is a great gap between evidence-based therapy, which establishes the scientific knowledge base for efficacy of an intervention, and evidence-based practice, which applies that therapy to less highly selected patients with the same disorder.2
We have to accept what psychiatry is. We change our nosology every decade, we label many activities as therapy, we employ a plethora of nonmedical practitioners, and we rarely have any actionable scientifically verified therapy advances that can be readily translated into professional behavioral change in the community. During the 1990s, the “decade of the brain” failed to find a molecular basis for mental illnesses and failed to identify effective drugs to treat them, as the NIMH predicted in 1989. During the next decade, “brain imaging,” our rhetoric about etiology changed, but this costly technology has not led to advances in treatment.
There has been skepticism about psychotherapy-less psychiatry based on the Sequenced Treatment Alternative to Relieve Depression (STAR*D) study and the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) results, the continuing shambles of state mental health systems, the meteoric rise of attention deficit disorder treatments, Pharma’s failure to publish negative findings, and the financial conflicts of interest of some of our luminaries. One might think this would increase psychiatry’s interest in its psychotherapy processes. Despite demonstrations of effectiveness of various psychotherapies, our field continues to rest heavily on organic etiologies and medication interventions.
The public seems to know that our field deals with soft, subjective phenomena and that psychiatric intervention can be useful when people are overwhelmed. The educated public does not actually believe that emotional decompensations are simply caused by biochemical aberrations. They know that emotional life is changeable and that the past inevitably influences the present. They know that working through any life-changing event is an essential human process that occurs with or without psychotherapeutic assistance.
The public and our profession do not readily grasp how psychotherapy works, however. I offer an explanation: comprehending, respecting, and eventually reframing the individual meanings that people take from their life experiences are the key processes of psychotherapy.
Eight related core concepts about psychotherapy
1. The patient’s trust is required. Patients begin with varying degrees of trust. Trust is facilitated by the therapist’s interest in helping the patient, the capacity to ask intelligent questions, and knowledge about the patient’s diagnostic category.
2. The therapist must provide a respectful psychological intimacy. Patient trust is undermined by poor intimacy skills, such as lack of evident interest, criticism, and failure to comprehend the narrative.
3. It is vital for the psychiatrist to understand the patient’s predicament. Understanding what led to the predicament is a multistep process that is not complete after the first session. Over time, the history becomes multidimensional; both the therapist and the patient grasp the individuality and the complexity of the situation. The predicament must be understood in ordinary human terms rather than professional jargon.
4. The therapist is a person of great interest to the patient. The therapist should assume the patient will have many changing feelings about him or her and will be reticent to share most of them in therapy.
5. The attachment to the therapist should be perceived, acknowledged, and respected. It should be discussed, in particular, when a separation or termination is approaching. Therapists are not readily interchangeable.
6. The therapist should not assume that patients believe that they have revealed the whole story. Rather, the therapist should assume that the patient has told as much of the story as he was able to tell at this point in their relationship.
7. Symptoms can get better! There is often an initial improvement that results from the new good attachment to a therapist. Complete symptom disappearance usually requires a significant change in understanding, social circumstances, or maturation.
8. The therapist should behave in a warm, friendly manner, unafraid of revealing minor aspects of his personal life. Psychotherapy is a conversation between 2 human beings!