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. 

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. 

Why Diversity is Therapy's Strength: What the Outcome Debate

Many believe that it would make sense to have a unified psychology with all psychologists agreeing on pivotal issues. The APS position advocates this singular position should be determined by a narrow view of science. A number of limitations to this perspective demonstrate why this 'logic' does not fit psychology. 

First, psychology is not a pure science in the narrow sense of the term. Instead, psychology is based on a broader view of science similar to what was purported by Albert Einstein and William James. The non-scientists often idealize the degree of truth that can be attained in science; however, the true nature of science is progressive, recognizing the the belief in the attainment of truth is the greatest threat to true science. This was what Einstein and James believed. 

"The most beautiful thing we can experience is the mysterious. It is the source of all true art and all true science. He to whom this emotion is a stranger, who can no longer pause to wonder and stand in rapt awe, is as good as dead: his eyes are closed." ~ Albert Einstein

Einstein believed that science, much like religion, was best rooted in an appreciation of mystery and the limits of one's way of knowing. Science which no longer questions itself is a dangerous science. Much of psychology embraces this broad view of science. The only way for all of psychology to agree is to denounce mystery and have all psychologists embrace the same worldview. If this were to occur, psychology could no longer grow or develop; it would, because it could do no other, embrace the status quo and provide a solid barrier to progressive science. To tie this back to the outcome research controversy this series of blogs is about, what some associated with APS are promoting as science is, quite frankly, bad science. This is not because of poor research methodology and, for most of them, not due to bad intentions. Rather, this is due to a severely limited philosophy of science and a deficient understanding of the role of science. This narrow view of science serves social control, not progress. 

Second, these representatives of APS do not understand that psychology's diversity is its strength. They seem to hold this idealized vision of science, and psychology, as something that is purely objective and value free. Nothing could be further from the truth! Psychology is extraordinarily value laden. In arguing for a using a narrow view of science and extremely restricted epistemology for outcome research, they are implicitly stating that this value system is superior and all must fall in line with it. If not, there is something wrong. As Nietzsche would say,

"No shepherd and one herd! Everybody wants the same, everybody is the same: whoever feels different goes voluntarily to the madhouse." ~ Nietzsche

Psychotherapy clients have a broad, divergent set of values. For a psychologist to claim one approach to psychology and psychotherapy meets the highly diverse set of needs associated with these values is more than naive, it is ignorant. Similarly, the position advocated for by these individuals assumes that all want the same thing from psychotherapy, which, too, is dangerous. When one believes this, it gives them permission to impose a particular outcome upon their client; it allows them to impose their values on the client. 

When a client comes to me for therapy, the first thing I do is not consult a research-based matrix to determine which therapy is best for my client based upon gender, culture, and diagnosis. Instead, I inquire about their values, share some about my approach to therapy and other therapy alternatives, and then together with the client make the decision about if I am the right therapist. It is not that I reject science; instead, my approach to determining therapy fit is one rooted in deep appreciation for my client's value system. After we agree to work together, I draw heavily on science to inform my moment to moment decisions in therapy, but not to determine them. In my view, science should constantly inform clinical decisions making, but not determine them. 

Some advocating the APS position would say that I use clinical judgment over science. I am not sure if this is because they are uniformed, have trouble understanding the complex model many practitioners advocate for, or are using this simply as rhetoric and political leverage. I fear the later, but hope for one of the former. Instead, what I am advocating for is to use science and clinical judgment that is informed by science. Science and research is very involved in my moment to moment decision making process, but I do not allow myself to be blinded by the science or reduced to something akin to a computer, just allowing an unempathetic science to determine what I should do each moment.

In conclusion, the diversity of opinions and approaches to psychotherapy serves two main purposes relevant to this debate. First, it promotes a progressive view of science that allows for science to develop and grow instead of becoming stagnant. Second, it better allows therapy to meet the diverse needs and respect the diverse values of 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.