Wednesday, February 1, 2012

Call Me Crazy

I was startled to read this week in the New York Times that psychotherapy is a "now-largely-discredited discipline." The reference was casual and matter-of-fact, as if the description were well settled fact. It appeared in an op-ed piece under the byline of a Gary Greenberg, identified in the author footnote as a psychotherapist himself.

I was startled because my spouse has been training and studying hard for several years to join those "largely-discredited" ranks. I visited a psychotherapist myself for a couple of years on her strong recommendation, and we have talked a lot about her chosen field.

I'm aware that psychotherapy has struggled all its life to establish itself as a science-based treatment. I also know that all forms of "talk therapy" for mental disorders are compared unfavorably in some circles to treatment with psychoactive medications.

But I can't remember hearing or reading anything like a categorical statement that psychotherapy, which at least still has enough cultural currency to be lampooned frequently in New Yorker cartoons, is a dead letter among people who really know the score.

This seemed like quite a headline to me, but it wasn't even Greenberg's topic, just a swipe he took in passing. His real subject was the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, known as the DSM, a catalogue of the known ailments that plague the human mind and spirit.

Greenberg writes that despite its efforts to present psychic suffering with the medical "rhetoric" used to describe physical diseases that have objective, observable symptoms, the DSM disclaims in its introduction any "assumption that each category of mental disorder is a discrete entity with absolute boundaries dividing it from other mental disorders or no mental disorder."

That sounds very close to an admission that therapists diagnose and treat mental suffering without knowing for sure what they're talking about.

This is not the same as saying that psychotherapists, especially talented or experienced ones, can't help their patients understand and reduce their suffering. But it does seem to mean that practitioners and students don't have a satisfactory common language for the massive amount of information they exchange about their cases and therefore tend to evolve approaches to their work that are highly individual, improvisational and idiosyncratic.

Some of those approaches must certainly be effective with some patients. If I understand correctly, they all trace their origins to the work of Freud, an authentic and acknowledged ubergenius, and the practice of psychotherapy has survived more than a century. Reports abound of cases in which seemingly hopeless psychotics were restored to sanity and went on to raise families, succeed in business and write life-affirming memoirs.

In my limited exposure to such material, however, it does seem that many of those reports are about the same handful of cases. That hints at what I think is a problem for psychotherapy more serious than the uncertainty reflected in the DSM over defining what its practitioners are trying to do or determining how good they are at it. The treatment of an individual patient goes on for years, sometimes indefinitely. So the number of cases that can be handled by any given number of therapists is necessarily limited.

The number of patients is self-limiting too. A patient typically takes to the couch two or three times a week, maybe more. The sessions are expensive and insurance may cover only part of the cost. Patients who work must take time away from their jobs for the sessions plus travel to and from. The number of individuals who can put all this together can't be more than a fraction of those who need help, and my sense is that those relative few are either fairly well-to-do or eligible for subsidies.

And this thin sample of DSM disorders becomes truly rarefied when we're talking about those poster children who achieve miracle cures of their severe psychosis. For them the planets must line up in spectacular fashion. The patient must come from a family with resources to commit him or her to an important institution. The case must draw the attention of a gifted practitioner, who gradually becomes heavily invested in, maybe even obsessed with the case. Both therapist and patient must be compatible in ways that allow them to develop a deep bond. They must both have the stamina to find and stay the therapeutic course that finally gives them victory.

Discredited or not, psychotherapy doesn't sound like a solution for the psychic ills of the 99 percent in the  21st Century.

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