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The Headcase was Googling himself earlier this week (like you don't) when he came across Louis Menand's fine piece in the New Yorker, "Head Case." Because one good head case deserves another, I thought I'd spent my inaugural post discussing—or, if you're into puns, analyzing—the article in more detail. (And if you are into puns, call me. But not after 5, because I'm at pun class in the evenings.)
Menand takes as his guiding premise that many mental health care practitioners are "hostile to the current psychotherapeutic regime." He's building upon a very solid foundation here. In the past few months several news articles have been published, centering around a recent report contending that therapists fail to properly weigh the latest scientific research.
One of these was my own (cough, painstakingly balanced) piece for the LA Times. As psychologist Scott Lilienfeld of Emory told me: "Many people in the general public are not getting ideal care." Several others in the field expressed the same sentiment in similar words.
Still, the situation's not entirely as bleak as parts of Menand's piece might suggest. For instance, he points out the work of British psychologist Hans Eysenck, who has found "an inverse correlation between recovery and psychotherapy." The implication is that going to therapy can only worsen one's problems.
In fact, the extensive meta-analytic work of Bruce Wampold at Wisconsin concludes precisely the opposite. His book, The Great Psychotherapy Debate, argues that any reasonable form of therapy, when practiced by a professional, is significantly more effective than no therapy at all.
Menand also writes that depressed patients treated with psychotherapy do about the same as those on medication. While that's true, studies by Steven Hollon at Vanderbilt have shown that patients given cognitive-behavioral therapy, or C.B.T., may actually do better over time than those on medication, because the technique teaches them how to manage their problematic thoughts.
Staying on the topic of C.B.T., Menand summarizes the work of psychologist Gary Greenberg, whose new book, Manufacturing Depression, is apparently quite critical of the method. According to Menand, Greenberg calls C.B.T. not so much a science as "an ideology."
Psychologist Drew Westen made a similar comparison to me when we spoke for my (cough, painstakingly balanced) piece for the LA Times. Here's his quote, which didn't make the final copy: "I think this is well-meaning ideology masquerading as science," Westen said of C.B.T. proponents.
Menand doesn't spend too much time on C.B.T., but I found it a critical fault line when discussing the scientific nature of mental health care. C.B.T, a method of therapy that aims to correct misguided thoughts, has become a psychological darling, largely because it lends itself to randomized controlled trials—considered the scientific gold standard.
But many professionals, seemingly of the Greenberg camp, are skeptical of the method's so-called scientific basis. Here are a few criticisms of C.B.T. research I encountered:
- Some C.B.T. studies suffer drop-out rates up to 40 percent—leaving only those patients well-suited to the treatment as test subjects.
- Other studies have modified competing treatments in ways that undermined their effectiveness.
- The same highly skilled C.B.T. therapists often administer the treatment during study trials—hardly proof that the therapy will work in the hands of average clinicians.
- C.B.T. studies are prone to a phenomenon called "researcher allegiance," in which experiments led by researchers with ties to a particular treatment find this treatment most successful. When this bias is eliminated, the therapy often performs no better than other methods.
For more details, see Wampold et. al's review in the October issue of The Behavior Therapist.
If nothing else, such points undermine the case for a clear-cut, highly scientific approach to psychotherapy. The topic is a tricky one. No one's against using a therapy method that has performed well in scientific research studies, like C.B.T. Psychologists all agree research should guide practice. But a common complaint among therapists who practice traditional methods—psychodynamic therapy, for instance—is that psychology shouldn't have to follow a "medical model" of treatment.
Medicine heals a specific ailment with a specific treatment. Many psychologists believe the mind is too complex to treat with such a formulaic approach. In short, one person's depression can't necessarily be treated the same way as another's. Michael Lambert of BYU recently explained it to me well:
"When a clinician works in a clinic they get people, not disorders. In that sense it's nothing like medicine. If someone comes in with a broken arm, you can X-ray it, and to some degree you're not dealing with the person, you're dealing with the broken arm. With psychological disorders we're dealing with whole human beings that can't be easily parsed."
The most compelling part of Menand's piece, in my mind, was when he broadened the discussion beyond whether psychiatry can be a science to whether it always should.
Take his hypothetical scenario of the "grief pill," which someone might take to "jump the emotional queue" of bereavement or loss. Your decision to take such a pill is likely to be a moral one, not a medical one, and Menand concludes, quite eloquently, that literature and the arts tackle these largely philosophical problems better than science.
I was reminded of a scene from the movie "Contact." Jodie Foster's character, a scientist, has just arrived at an alien planet. She's the first Earthling to view the strange land, but despite all her observational training she struggles to describe what she sees. "They should have sent a poet," she says.
The only part of the piece I had a real problem with was the headline, "Head Case," and not because it wasn't a good headline, but because now, forever more, people will think I chose the name of this blog based on the title of that piece. And this will upset me not for any rational reason, but because that is the life of the Headcase. Someone pass me a grief pill.
