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Letters to the Editor: Response to “Reforming Mental Health Care”

Letters to the Editor: Response to “Reforming Mental Health Care”

[Editor’s note: In June 2014, we published “Reforming Mental Health Care: How Ending ‘Recovered Memory’ Treatments Brought Informed Consent to Psychotherapy” by R. Christopher Barden, PhD, JD. Dr Barden’s commentary elicited a number of lively responses. Here we present two letters, along with Dr Barden’s response to the first. This exchange marks the culmination in print of what began with Dr Richard Noll’s article, “Speak, Memory” and the “repressed recovered memory/multiple personality disorder” iatrogenic epidemic of the late 1980s and 1990s. We welcome your comments.]

Response to Dr Barden’s

“Reforming Mental Health Care”

It is quite understandable why psychologist-attorney Christopher Barden should want to take credit for psychiatric reform and for bestowing informed consent on psychotherapy patients; in this chaotic, complex, multifactorial world one must, I imagine, take credit when one can. It is also understandable that an attorney, even if also a psychologist, might present only one side of a case (that is what they do); for completeness, however, it may be instructive to identify some factors omitted in regard to the changes he noted.

The role of malpractice insurers is omitted. After a few of the huge runaway jury awards to which Dr Barden refers, insurers became quite prompt in settling such cases as, presumably, a form of damage control, especially since dozens, if not hundreds, of such cases, valid and bogus alike, were waiting in the wings. As research on the “other side” began to emerge—studies of how memory actually worked—and defense attorneys learned how to defend such cases successfully, there was a sharp drop in cases when prompt settlement could no longer be relied on. “Reform” did not happen so quickly merely because of successful litigation against practitioners. Indeed, many of us who testify in such cases have not even heard of such a case in years.

The role of the 1992 Lanning report is omitted. The FBI’s Kenneth Lanning became the actual Fox Mulder (X-Files protagonist) when he began to be assigned satanic ritual abuse cases that were claimed to have interstate manifestation, hence, an FBI issue. Approaching, from a pure law enforcement perspective, the claims about murdered persons, ritually sacrificed babies, and the like, he found no physical traces of such events in any instance. That was a tipping point that had no relationship to actual litigation.

The normal role of recall in psychotherapy—and medicine—is omitted (“When did you have your last vaccination?” “I don’t recall, let me think: oh, yes.”). Normal life is rife with memory recovery, as is psychotherapy. Since psychotherapeutic exploration often goes in unexpected directions with unexpected recollections and unexpected effects, it is especially problematic for patients to give informed consent to so many unknowns. When a patient reveals something previously long unrecalled, is that repression? Avoidance? Dissociation? Simple forgetting? It is not often possible to distinguish among these phenomena.

It may be useful to recall that evidence-based practice began in general medicine first, as the ability of the field increased so as to obtain data from an ever-widening pool of sources. While identifying such an evidence base is inherently more complex in psychotherapy, I would agree with Dr Barden that that is probably a good thing.

Thomas G. Gutheil, MD

Dr Gutheil is Professor of Psychiatry at Harvard Medical School, Boston, and a member of the Psychiatric Times editorial board. He has written extensively on forensic memory issues, often pleading for non-hysterical and non-extreme conceptualizations. In the one “memory” case for which Dr Gutheil testified for the defense against plaintiff’s attorney Dr Barden, the defense prevailed. Given the vicissitudes of juries, Dr Gutheil refrains from taking credit for that.

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