Psychologists in Independent Practice

Standing up for Our Craft

By William A. MacGillivray

I recently attended the Division of Psychoanalysis Spring Meeting. One of the featured speakers was Jane Fonda. I initially was resistant to the idea of attending this talk and annoyed at the presenters for organizing a panel that included someone who was asked to attend because of her “star power.” I was aware that she had recently written a memoir, which included a dramatic story of her investigation into her family history and the impact of her mother’s suicide on her life. But, what could Jane Fonda have to say about psychoanalysis? Well, she had quite a lot to say, nothing terribly original, but she quoted all the right people and addressed reasonably well the importance of a feminist voice in psychoanalytic thinking. What was more fascinating and truly eloquent, was her tribute to her therapist and the impact of therapy as a voyage of discovery. She observed that all her life she would have called herself a feminist, but it was only after therapy that she could feel it in her bones.


There was a lot more to her talk, but what I want to convey that seemed so exciting to hear was her insistence that psychotherapy, the “talking cure,” is a radical and life-changing experience. This simple observation struck me as quite novel in the context of the current crisis in our field. Psychotherapy is under assault. We all know that. What we are less aware of, I think, is the insidious nature of this assault on our work. Many therapists have internalized a negative view of the value of their work. I realize this is a strong statement and I can evade objection further by insisting that this devaluation operates on an unconscious as well as conscious level (after all, I am a psychoanalyst!). Here is an example. Many of our professional organizations have tended to present our work in a more “positive” context, insisting that psychotherapy is not the only thing we do since we are involved in prevention and social action. My own Division of Psychoanalysis was recently featured in the Monitor on Psychology (the American Psychological Association monthly magazine) touting the outreach efforts of our members. The message seemed to be that we are good and valuable to the extent we are not “sitting behind the couch” and instead are out there working in other ways for social change.

…psychotherapy, the “talking cure,” is a radical and life-changing experience.
I honor the efforts of psychotherapists who perform crisis work during disaster, who help out in homeless shelters, or who spend quality time with a foster child. These and countless other service activities are important and vital. But they are not psychotherapy and they cannot replace psychotherapy in the lives of our patients. Returning to Jane Fonda’s “story,” it was psychotherapy that radicalized her, that transformed her life in ways she is only now beginning to explore. That’s what psychotherapy can do! Why are we not able to stand up for this core aspect of our identity? What keeps us from speaking out, from writing to our local papers, for example, whenever a new drug is touted as a cure for the “disease” of anxiety or depression, or whenever a quick technique is praised over the demands of time and patience?


Medicalization of Our Society


This should come as no surprise to any of us. Our patients, our society, have been saturated with the notion that our emotional difficulties are lodged in our brains and that once our “chemicals” are balanced all will be well. The recent movie, A Beautiful Mind, illustrates the power of the medical model. In the movie, the implication is quite clear that John Nash, the brilliant mathematician who had been diagnosed with schizophrenia and suffered for years with mistreatment at the hands of the medical profession, including involuntary hospitalization, was successfully treated with medications and his return to sanity was achieved when he finally became “medically compliant.” In the PBS documentary, A Brilliant Madness, however, a markedly different story is told. We are informed that Nash stopped taking his medications long before he was “restored” to sanity and is still off drugs. More eloquent than that, the documentary ends with the words of John Nash on his cure: It was love that did it. Nash relates that throughout his illness it was the patient understanding of his wife and friends that eventually led him back to sanity. Even in this fine production, there was continued obeisance to the medical model; including stern warnings that Nash’s “refusal” to take his medication was a dangerous, albeit successful, decision. There was a particularly (unintentionally) funny scene as the narrator describes the onset of Nash’s delusions and the scene shifts to a picture of the brain, as if to insist, there are those pesky hallucinations!


There is little doubt that medicine has effected significant changes in people’s lives and the ability of life-saving drugs to stave off and even reverse physical conditions associated with cancer, heart disease, vascular illness, diabetes, etc., is truly remarkable. I also think few psychotherapists would argue that medications to relieve crippling symptoms of fear, anxiety, and emotional distress should not be available to our patients. But the data is in, psychotherapy works, more therapy works better than less therapy; patients’ controlling their therapy works better that others’ controlling the therapy. Patients may not get the immediate relief of medications; but psychotherapy brings sustained benefits beyond relief. And even psychoanalysis ends, while a lifetime regimen of multiple medications is truly interminable. The devastating side effects of medication continue and the new “atypical antipsychotics” have all too typical side effects that are life limiting, if not life shortening.


Here is another example. I recently attended a conference at Harvard Medical School on child and adolescent psychopharmacology and lecturer after lecturer proceeded to define and delimit the various childhood disorders refreshingly unconcerned that the diagnostic system they rely upon is hopelessly inaccurate. And how do researchers reconcile the fact that the diagnostic categories are hopelessly jumbled up? By solemnly invoking the concept of “comorbidity”: the disorder is in the patient and not in the language categories that define the same behavior as occurring in a range of diagnostic conditions. Worse was the routine tossed off line, “Of course, CBT will help with this condition.” Worst was presenting research indicating that long-term depth psychotherapy works best for bulimia with the sad conclusion, “…but managed care doesn’t pay for this.” Remember, this was at Harvard!


As psychotherapists, we can bemoan our fate and blame “the media” or “Big Pharma” for the neglect of the value of therapy in our society. Many of our psychiatrist colleagues have given up practice of psychotherapy altogether, citing the lack of reimbursement. Some of our colleagues attempt to cope by gaining prescription privileges, insisting that they will not go the way of the psychiatry (“The right to prescribe is the right not to prescribe.” Yeah, yeah). But the fault also lies with us, with our professional organizations and our own willingness to buck the tide and take a stand to protect psychotherapy.


The Dr. Phil Syndrome


Now, I don’t want to pick on Dr. Phil. For all I know he’s a great therapist. I have only seen him once. I do think, however, he is an exemplar of a particular mindset concerning psychotherapy. First, it should be fast, a sound bite between commercials. Secondly, it should be directive and superficial. Once again, I’m all for being directive and I cannot vouch for the profundity of my comments to patients. The troublesome message that I think comes through with this commercialization of psychotherapy is that “anybody can do it.” This certainly has been the mantra of managed care industry as it willingly pays the same rates for “practitioners,” regardless of their level of training, their years of experience, and/or whether or not they have a mental health degree at all.


There is a peculiar confluence of interests with patients wanting a “quick fix,” since the culture continually informs them that this is their “right” and a natural progress of progress in all areas of their lives, and managed care, which preaches the same mantra for its own benefit. Even institutions that are not beholden directly to managed care have joined the zeitgeist that suggests that therapy can be both fast and delivered by “highly-trained” technicians.


Reclaiming Lost Ground


The National Coalition of Mental Health Professionals and Consumers is the one organization that seeks to combat the external forces that devalue the practice of talk therapy in the name of both patients and therapists. We also maintain that all those who support the principles of privacy, access, quality and choice have a place in this struggle and we do not participate in organizational struggles and turf battles that can divide and weaken our message. If you have read this far into the article, you are doubtless more or less committed to these goals. I want to challenge you, however, to put these goals into action. If we are to reclaim the lost ground and preserve the legacy given to us by Freud, Perls, Rogers and so many others, we need all of you to act. Here are some simple steps.

Copyright 2006 Psychologists in Independent Practice