Existential Psychology Weblog by Louis Hoffman

The Anatomy of an Epidemic By Robert Whitaker Book Review

I find the overuse of the idea of "must-read" books to be quite annoying, yet Whitaker's The Anatomy of an Epidemic is a book that I would say is a must-read for mental health professionals and consumers, or anyone whose life is impacting by someone on psychotropic medications. Whitaker is not a mental health professional; he is a journalist. He began his interest in psychotropic medications when he was part of a group that wrote mostly "industry-friendly" articles about new medications and clinical trials. He did not begin with an agenda against big pharma or psychiatry, but his investigations gradually caused concern. The more he investigated the more he became concerned with psychotropic medications. It was the data and the stories of how these medications impacted the lives of so many that drew him to this topic. In other words, he came to it honestly. And he's done his research. He knows the topic well. In fact, I would say that he has likely developed a much better understanding of the outcome studies than the majority of the professionals prescribing these medications. 

Whitaker looks at the major groups of psychotropic medications - anti-depressants, anxiety meds, antipsychotics, bipolar meds, and meds for Attention-Deficit/Hyperactivity Disorder. Remarkably, an honest look at the literature seems to lead to the same conclusions on all of these meds and can be easily summarized:

1. Medications often are effective in the short-term.
2. The effectiveness of medications decrease over time and are associated with a greater likelihood of the problem become chronic.
3. Medications often lead to poorer long term outcomes along with the likelihood of increased psychological and physical problems (in fact, long-term use of many medications are associated with shorter lifespan). 

Given this, why would one take medication for psychological disorders?? The data seems to support the position that being heard more frequently: medications tend to only be effective and beneficial in the long-term for very severe impairment. Yet, medications seem to be prescribed with little more concern than recommending ibuprofen for a headache. In fact, Whitaker says that 1 in 8 people in the US are on a psychotropic medication. Furthermore, for the vast majority of these individuals, the research suggests these medications over time will decrease their quality of life, increase the length and severity of their impairment, and cost them (and the rest of us) a great deal of money. In particular, Whitaker demonstrates that use of these medications increases the likelihood that someone will be legitimately unable to work and in need of government financial support. 

One wonders how this occurs. Although Whitaker did not go as deep into the corruption as some other books on the topic, he does expose how pharmaceutical companies and psychiatry have colluded in one of the greatest marketing scams in history. On many occasions, this includes outright deception regarding the research results and hiding or covering up information on dangerous side effects, including the increased risk of suicide. This scandal has literally cost people their lives. Yet big pharma and psychiatry continue to be allowed to proceed with these gross deceptions. 

As Whitaker demonstrates, big pharma spends millions of dollars sponsoring events at the American Psychiatric Association's convention. They give large gifts to top academics to be spokespersons for them. They even give gifts to the local experts to promote various drugs. Indeed, it seems big pharma has bought the opinions of many "so-called experts" who are often even coached in what specifically to say at various conferences, conventions, and other speaking presentations. It is a disgrace to the academy that they have not intervened stronger in the corruption of many academics who receive large amounts of grant money and other gifts to promote medications using false and distorted interpretations of the research. Many of these distortions end up in the text books and other professional sources, including text books in mental health professions outside of psychiatry. The corruption is pervasive.

I have concerns, too, that the next market is the international one. Whitaker addresses this issue indirectly. He went well beyond the outcome literature and did comparisons between different regions and countries. The results are clear. The US and many other developed countries are fairing much more poorly than the developing countries. Countries that do not rely upon psychotropics have greater recovery rates. Similarly, the recovery rates in the US were much higher and chronicity of problems much lower before the reliance on psychotropics became the primary form of treatment. 

But before encouraging people to throw away their medications, there is another problem. It is not easy and, sometimes, not safe to get off these medications. Quickly discontinuing medications can cause "rebounds" and other side effects that can be quite dangerous. Getting off medications safely generally requires that this be done gradually under the care of a medical doctor. However, Whitaker points out that there is little research on how to do this. 

To resolve the problems created by the gross, broad-based misuse of psychotropic medications will take many, many years if we set an agenda to resolve this now. For many, there will be no recovery from the damage that has been done. This is a sad story, but a story that requires action to prevent further harm being done.

If you are skeptical about the importance of this issue, don't just read Whitaker's book. Go to the original sources and read on both sides of the issues. I am confident that most who engage in such an endeavor will come out realizing that Whitaker is exposing one of the great scandals in US history. 

Emory Cowan: Unrecognized Humanistic Hero

This blog was original written as I was reflecting upon my years as a core faculty at the Colorado School of Professional Psychology/University of the Rockies shortly after accepting a position at a different school. It was submitted to the Heroes of Humanity Project (http://www.heroesofhumanityproject.com), but felt it also needed to be shared with a broader audience. 

Emory Cowan is one of the least known great figures in the history of humanistic and existential psychology. A Vietnam veteran and former minister, he found his way to the existential writers largely through literature. Later in his professional career, Dr. Cowan became a Marriage and Family Therapist and then attended Saybrook University where he obtained his PhD studying with Rollo May and other greats of the humanistic-existential tradition. While studying at Saybrook, he was chair of the psychology program at Chapman University’s Colorado Springs campus. When Chapman decided to shut down this campus, Dr. Cowan met with the faculty and asked, “Are you ready to quit teaching? I’m not.” Emory and these faculty then decided to build the Colorado School of Professional Psychology (COSPP).

It was not easy to build a graduate school from scratch in the late 1990s, but Emory, Sue Cooper, and other founders of the school made the seemingly impossible happen. They attained regional accreditation with many accolades on the first attempt. COSPP, within years of accepting its first student, was beginning to receive national recognition, including two nominations for Charolette Buehler Award with the Society for Humanistic Psychology.

Although not a humanistic or existential school, the school’s humanistic values and existential influence were evident to anyone blessed to walk the halls of this school. Despite the great academic success of the school and the success of its early graduates, the financial pressures of a new school were too much, leading to COSPP being sold and becoming part of the University of the Rockies (UoR). Today, much has changed from the original spirit, culture, and values of the school, but COSPP was a shooting star and credit to the humanistic and existential movement for the few years it streaked across the sky. During that time, many influential humanistic scholars (Kirk Schneider, Ed Mendelowitz, Myrtle Heery, Tom Greening, and David Elkins, to name a few) taught and spoke at COSPP/UoR. Also, many students and future leaders in the humanistic/existential movement studied at COSPP/UoR.  Through these people, COSPP and the influence of this great man continue.

As a leader, Emory had a number of characteristics that were quite influential on the success of the school. First, Emory is very inspirational, especially through his abilities as a story teller. His accounts of how the school began became mythical (in the Rollo May understanding of myth) and served to sustain the school through many difficult periods. Second, Emory was very attuned to his faculty and their needs. He seemed to know when they needed encouragement and inspiration, and he was good at delivering at these times. Third, Emory was very human. He did not hide his flaws or mistakes, he shared them with us. He trusted people with his imperfections. Emory was aware, I believe, of the risks he took in sharing his imperfections with us, but he also seemed to know that in doing so we would come together stronger, each of us drawing upon our strengths and recognizing our limitations. His faculty knew that as long as they took responsibility for their limitations and mistakes, they would receive compassion, acceptance, and support. Part of what united us as the strong team we became was that we all knew our limitations, took responsibility for them, and asked for support and help. We learned from each other and took care of each other. And no one wanted to let Emory down, not because of the fear of consequence, but because they did not want to disappoint him. This bound us like a family – one that sometimes fought, often disagreed, but we stuck together.

Emory Cowan had an enormous impact upon me, in particular. I was a young faculty member with little formal training in existential psychology, my primary professional passion, when I met Emory. He was willing to take a chance on me and hired me as a faculty member at COSPP. It was there that I was provided with the environment where I was able establish myself and my professional identity. Now, having recently accepted a position at Saybrook University, one of the top humanistic and existential schools in the world, I know that the many accomplishments and successes of my career would not be if not for Emory Cowan. I know, too, that I am one of many touched by Emory. So many faculty and students, and now their students, were impacted by what Emory and the other founders of COSPP created. Today, there are many young scholars who I have no doubts will make great contributions to the future development of existential and humanistic psychology, that owe their foundation to Emory’s school. Although Emory Cowan’s name may never find its way into the History of Psychology textbooks, or even the histories of humanistic and existential psychology, his contributions surely make him one of the greats of this movement. His influence will live on, even if unrecognized.

A Depth Psychology Perspective on the Immigration Issue

In the beginning we create the enemy. Before the weapons comes the image. We thinkothers to death and then invent the battle-axe or the ballistic missiles with which to actually kill them. Propaganda precedes technology... Instead of being hypnotized by the enemy we need to begin looking at the eyes with which we see the enemy… We need to become conscious of…“the shadow.” The heroes and leaders toward peace in our time will be those men and women who have the courage to plunge into the darkness at the bottom of the personal and corporate psyche and face the enemy within. Depth psychology has presented us with the undeniable wisdom that the enemy is constructed from denied aspects of the self. ~ Sam Keen

Since the election of Barak Obama as president of the United States, some have proclaimed that we are living in a post-racial society. Despite these claims, an abundance of evidence suggests that much latent racism still exists and now is rising to the surface. One example is the increased intensity over immigration and illegal alien issues. As a preface and to decrease the amount of ire and possibility hate directed at me that this post could stimulate, I am not saying that all who are calling for stricter immigration rules or who support the new Arizona law are racist. Yet, I think racism, conscious or unconscious, is a primary motivator for many in their support of the Arizona law. I also believe there are other reasons for these positions, too. 

The quote from Sam Keen above I believe to be one of the most important quotes for our society today. Essentially, Keen is arguing that hate, strong criticalness of others, and the labeling of other groups as bad or evil has its roots in the person voicing these positions more than in the individual or group who is the recipient of these labels and attacks. Before we condemn, we should always look inward with a close examination of ourselves. Most often, I believe, we will find that we are part of the problem, too. 

A fairly obvious example of this is illustrated through many of the homosexuality scandals within the evangelical church. Numerous times in the past several years, some of the evangelical leaders voicing the strongest condemnation of homosexuality and same-sex marriage/partnerships have been caught engaging in homosexual behavior. Depth psychology would suggest that the passion, and I would say hate, directed toward gay and lesbian individuals was likely rooted in their own inability to accept aspects of themselves, or what Jung would call the shadow and May would call the daimonic. I am not saying they are gay or lesbian, or even bisexual. Maybe these are heterosexual individuals unable to accept some same-sex directed impulses. Of course, this is impossible to know, but yet a very plausible explanation. 

Returning to the immigration/illegal alien issue, other groups of people are often the recipient of negative projections that serve as the basis for prejudice against them. For instance, the target of the immigration issue is often the Latino/a population, who are mischaracterized as criminals, lazy and trying to take advantage of the system. Ironically, the vast majority hold conservative family values, come to the United States to work, and work hard, and are very willing to contribute to the system. The evidence against these stereotypes of the Latino/a population is overwhelming, yet they exist and seem to grow stronger over time. From the depth psychology perspective, it can be maintained that many of these beliefs again begin with the self. Fears are projected upon the Latina/o population and used to justify one's position. Even the frequently used argument that "they are here illegally" has little basis. Ignoring that most individuals going through the process established by our government to get citizenship or permanent residency status will need to spend a portion of their time being here illegally in order to be here legally, we can also be thankful that those of us who are here legally do not have to face the possibility of deportation every time we break the law (speeding) or bend it (taking liberties and bending the law with our tax deductions). These are blatant double standards and double binds.

Blaming immigrants for the problems in the United States is simply a way for us to avoid taking collective responsibility for the problems we have created in this country. Some argue that the immigrants are taking "our" jobs, yet we refuse to take collective responsibility for the economic crisis which has created the greatest job crisis in recent American history. We blame illegal aliens and immigrants for health care issues, yet we too long have failed to address the problems with our own health care system. We blame illegal aliens for crime yet we cannot address the extraordinarily high rates of violent crime in the United States or the overcrowded prison system. 

If we want to solve the economic and crime problems in the United States, we need to be willing to take an honest look at ourselves and recognize that we are the problem. Neither of our political parties are showing the leadership that is needed in this vein. They are too busy pointing fingers at each other and blaming instead of looking at themselves. We need both political parties to be responsible and accountable for the corruption that exists in politics today. It is impossible, if we are to be honest, to say that one party or the other has the moral high ground. Both political parties, at their best, have good intentions with different plans about how to address problems. The difference in the parties often is more about pragmatics than morals, but we turn it into moral issues. Yet, both parties are filled with corruption, power struggles, and resistance to taking responsibility for their own problems and failures. We need political and other leaders in this country to show the type of heroism that Keen talks about -- the courage to look within and take personal responsibility instead of projecting our failures and shortcomings on others and then condemning them. 

Reflections from China: Rethinking Education

One of the presentations I was looking forward to most during my time in China was a "dialogue session" with Xuefu Wang on Nietzsche and the important Chinese scholar, LuXun. I was presenting on Nietzsche and Xuefu on LuXun. The presentation was well attended and went very well. However, one question asked during the dialogue session particularly stands out to me. A high school student from China who attended the Existential Conference stated that in high school she had been exposed to some Nietzsche quotes by her teacher to help inspire students in their education. Her question was how high school students in the United States respond to Nietzsche. In my answer, I stated that I wish high school students in the United States knew who Nietzsche was! 

I am deeply worried about many of the trends in education today in the United States from high school to college to graduate education. Although acknowledging my bias as this is my profession, I strongly believe that education is one of the most critical aspects of the future of the United States. And I believe we are failing. Education is taken much more seriously in many other countries around the world. Our standards and ways of measuring success in education are quickly deteriorating. At its best, education in the United States focuses on learning content and measures attaining knowledge as success. However, content without the ability to think about it is useless, meaningless, and potentially dangerous. Yet, this seems to be our best. We have completely lost sight, it seems, of teaching individuals how to think. I know this is an overgenralization as there are some exceptions to this; however, it seems they are fewer and fewer. 

The greatest minds in the intellectual history of the United States, such as Albert Einstein and William James, understood this problem well. They knew the limits of science, which too often focuses on the accumulation of facts, and recognized the importance of creativity and intuition in furthering science, theory, and scholarship. But today we see the arts cut from education. Fewer teachers, it seems, know how to teach critical thinking. Students often seem to think that critical thinking is just being critical. 

One of the takeaway lessons for me from the First International Conference on Existential Psychology was that we in the United States have much that we can learn about education from the international community. As many of us from the United States were, I was so taken by these young students attending the conference. Not only did they choose to attend a high level intellectual conference, but they participated with great questions and contributions. Their excitement for learning and passion for the topic was quite inspiring. 

Opening Address at the First International Conference on Existential Psychology

First, allow me to acknowledge some people and organizations that made this conference possible. Xiaozhaung University, and particularly Dr. Tao, graciously provided the facilitates for the conference and many hours of organization, as well as financial support. The China Institute of Clinical Psychology provided organizational and financial support for the conference. The Zhi Mian Institute also provided financial and organizational support over the 2-years of planning for this conference.

Reflecting back, the seeds of this conference may have begun in the words uttered in a hotel lobby about two years ago: “maybe we aren’t thinking big enough.” Mark and I were sitting in a hotel lobby, energized by the reception existential psychology was receiving on the first of our journeys across China. Soon, Xuefu joined us in the planning and the energy quickly began to build. Two years later, here we are. And this is amazing! We have most of the top existential psychology scholars in the world with us here today, in Nanjing, China.

The title “existential psychology” may have emerged in the West, but it does not belong to the West. In the West, the first use of the word “existential” was applied to a particular group of ideas well after the death of Soren Kierkegaard, who is commonly identified as the originator of existential thought. In much the same way, existentialism has had a presence in Eastern thought well before the label ever came here.

And this was our purpose from day 1, to bring Western existential thought into dialogue with Eastern existential thought. The dialogues are about encounter, mutual exchange, and mutual learning. This is now my third trip to China focused on existential psychology. We have also hosted Mark, Xuefu, Charolette, and JiaJia in Colorado as they have brought indigenous Chinese existential ideas to the United States. Although there is much commonality in Eastern and Western approaches to existential psychology, there are also challenges and the need for cultural adaptation and critique. This, too, has been central in our intentions and what we have engaged in over the past three years. What we embark on today is a continuance of this process with an invitation for all of you to be participants as we learn, create, and grow together. From this encounter, I am certain we will grow individually and collectively, and that we will push existential psychology to grow along with us.

Today, I am proud to be here beginning this awe-filled journey with so many friends. I am joined by students who have lived the Nietzsche lines that “a student repays his [or her] teacher poorly if remaining nothing but a pupil.” You more than students; you have undertaken this journey with me and you are my friends, my colleagues, and my teachers. I am honored, this trip, to be joined by many colleagues from the United States who are the foremost leaders in existential psychology as well as individuals who embody the existential spirit and are among the top psychology scholars in the United States. I am proud to be joined by many leading scholars from the East who I have been privileged to get to know and others who I hope to begin getting to know over the next three days. You have humbly taught me much. Last, it is one of the great honors of my life to be standing here with my two good friends, Mark Yang and Xuefu Wang, who have worked tirelessly promoting and developing existential psychology in China. Mark, having studied and contributed to existential psychology in the United States and China, symbolizes this east-west dialogue. Xuefu is a true scholar of Chinese culture and existential psychology. Indeed, I believe Xuefu is rightly identified as the leading scholar of indigenous Chinese existential psychology. We are all part of this very prestigious group that is making history in existential psychology. Now let us join together to begin the journey. 

Psychotherapy Outcome Debate: Rhetoric and Marketing One’s Position

Science ought to inform one’s positions and the perspective one is advocating for, not be used as a political weapon. However, it seems today that science has too often been co-opted for self-serving purposes. This, I believe, is too often the case in the outcome therapy debates in psychotherapy.

For many years I have maintained that this debate of “who’s best” is quite adolescent and not very appropriate for professional dialog. In particular, my concern is that we have been too focused on the self-serving debate of whose approach is best and not focused enough on how to work within the various approaches to make them more effective in meeting the diverse needs of our clients. This debate is a distraction that does not serve clients and does not serve the professional community.

As I have discussed in this blog series, there is plenty sufficient evidence to, at the least, cause one to seriously question the superiority of any approach to therapy. So why does the debate continue? I believe it is more about power, control, and job security than science or protecting the profession, as is often claimed. Certainly, there are some approaches to therapy, such as rebirthing and conversion therapy, that have caused harm and warrant strong suspicion. However, one is very hard-pressed to find any evidence that the majority of psychotherapy approaches cause harm. In reality, some therapists from all the different theoretical orientations cause harm. This merely suggests that any approach to therapy can be misused and cause harm.

Obviously, a personal benefit exists in being able to say that one’s approach to therapy is superior to others. To name a few, it provides better access to managed care/insurance panels, creates job security, creates openings for academic positions, and increases access to research grant money. These are strong incentives to engage in political rhetoric about the superiority of one’s approach and to wage science in an effort to bolster this position. It provides incentive to develop research to support one’s view of the superiority of their approach. Outcome research is often done by individuals with a vested interest in a particular outcome. As an example, much of the research comparing the effectiveness of medication versus psychotherapy has been supported by pharmaceutical companies. The researcher’s paycheck is part of an investment, quite literally. In other instances, individuals that practice a particular therapy orientation often are the same individuals that compare its effectiveness to other approaches. It is not surprising that the approach they advocate for often is shown to be superior.

Any time we explore a position on outcome literature, we need to take a look at the motivations, implicit and explicit. We need to consider where the funding is coming from. We need to consider other pressures that may influence how the research study is designed and how the outcomes are interpreted. This is one of the many reasons why I have more respect for the research done by individuals such as Bruce Wampold, who did not have an invested interest in how the research came out. And his research has suggested that the various therapy modalities tend to be equally effective. In the large majority of outcome research comparing the effectiveness of different modalities, there is a very clear vested interested in finding the superiority of one approach.

Even with reviews such as this blog series, one should consider the motivations and contexts. As is evident, I am invested in demonstrating that existential psychology is a valid approach to psychotherapy that produces good outcomes. Little doubt, this impacts my motivation for writing this and how I write this blog series. But I am also invested in recognizing the value of different approaches to psychotherapy. I consider myself a scientist, a philosopher, and a critical thinker. All of these identities impact the way I view the world and professional issues. I pride myself in being passionate, yet not trying to privilege my position or values over others. It is my hope that this intent, to not privilege my views, helps me take a more balanced approach to reviewing this topic. In the end, it is necessary for these ideas, too, to be critiqued.

When you look at many of the narrowly-defined scientific paradigms, they are not open to such scrutiny. They will accept critiques coming from new science, but they discount external critiques of the basis of how they understand science. I am sure that what I write in this blog series means little to them. It is simply another unscientific threat to science. I think this is unfortunate, especially in a country that produced great scientists of the likes of William James and Albert Einstein; individuals who truly engaged in a broad based approach to scholarship and science, who try to extend the limits of science, and who recognized the limitations of their own work. 

Psychotherapy Outcome Debate: Philosophical Issues

All science is based upon a philosophy, whether it is implicit or explicit. The same is true for the science of psychology. However, through much of the 1980s and 1990s, and even into the 21^st century, there was a movement afoot that seemed to suggest psychological science had risen above philosophy to a pure science. Many seemed to believe that we no longer needed to talk about how we know what we know (i.e., epistemology and the philosophy of science). The philosophical basis of science did not go away, it was just naively ignored and pushed to the implicit levels. The devaluing of philosophy and critical thought made it easier for narrowly defined scientific approaches to begin to gain dominance, but it did so at a great cost. Increasingly, it seemed, therapists were trained to be technicians who did not need to be able to think about therapy, just apply their techniques. There were even rumors that computer programs were being written with the belief that their ‘scripts’ could provide therapy as effectively as a highly skilled therapist.

Although it has been a while since I’ve heard rumors of the therapy computer programs, many therapists still aspire to be more like computers than genuine, healing human beings. I have many concerns about this, but will limit this post to a few. The first philosophical blunder is the belief that all means lead to the same end, so the shortest means is best. Stated differently, if all therapies tend to be equally effective in treating symptoms and diagnoses, then shouldn’t we focus on the quickest route? My answer is a resounding “No!”

The most evident example is the therapy versus medication debate. It is evident that there are differences between relying upon a psychoactive chemical to produce a mood change as compared to using an interpersonal relationship. These medications produce side effects that often are undesired. And, quite frankly, these medications have not been around long enough for us to have any conclusive evidence about their long term impact. When we apply this to psychotherapy, we can see that the various therapy approaches also have different “side effects,” or what David Elkins (personal communication) liked to refer to as “extra-therapeutic benefits.” These “side effects” or “benefits” of therapy are often positive, as compared to the negative effects of medication. As an example, cognitive-behavior and rational-emotive therapies are likely to have the extra-therapeutic benefit of promoting a rational thought process. Psychodynamic therapy is likely to have the extra-therapeutic benefit of increased insight into one’s history and relationship patterns. Existential and humanistic therapies will provide the extra-therapeutic benefit of increased insight into intrapersonal and interpersonal issues, as well as the various existential givens. I would maintain that existential and humanistic therapies would also promote deeper, healthier relationships, recognition of one’s life meaning, and an improved ability to constructively utilize a wide range of one’s emotions in personal growth. So, yes, most therapies may help alleviate symptoms equally effectively, but therapies are not all the same. We need to help clients consider what extra-therapeutic benefits they are seeking when considering the fit to a particular approach to therapy.

Let me briefly discuss one more philosophical issue: The belief that outcomes measures measure what they purport to measure. I discussed this some from a research perspective in the previous blog, but allow me to look further into the demand characteristics this time. Demand characteristics refer the idea that clients often will consciously or unconsciously attempt to understand what the researcher is looking for and then modify their behavior to conform to this. In psychotherapy research, it is pretty evident what is being investigated, but when there is a high level of congruence between the therapy measure and the approach to therapy, there is an increased susceptibility to demand characteristic. For example, when the Beck Depression Inventory (BDI) is used to measure therapy outcomes, it is pretty evident that this measure is focusing on the cognitive appraisals similar to what is being discussed in CBT. Other approaches, which may focus on encouraging a client to experience and then work though feelings, may encourage a different type of response (i.e., demand characteristic) on the BDI. Therefore, the measure is inherently biased toward CBT in this example.

Similarly, it could be argued that in CBT you are ‘teaching to the test.’ The primary focus in CBT is encouraging clients to change their thoughts with the belief this will change their emotions. If, then, the client is given a test on how well they are doing on these lessons, they may feel pressure from the therapist and internally to answer the questions in a way suggesting that they are learning what they are supposed to learn. In other words, they want to pass the test. This leads to the inherent possibility that clients will feel pressured toward self-deception instead of healing. I don’t mean these criticisms to invalidate CBT. I truly believe CBT is a valid, effective approach and believe this approach to therapy is the best fit for many clients based upon what they want from therapy. However, there are serious limitations to the outcome research often interpreted to suggest this approach is superior to other approaches to therapy.

In this blog, I only covered a few of the many serious limitations to a narrowly defined scientific approach to outcome research. Many more exist, but that would be the subject of a journal article or book, not a blog. Science without philosophy and critical thought is nothing more than rhetoric. We must understand the context of science, critically think about its findings, and understand the implicit biases in the approach to science if it is going to have any validity at all. Promoting blind science is no better than promoting blind faith; both are dangerous. 

Psychotherapy Research

Research on psychotherapy has taken many different directions over time, as discussed in my previous blog. Although a bit of an oversimplification, most outcome research tends to fall into one of two camps: 1) Empirically Supported Treatments and 2) Common or Contextual Factors Research. I will discuss each approach briefly analyzing the strengths and weaknesses of each. 

The focus of the Empirically Supported Treatment, at its heart, is to evaluate the effectives of a narrowly defined treatment approach. This is a noble effort. First, it provides information that gives the appearance of being rather clear and straightforward. Oftentimes, it facilitates the development and improvement of very structured therapy approaches that are fairly easy to follow. These approaches often are very appealing to insurance companies and managed care, allowing psychotherapy to have an inroad in to reimbursement options. 

However, this approach has too often attempted to become something more than it is, leading to several major problems. First, this approach has often gone down the path of comparing psychotherapies trying to 'prove' which approach is best. I have concerns about the motivations, utility, and philosophy of science of such attempts. Researchers often are rooted in one of the therapy approaches reflecting a particular philosophical system and design or utilize measures that are best suited for the particular approach to therapy. Stated more clearly, different outcome measures are better suited to measure different types of therapy. 

Let me provide a brief example. The Beck Anxiety Inventory (BAI) and the State-Trait Anxiety Inventory (STAI) are two common measures of anxiety, both reflecting different theories. The BAI focuses mostly on one's perceptions of anxiety (i.e., cognitions) and little on visceral symptoms (i.e., bodily symptoms). The STAI, conversely, focuses more on visceral or bodily symptoms. The BAI is typically used in evaluating the effectiveness of cognitive behavioral therapy (CBT), which makes logical sense in that in focusing on defining anxiety primarily by cognitions and perceptions. In CBT therapy, the therapist is working on helping the individual change cognitions and the BAI evaluates this. However, it assumes that cognitions and experience will be equivalent. This creates a few problems, such as demand characteristics, in which clients are encouraged to change their cognitions in a direction with the assumption that the accompanying emotion will follow. This is not always the case. Sometimes cognitions change, the BAI results change, and the experience does not. Other forms of therapy focus on targeting the visceral symptoms more directly, without being as concerned about the cognitions. This therapy could potentially be effective by the STAI and not the BAI. In other words, as soon as an outcome measure is introduced, so is a bias. 

Studies rooted in the Empirically Supported Therapies tradition tend to emphasize a fairly controlled research setting, which also introduces limitations. This approach is biased to more structured, solution-focused therapies and against the more fluid, relational depth psychotherapy approaches. However, even many solution-focused practitioners point out that the therapy conducted in these research studies often do not reflect therapy in the real world. It takes the relationship out of even the solution focused approaches. In particular, therapists often follow structured guidelines on how to intervene at a particular point in treatment and are discouraged from following clinical judgment and experience about when adaptations are necessary. 

The controlled aspect introduces another serious limitation. First, careful screening is conducted to assure the client meets the right criteria, which often means not including individuals with complex issues or dual diagnoses. This is a large portion of the population entering therapy! Studies also have to carefully consider which factors to include and control for as potential confounding variables, but cannot include too many factors as if enough factors are controlled for, the natural co-variance across influences would reduce any unique variance to non-significant levels. Variables such as the therapeutic alliance and client motivation, which meta-analytic studies suggest are very important, are generally not included. Thus, it is very difficult to say that it is the techniques, or what is intended to be measured, that is actually being measured. These serious limitations do not suggest we should throw away this type of outcome research, but rather we need to acknowledge there are many very significant limitations. We are only getting a small bit of truth at most in these studies. 

Common Factors Research emerged from broad, critical reviews of the research, meta-analyses of previous research, and new research across therapy approaches into other factors not accounted for in the empirically supported treatment paradigm, such as empathy and therapist factors. This includes many very rigorous research approaches that are better able to take into consideration factors, such as the therapy relationship, that the empirically supported treatment paradigm frequently ignores.

The results are consistent: The two most important factors predicting therapy success are 1) client factors and 2) the therapy relationship. Both of these factors are generally not given much consideration in the empirically supported treatment paradigm! These two factors alone account for most of the therapeutic change (see Humanistic Psychology: A Clinical Manifesto, 2009, by David N. Elkins, for an in depth review of this research). 

One of the most fascinating aspects of this research is regarding technique. In the various meta-analytic studies, the role of technique generally accounts for somewhere between 1.5% to 7% of the variance in therapy outcome. However, even with this, it is not a particular technique that accounts for the variance, but that techniques are used. This means that the efficacy of any particular technique would be much less than the 1.5 to 7%! What accounts for a greater portion of the therapy effectives could be labeled as the therapist and client belief in the therapy modality used. In other words, the therapist believing in what they are doing and being able to inspire hope in their clients is more important than the type of therapy the therapist employs! The moral of this story is to make sure you believe in what you are doing and choose a therapy orientation that fits. From this perspective, we should be less interested in coercing young therapists into a particular orientation, but more interested in helping them find the orientation that is the best fit for them. 

In conclusion, outcome research is complex. Anytime you heard that it is clear and simple, be suspicious. I believe that the most rigorous and complex research on therapy outcome strongly suggests that what we should be most concerned about is 1) client factors, 2) the therapy relationship, and 3) helping therapists find a therapy modality that they believe in. This last factor, although not in the two factors identified by meta-analyses as most predictive of successful therapy outcomes, I think is related. When therapists are doing something they believe in and are passionate about, and are concerned with helping clients find the best fit (as opposed to trying to convince every client they are the best therapy for them), they will build better therapy relationships with their clients. 

What Consumers and Clinicians Should Know About the New Mental Health Controversy - Introduction

I'm guessing most people do not even know there is a new mental health controversy, yet for mental health consumers, this controversy could greatly change how psychotherapy is offered. A recent article in Newsweek even highlighted this. For many years, there has been a debate raging in the field of psychology about which approach to therapy is "the best." In response, many of us have argued that this debate makes little sense. There is good evidence from multiple sources that, with a few exceptions, all approaches to psychotherapy are effective; however, we didn't have the research to support it. Meanwhile, a number of individuals proclaimed that certain approaches to therapy were superior. Gradually, these individuals not only declared their approach was the best, but they tried to prevent others from practicing other approaches to psychotherapy. 

Then came Bruce Wampold and a host of other researchers who did very large studies examining all the research to date on psychotherapy effectiveness. The results were clear: all psychotherapies are equally effective in treating symptoms. Increasingly, the field of mental health, convinced by this research, began to change and become more accepting of the diverse approaches to psychotherapy that existed. 

Recently, the Association for Psychological Science (APS) came out with rhetoric a-blazin' declaring that psychology has lost its scientific roots and declaring a plan to restore the scientific basis of psychology and psychotherapy. In reality, even this statement is built upon a distorted view of history. So why should consumers care about this issue?? Here are just a few reasons:

1. If the APS approach becomes dominant, it would greatly restrict the consumer's choice in deciding which type of therapy they would prefer.
2. This approach suggests that science, not individual choice, should determine what outcomes are appropriate for therapy. 
3. It is possible that this would restrict the reasons why an individual could go to psychotherapy, making it difficult to seek treatment without having a diagnosed mental illness, which often comes with stigmatization. 
4. This could lead to greater restrictions on the number of therapy sessions consumers are allowed to seek. Recently, there has been a move toward more inclusive coverage of mental health; this could potentially be reversed leading to more restrictive coverage. 

The APS seems insistent not just on promoting a scientific approach to psychology, but declaring all other approaches to inferior, invalid, and possibly harmful to the general public. This is scientism that appears to be invoking a zealousness similar to religious extremists, instead of the temperament of science. In my view, it is the diversity of approaches to psychology that is our strength. It allows for us to honor various value systems, ways of knowing, and therapeutic approaches. To say there is only one appropriate route to mental health or only one appropriate understanding of mental health sounds like religious fundamentalism or extreme egoism, not science. 

My response will focus on several topics:

• Why diversity is psychology's strength
• A brief history of the examination of psychotherapy effectiveness
• A Response to APS Part 1: Research
• A Response to APS Part 2: Philosophical Issues
  
• A Response to APS Part 3: Rhetoric and the Marketing of One's Position
  
• A Response to APS Part 4: Diversity Implications
  

In closing, I must say that I am sad to be writing these blogs. For many years, I felt that the debate over "who's best" was a childish debate. Our time would be better spent focusing on working with individuals who are suffering or seeking growth, improving our current methods, and promoting conversations between different approaches so we could learn from each other. Instead, the building of egos appeared more important than the true mission of psychology and psychotherapy. This should be an embarrassment for the field. Yet, just when it appeared we were moving on, the childish ways return. Maybe some day psychologists will move beyond egotistical politics to focus on understanding the human condition and providing the service of compassion. 

Veterans Day Tribute: Understanding PTSD

This may seem like an odd way of paying tribute to our Veterans, to focus on PTSD; however, I hope that it quickly becomes evident how this is very much in the spirit of supporting our troops. 

Since the onset of the war on terror and the war in Iraq, I have been very disappointed what the idea of "supporting our troops" has sometimes meant. Soldiers were on extended tours, often under-equipped, frequently mistreated for acknowledging psychological distress, and not given adequate care when they were injured and no longer able to serve. Many soldiers were publically humiliated for acknowledging psychological problems resultant from their military service. Yet, for many, "supporting our troops" meant supporting the war, but not necessarily taking care of our troops. 

Posttraumatic stress disorder, or PTSD, plays a big role in the politics of supporting our troops. I am not a bit fan of diagnosis and believe mental health professionals should diagnose cautiously and only when necessary. Yet, I am very disturbed when mental health professionals in the military or professionals working with our troops and veterans in other contexts say they don't believe PTSD exists. These individuals are generally not engaging in the philosophical discussion on the nature of mental illness and diagnosis; they are discounting the suffering of the soldiers and, in essence, saying their problems is because they are weak. . 

Although PTSD is called a mental illness, the symptoms can really be understood as largely adaptive behaviors that have become maladaptive patterns once not longer in a combat setting. The symptoms of PTSD include 1) hypervigalence, or being excessively aware of one's surroundings, 2) exaggerated startled response, 3) poor trauma recall, 4) Intrusive thoughts and nightmares, and 5) avoidance of thoughts, feelings, people, and places that remind them of their traumatic experience. In this partial list, it is already evident that each of these symptoms can have a positive role in responding to a traumatic situation. Hypervigalence helped the soldiers survive when in combat through being attuned to the potential dangers in their surroundings. The exaggerated startle response is partially a learned behavior, but also serves to quickly activate the flight/fight response. Poor trauma recall helps individuals block out the bad experiences until they are in a place they can face them. The avoidance of reminders of past trauma serve a similar purpose. The nightmares and intrusive thoughts illustrate the other part of the paradox. Although it may be healthy to block out bad memories at times, it is also necessary to process them. Dreams often serve to help individuals process and consolidate memories; however, for many individuals with PTSD there is too much to process and the dreams become overwhelming. Some research suggests we dream more on vacations or other times when our unconscious recognizes we are in a safe and restful place that can allow the processing of the difficult information that had been contained in the unconscious. Therefore, dreams and intrusive thoughts can be a reminder that this information needs processing.

PTSD, then, can be seen as a natural response to a difficult situation; however, most people do not understand what PTSD is like or the purpose it serves. This includes many spouses who are bewildered when their spouse comes home a different person than when they left, or when they returned home without many problems after 1 or 2 tours, but after 3 tours begin showing PTSD symptoms. 

This is why we need to be very concerned when people use this diagnosis carelessly. Following the recent shootings at Fort Hood, many mental health professionals recklessly and irresponsibly began talking about the "likelihood" that Hasan, the shooter, suffered from PTSD without even gaining information about Hasan's background or direct exposure to combat or other trauma. Even though it is now understood that PTSD would not likely fit Hasan, the damage has been done. 

The message that this irresponsible use of invoking PTSD sends is that individuals with PTSD are dangerous. For individuals who know little about PTSD, this may cause them to fear people who have this diagnosis or, quite possibly, to fear people returning from the war in general. These veterans are often desparately in need of our love, support, and compassion, but irresponsible use of the label PTSD may instead cause people to fear and keep their distance from veterans. 

In truth, irritability and anger issues are connected with PTSD. However, it is a very small percentage of people with PTSD that become violent and, when it occurs, it is very rare for it to be something like what occurred at Fort Hood. When individuals with PTSD are violent, it is often connected with other issues - their own or systemic - that contribute to the violence. For example, many do not have adequate access to treatment. Many vets have repeatedly requested more frequent therapy sessions and other service options, but are told the services are not available because of the high demand. Others are concerned that if they seek treatment, this could jeopardize a promotion, their status in the military and ability to continue to serve, or are afraid they may be mistreated by peers or supervisors for admitting problems. Although many have sought treatment without these negative consequences, there are enough examples of this occurring to justify the concern. 

What, then, does it mean to "support our troops." I believe supporting our troops mean showing them the respect and compassion they deserve for choosing a career based in serving and protecting US citizens. One can do this with or without supporting war efforts, with or without agreeing with the decisions made by our politicians about when to use military action. Our soldiers are not given the choice about which wars or in which combat situations they will participate. They enlist to protect our country, period. They must put their trust in our leaders to make good decisions about when to put their lives at risk. It is dangerous to collapse the idea of supporting our troops into the notion of supporting our political leader's decisions to go to war. From the vets I have worked with, some believed in the war efforts and some did not. Many reported they felt they had to support and believe in the war efforts when there was the possibility of being deployed; it was dangerous to be considering if it was a just war when they had to make life or death decisions involving when to pull a trigger. Yet, when the possibility of deployment was over, they began having to reconcile their beliefs and values with what occurred. I cannot imagine how difficult this must be for our troops. 

To conclude, nothing I could say would adequately express the gratitude I have to our troops. I am angry about some decisions that have been made to put their lives at risk when I didn't feel it was warranted, but I also am glad I was not the person who had to make these incredibly tough decisions about when to use our military. It is not an easy decision either way. I am also angry that our troops have not always been given the resources they needed when deployed and that they sometimes have been mistreated and neglected when they returned home. But supporting our troops is not about politicians or politics, it is about supporting the people who have enlisted in armed services because they are committed to their country and protecting all of us. This, I hope, everyone can agree upon.