LOL.

Okay — if that’s your opinion, fine. But you’ve really got to stop pretending that what you say is therefore supported by the bulk of psychological practitioners (or for that matter, the bloody evidence).

therapist-patient fit is so crucial to talk therapy’s outcome: just as doctor-patient fit was so crucial to medical therapy’s outcome in the eighteenth century.

Doctor-patient fit is still crucial to outcomes, even in the 21st century. (And btw the current biomedical/scientific model of allopathic medicine was developed in the mid-19th century in Germany and not widely accepted in the US until the Flexer report in the early 20th century, so you may want to update your dates a bit if you’re planning to use that analogy again.)

Back to fit…the patient’s experience of her encounter with the doctor is one of the primary determinants of the patient’s willingness to follow up. In those diseases in which outcomes are determined in part by self-management (arthritis, asthma, diabetes), that kind of “fit” improves outcomes by any measure.

I think the double-blinded, placebo-controlled trial is over-rated even for straight pharmacology and I’m kind of horrified at the idea of exporting it into other fields. I don’t want Congress to start passing bills mandating what sort of treatment people should have for depression or for diabetes. I want a single-payer health care system that allows for consensus decisions about best practices in both physical and mental health, with enough money to pay people for decent care, and a concerted effort to counter the stigma attached to emotional and mental illness. Far as I can see, the illnesses we’re talking about have both environmental and genetic causes and both neurochemical and behavioral manifestations. And all illness is, ultimately, culturally defined; people in Ghana treat physical illness differently, too – and meds work differently for infection in people with varying beliefs about meds.

As for the rest of what you say about

Ask yourself how you’re defining “effective.” When psychologist talk about talk therapy’s efficacy, they’re comparing it to medication. They’re not comparing it to talk therapy placebos — i.e., giving an actor a white coat and telling the patient that the individual is a psychologist. And, like it or not, that’s what I need to have in my hands before I can convince my boss to sponsor mental health bills. (And when I’m talking about sponsoring bills, I’m talking about a post-’08 election in which Democrats control both the Legislative and Executive branches.)

Further, recent lobbying efforts to increase mental health funding in Africa over the past few years has really shot psychology as a whole in the foot. Why? Because some Congressmen asked the Congressional Research Service to create a report giving us an overview of African psychology institutions and needs. Even though it didn’t directly touch on psychology in America, politicans aren’t as dumb as they look on CNN: they (and their staffs, i.e., me) connected the dots on our own.

It turns out that medical anthropology’s recent explorations into mental health has really terrible implications for Western psychology. Doctors in a number of nations noted that people would come to see them for some diseasses, but not others — namely depression. Medical anthropologists picked up on this. First, they noticed that the mental health issues faced by individuals in some nations just don’t match the DSM-IV. People who would be locked away in America are considered quirky by Nigerian and Ghanian standards, and quirky people in America would be deemed completely insane over there. (The report described the situation in a number of nations, but I highlight Nigeria and Ghana because most of my friends in law school are from there.)

Further, anthrpologists noticed that when mentally ill individuals did try to see Western psychologists for talk therapy, talk therapy just didn’t work. The patients just went back to noticed that in a number of cultures, clan and tribal leaders function as psychologists despite having minimal formal training for their positions. Talk therapy just can’t be exported to Ghana and Nigeria the way quinine or AZT can.

Why can’t talk therapy be exported? Because (1) the conception of self underlying psychology is fatally flawed and ultimately only adequate for Western culture, and (2) talk therapy’s healing power comes primarily from having an individual in a position of cultural authority listen and provide individualized advice to lowly ole’ you. This would also explain why therapist-patient fit is so crucial to talk therapy’s outcome: just as doctor-patient fit was so crucial to medical therapy’s outcome in the eighteenth century.

Now, it’s entirely possible that these ideas are wrong. But the evidence gathered from other fields is becoming more and more substantial each day. In order to prove medical anthropology’s implications wrong, we’re going to have to see talk therapy trials with placebos.

Well that’s great that Adler got some borderlines to come into his office and respond to his talk-therapy, I haven’t read his outcomes, but I’d posit that they are mostly anecdote based, mostly relying on self-assessment by the patient or self criticism by the practitioner.

So your stance is that any treatment, regardless of the opinion of the client, practitioner, or general profession community, is assumed to be invalid if it cannot be easily quantified? What standards would you use for assessing treatment of an illness that doesn’t conform to the medical model? More to the point, how would you get around the problems you seem to be forseeing? How do you measure health and illness quantitatively when discussing what is essentially a qualitative issue?

the nature of a large number of psychological disorders negates the willingness of the sufferer to participate proactively in the process of talk therapy in any of its forms. Then of course there are some PD’s who’d love nothing more than to participate in therapy and make for a good outcome, whatever the clinician decides that might be, say for example, someone with a dependent disorder. What then? Who judges what is a positive outcome?

I’d say that a positive outcome is a significant reduction of anxiety, reduced dysfunction, improved reality testing, and a reduction in maladaptive behaviors characterized by the patient’s disorder. To use the example of someone with dependent personality disorder, simply cooperation wouldn’t really be what you were looking for. You’d be looking for the client to have less anxiety around being alone or unattached, you’d want to see their valuation of themselves be less linked to others, you’d be looking for a reduction in characteristically dependent behaviors, you’d be looking for increased personal independence. Who would judge these outcomes, well, I’d say the therapist would be a good candidate but you could always have colleagues review session tapes if that wasn’t enough for you. As for client self reports, only an idiot (or a claims adjuster) would give a self-report survey to client and expect to get accurate data.

Are you saying that schizophrenia is not a brain disease but now is a personality disorder? You’ve got to be kidding! I’d really like to see the research that can conclusively prove that personality disorder can cause brain diseases such as schizophrenia, bi-polar or severe clinical depression.

Am I saying that schizophrenia isn’t a brain disease but instead a personality disorder? Nope, doesn’t look that way to me. What I was saying was that schizophrenia is related to personality disorders (especially in the public mind) because the presentation is similar. Schizophrenia is a breakdown of the individual. Granted, it has a much more biological basis than PDs, but it would be hard not to see the similarity. Lets put it this way, if you were put in a room with a schizophrenic on a good day and someone with a schizotypal PD, and you had no other data, do you think you’d be able to tell the difference most of the time? Does that mean their illnesses have the same cause? No, of course not. Does that mean that a non-expert might confuse them? Probably.

If the shoe fits….

You are not only sounding like an ass, but an arrogant one at that. To presume that no one here knows as much about mental illness as you is presumptuous at best.

Well, for that I apologize. You’re right, I assumed that you didn’t know what you were talking about. I could defend that assumption pretty well, but that wouldn’t make it any less wrong. I’m sorry for that.

The absolution/redemption basis of talk therapy, while on some levels is helpful to people, is justifiably seen as bubkis by many people, especially when asserted as a solution to diseases that respond well to medical treatment.

It is your profession’s clinging to nineteen century views of mental illness that often holds back progress on mental disease sir.

Well, I do kind of agree with you. I really think that lumping all forms of talk therapy together isn’t a good idea, and that some a much more effective than others. A lot of the talk therapy done today is client centered, and (unless we’re talking about grief counseling) I agree with you that it isn’t a very good treatment for serious illness.

I really think you and I are talking about two very different things here. You keep mentioning diseases that respond well to medical treatment. I can’t think of too many outside of the ones we’ve already mentioned. For something like schizophrenia, I still think that therapy is very valuable for patients (especially those who don’t have severe cases) who want to eventually get rid of the side-effects that come with even the atypical antipsychotics. Even beyond that goal of getting rid of meds, I think therapy can be valuable in repairing some of the environmental stressors that can aggravate even purely organic illnesses. Still, I can see and accept the other side of the argument there.

As for the crack about the 19th century, I’ll own that. I’m a disciple of Freud and Jung, and I lean more towards the philosophical roots of psychology than the medical roots. The 20th century theorists that have influenced me come from the existential and the transpersonal branches. I’m fully aware that I’m in the minority in terms of philosophy, but I also feel that someone has to argue against a total transition into the medical model.

Many psychiatrists feel this way, so you’re not coming out of left field with your opinion.

However, I feel both your posts attempt to create your position as one which is uncontested or unconflicted. This is true in neither case. There’s room for disagreement by educated individuals about the role of medication, and the treatability of personality disorders.

The problem there is that psychiatrists feel that way because psychiatrists don’t have a drug that can easily treat axis II disorder. But psychiatrists don’t really treat patients very often, they do a 15 minute consult and reach for a scrip pad once every month or so. Actual therapy (think kind the person I was responding to said didn’t work for this population) is done by psychologists and masters level clinicians. I don’t really that that there is room for disagreement when it comes to the treatability of Axis II disorders outside of antisocial. Perhaps not every patient will be open to treatment, but simply writing off an entire class of seriously ill people (as Kate seemed to be suggesting) strikes me as downright offensive. Axis II disorders are among the most disruptive and devastating mental illnesses in existence. They are pervasive disorders that a lot of clinicians don’t want to treat because the clients are difficult and often unpleasant. That doesn’t mean they do not deserve care or that they are somehow too horrible to be worthy of care.

As for my stance on meds, I know theres disagreement, but I still feel that the use of medication as a cure has done more damage to mental health in this country than Reagan’s block grants or JFK’s community mental health centers. The problem with medication is that its expensive, has extremely unpleasant side effects, and only masks the symptoms of disorders that don’t have a strong biological basis. I believe, quite strongly, that medication is a very good tool for crisis intervention and for normalizing life but a very bad tool for long-term symptom management. More importantly, most psychotropics aren’t proscribed by psychiatrists (partly because there aren’t nearly enough psychiatrists in this country if you don’t live in a major city). The numbers vary by study, but somewhere between 60%-80% of psychotropic drug scrips are written by GPs with no specialized training in mental health. Its pretty clear that these doctors are treating mental illness like strep throat or high cholesterol.

And when I started my treatment, let’s not forget that my employer paid 100% of my premiums.

And I was around when Ronald Reagan took office, and yeah, I DO blame his crappy, “welfare queen,” poverty-sneering policies and the resulting arrogant attitudes of the wealthy for the severely mentally ill homeless people I see every day in my suburb.

I’ve been in and out of talk therapy for 25 years, on and off, for treatment of depression and anxiety. Talk therapy is hard work, and emotionally taxing, which is why it has taken me so many years to dig to the bottom of things. I’d go for a couple of years, quit, get to a bad place again, go again, get a little bit “better,” run out of money or insurance, quit, etc.

I first took meds to treat PPD 6 years ago, and it helped me so much I can’t even describe the feeling of relief. Yes, it “numbed” the feelings somewhat so I could bear to talk about them in therapy. I got to a great place and then the trauma — and now I’m back on meds and in therapy together, and I finally feel like I’m making big progress. And look how much time and care it took!

I may be on meds for the rest of my life. I don’t know. But I’ll do whatever it takes to keep feeling better than I ever have

in my whole life.

(Until the entire health care system breaks down and I can’t afford any more treatment, that is. Currently I pay $800+ per month for our family’s health insurance, which covers things pretty well.)

And my depression and anxiety aren’t even severe. They’re probably levels at which many of us just live our whole lives.

I think to advocate one treatment or other for every person is narrow-minded. I feel comfortable offering that opinion even from my comfortable armchair.

Disclosure: My talk therapy has ALL been with LCSWs and clinical psychologists (some better than others), and my meds are regulated by a psychiatrist.

State-funded mental health care wasn’t all that great in many respects,

That’s putting it mildly. I personally knew someone whose relatives committed her merely for being unconventional during the 1950′s. While she was able to resume a seemingly normal life since then, she has been scarred by her institutionalization experience. By committing her, these relatives of hers behaved no differently from tyrannical Fascist and Communist regimes who used mental institutions as a way to punish and control dissent.

As for the larger issues of mental health in this country….that defunding was in itself, stark evidence of how mental illness is stigmatized in this and many other societies. We really need to implement the outpatient/hospice care part that was not implemented during the 1980s. The fact mental illness is not treated as a physical illness is disturbing, a signifier of the widespread ignorance of mental illness in our society, and quite unfathomable to me.

My caps were overblown. They sounded better in my head. ;) Sorry ’bout that.

Adler built his career treating Borderline patients.

Well that’s great that Adler got some borderlines to come into his office and respond to his talk-therapy, I haven’t read his outcomes, but I’d posit that they are mostly anecdote based, mostly relying on self-assessment by the patient or self criticism by the practitioner.

The nature of a large number of psychological disorders negates the willingness of the sufferer to participate proactively in the process of talk therapy in any of its forms. Then of course there are some PD’s who’d love nothing more than to participate in therapy and make for a good outcome, whatever the clinician decides that might be, say for example, someone with a dependent disorder. What then? Who judges what is a positive outcome?

Also, before making sweeping generalizations about what can and cannot be treated, do yourself the favor of doing at least enough research to get basic concepts right. “Sociopaths” aren’t a separate class of patients from those with personality disorders, they are individuals who display a certain kind of personality disorder.

Yes, sociopath as I used the term doesn’t belong in scientific conversation, but I’m not writing a white paper today. My apologies. Sociopathic as many use the term today most closely describes an individual with personality disorder that tends to display in more aggressive, extroverted ways that cause more loss to society and are probably the least responsive to any type of intervention I’d guess than say, a typical borderline.

Schizophrenia (in all it’s forms) is a breakdown of the individual and of reality testing, as such it is intimately related personality disorders. Bi-polar disorder has a pretty high rate of comorbidity, and shares patterns of behavior and presentation, with several personality disorders.

Are you saying that schizophrenia is not a brain disease but now is a personality disorder? You’ve got to be kidding! I’d really like to see the research that can conclusively prove that personality disorder can cause brain diseases such as schizophrenia, bi-polar or severe clinical depression.

I hate to sound like an ass, but non-experts armchairing these issues is what caused the breakdown of care we saw in this country from when the CMHA passed in 1963 to present.

If the shoe fits….

You are not only sounding like an ass, but an arrogant one at that. To presume that no one here knows as much about mental illness as you is presumptuous at best.

The absolution/redemption basis of talk therapy, while on some levels is helpful to people, is justifiably seen as bubkis by many people, especially when asserted as a solution to diseases that respond well to medical treatment.

It is your profession’s clinging to nineteen century views of mental illness that often holds back progress on mental disease sir.