COVID-19 risk tolerance and therapy

I’m increasingly asked by patients and potential patients when I plan to see people in the office again. I had been an exclusively “in person” psychiatrist and psychotherapist until mid-March of this year, when the pandemic forced even skeptics like me to convert completely to remote (“virtual”) treatment. Like many of my colleagues, over the past three months I’ve made an uneasy peace with phone and video sessions, and all the accompanying rigmarole. Although I can work with it, it’s far from ideal. I look forward to dispensing with the earbuds and glitchy bandwidth and resuming my prior practice.

While some folks hope I’ll see them in the office right now, others fear I’ll “force” them back before it feels safe. I assure them I won’t. Even when the office reopens, I anticipate a hybrid situation for months to come, a combination of office and online appointments. Normality is a long way off.

After all, risk tolerance varies. Some of my fellow San Franciscans now share walks outside without masks — nominally six feet apart, but not always — and some are again dining in outdoor cafes. Others are not. Even leaving aside political theater and virtue signaling, reasonable people can disagree about what feels safe.

While it would be comforting to ascribe differing risk tolerance solely to logic and the biologic, e.g. older people are at higher risk, it is far more subjective than that. Partly it’s self-image: are we proud of being sensible and prudent, or fearless and no-nonsense? Are we the type to cite scientific studies, or our gut? Do we sacrifice on behalf of others, or believe only bleeding-hearts do that? Partly it’s modeling by others, variously called peer pressure or social learning theory. If everyone nearby wears a mask, we’re more comfortable wearing one; if others reopen their therapy offices, we’re more apt to reopen ours.

The arbitrary way most of us make these safe/unsafe determinations also reflects wishful thinking and confirmation bias, cognitive tricks we play on ourselves to rationalize unsafe behavior — or conversely to scare ourselves when the situation isn’t that bad. “COVID-sorting” is essentially the use of prejudice and stereotypes to make safety assessments. We’re loath to see our own decision-making in such unflattering light, but of course we readily see irrationality in the fools who decide otherwise.

I’ve been in online discussions with mental health professionals across the country. Some are actively strategizing how to medically screen patients at office entrances, how to disinfect surfaces between patient appointments, how to conduct sessions while masked. Others sound pessimistic about ever going back to the office. I imagine this variation isn’t unique to my field. It was far easier to hunker down uniformly a couple months ago than to customize a re-emergence now.

Adding to the challenges faced by many businesses are special considerations for therapy practices, where feeling safe is crucial. Psychotherapy can only happen when words can be said and reflected upon without harmful real-life consequences. It exists in name only if either party fears a potentially fatal illness in the encounter. Indeed, it’s the therapist’s duty to assure safety in treatment, which is why our ethics forbids sexual and other forms of exploitation. The same rationale obliges therapists to take reasonable steps to assure the safety of both parties from viral and other medical threats.

And if that weren’t enough, these practical matters pale in comparison to the realm of fantasy, where under normal conditions patients may imagine the therapist to be benevolent or evil, soothing or toxic, and themselves impervious or vulnerable, lovable or repulsive. When explored as transference fantasy, these reactions can lead to insight and change. However, when toxicity and vulnerability stem from actual health risks, their value as guideposts to the unconscious is lost.

Ultimately, my answer regarding reopening the office hinges on inertia — my willingness to take the necessary steps — and practicalities, not unconscious fantasies. Will doing so necessitate calling patients the night before to screen for illness? Checking their temperature at the sidewalk entrance, one floor down? Supplying hand sanitizer and spare masks, posting signs, cleaning chairs and other surfaces between appointments, keeping office air flowing with fans and open windows?

Is this rigmarole preferable to the rigmarole of online intake forms, frozen video feeds, garbled audio, and occasionally needing to switch to the phone halfway through a session? It’s hard to choose between two bad options. And even if I decide “in-person” is preferable, will many of my patients concur? While it was my decision to exclude them from my office in March, it will not be my decision alone to readmit them.

Deciding when to reopen a therapy office isn’t only a question of risk tolerance. It’s balancing risk against expected benefit — two subjective estimates — and weighing competing rigmaroles. Even as a fairly risk-tolerant person, I am not ready to reopen my office just yet. By my estimate, the calculus still favors waiting to reopen another day. I only hope that, somehow, that day comes soon.

Antisocial masking disorder

Features of Antisocial Masking Disorder include:

  • Violation of the physical or emotional rights of others
  • Irritability and aggression
  • Lack of remorse
  • Consistent irresponsibility
  • Recklessness

(Adapted from DSM 5 Antisocial Personality Disorder)

Whew, that was fun.  Those guys are crazy.  

But let’s be fair and make some distinctions.  At one extreme are those who deny reality.  A few conspiracy theorists hold that COVID-19 is a hoax, or more narrowly that it is real but overstated by political opponents, in order to hurt Trump’s presidency and re-election bid.  It’s a psychological curiosity to maintain such claims in the face of photographic evidence, first-person accounts, a large number of certifiably dead people of all political persuasions, and so on.

Lately the objections have shifted somewhat.  Many protesters now argue that masks don’t help: that they don’t stop the virus, or that they even increase risk by leading wearers to touch their faces more often.  These claims, too, fail in the face of science as well as common sense.  No one normally objects to covering a sneeze or cough.

Then there are subtler objections.  It’s true, for example, that Americans valorize risking one’s life in defense of freedom.  Shouldn’t we similarly honor those who make the individual decision to be free, of masks and social distancing in this case, at the cost of increased infection risk?  Isn’t this akin to taking up a risky sport, or volunteering for hazardous duty?

The difference, of course, is that masking and social distancing aren’t for the individual alone.  These acts protect others.  Like obeying speed limits and fire codes, the life you save may not be your own.  For most of us who wear masks to fight the pandemic, not doing so seems selfish: a conscious choice to maximize one’s own freedom by imperiling others.  We’re all in this together, we plead; do it for your neighbors and elderly relatives.  New York governor Andrew Cuomo recently argued that wearing a mask shows respect for health care workers risking their lives, and for one’s fellow citizens.  Unfortunately, in an age of tribalism, this sort of collectivist argument rubs some the wrong way.

There’s another dynamic at play here too.  It may seem minor, but for the protesters it surely isn’t.  Cuomo didn’t dwell on the concrete benefits of mask-wearing; he stressed what it symbolizes.  A mask shows the wearer is respectful, virtuous.  This argument sounds a lot like virtue signaling: a gesture to convey virtuous values without necessarily accomplishing anything.

Here’s another example.  I’ve been wearing a cloth mask whenever I walk outside.  Yesterday I was strolling several blocks to an outdoor market, where due to the lines and crowd I’d definitely need and want to be masked.  But the sidewalks on the way were nearly deserted.  I’d face no increased risk by breathing freely, nor would I risk anyone else.  I wore the mask partly out of habit, and partly, I realized, to convey my righteous pro-mask stance.  The latter is virtue signaling, as wearing a mask outside on a deserted city block offers no practical advantage.  It inconvenienced me, and made it a bit harder to breathe, for no reason but symbolism and self-image.  I took it off until I neared the market.

My sense is that many mask refusers are enraged by virtue-signaling.  The populism that brought Trump to power actively rejects “I know better than you” statements and gestures, especially those laden with moral overtones and real-life costs.  Yes, it’s childish in a “cut off your nose to spite your face” way.  After all, wearing a mask in markets or stores really matters.  One might say that self-defeating behavior is true of Trumpism in general — more about expressing visceral opposition than a considered alternative.

This didn’t arise out of nowhere.  For years, the left has taken moral stands that strike the right as precious: saving whales, using the right pronoun, denigrating meat-eating and gasoline use, and so on.  Let’s grant that each of these causes would make the world a better place in the long run.  However, in the short run these admonitions can come across as scolding, elitist, and out of touch with everyday concerns.  People react badly to that.  The chiding sounds parental.  Emotionally, it invites angry adolescent rebellion.  To make matters worse, dismissing such reactions as hopeless or deplorable merely adds dead-dinosaur gasoline to the fire.  It’s a bit like a parent telling a teen he’s a loser and won’t amount to anything.

In family therapy, there’s often an “identified patient”: usually a child or teen with overtly pathological behavior who expresses the whole family’s otherwise hidden dysfunction.  In larger society, too, playing one type of “sensible” role may invite others to play a complementary role that looks more overtly pathological.  Authoritarians breed rebels, codependents invite manipulators, and so forth.  If an angry minority fights sensible public health measures using immature, self-defeating behavior, it’s wise to consider what’s provoking them.  And to recognize that everyone, not just our political opponents, is influenced by emotional irrationality.

The answers to our sincere questions may be uncomfortable ones that implicate ourselves.

To be clear, no one should use psychiatric diagnosis to critique a political position.  It’s a feel-good tactic that inevitably backfires.  Some mental health professionals tried with Donald Trump, and only encouraged his defenders to lodge counter-charges of mental illness in more liberal politicians.  When it comes to masks, it might be argued that the pro-mask majority are “anti-social” in a colloquial sense: we privilege scientific/medical theory over immediate human connection.

Pandemics have been with us through history.  Likewise, resistance to pandemic masks isn’t new.  Many arguments used today against masks were used a century ago in the 1918 flu pandemic.  We know a lot more about viruses and epidemiology now than we did then, and the scientific rationale for masks and social distancing is stronger than ever.  But social dynamics haven’t changed much.  People still don’t like being told what to do, especially if there’s a suggestion they are willfully ignorant or morally deficient.  It’s incumbent on those advocating pro-social behavior to make it a win-win proposition, and not a moral failing — or a psychiatric disorder — for resisting.

Online therapy revisited, thanks to COVID-19

It was 2013. Hi-tech entrepreneurs were excitedly “disrupting” industries, bringing goods and services closer to users. Uber replaced cabs, Kickstarter replaced investors, and telehealth companies offered convenient, at-home medical care over smartphone video. Why waste time going to an office or clinic, especially if you’re not feeling well? Why spend so much money? The physician’s physical examination had been oversold. It wasn’t really needed.

Psychotherapy never required a physical exam in the first place, and so was even more ripe for disruption. Therapy, after all, is just talk. A phone call will do, although that lacks cutting-edge tech and huge potential profitability. Proprietary video channels solve those drawbacks. Therapy could be mass-marketed as a commodity more than a professional relationship, always available and as close as your phone. It was sold to the public with a fresh, slightly subversive undertone: fire your shrink and use our app. Have therapy at home, in your pajamas if you like. It’s even “evidence-based,” a sleight-of-hand that substitutes symptomatic improvement for truly feeling well.

In 2013 I was skeptical of the burgeoning popularity of online therapy:

When the alternative is no psychotherapy at all, the utility of conducting it online seems obvious.  Example scenarios include patients who are bedridden or otherwise immobile, those in inaccessible locations such as Antarctic explorers, and those who are immunocompromised or highly contagious with an infectious disease…. It is more potentially problematic to choose online therapy over in-person treatment when both are practical options.


Back then, choosing online therapy over face-to-face struck me as corner-cutting: opting for fast food over fine dining. Yes, it was easy to imagine implausible conditions where the former was the best available or the only practical option. But that wasn’t the reality. Instead, online therapists and their patients chose convenience, the innate attractions of tech, and sometimes a lower fee, while settling for a substandard experience.

It’s 2020 now, and times have certainly changed. In the midst of the COVID-19 pandemic, it hardly ever makes sense to risk infection in the psychotherapy office. Conducting sessions by video, or simply over the phone, is much closer to standard therapy than it is to nothing — close enough that holding out for the real thing is recklessly rigid. Other things being equal, in-person therapy is still superior to the online variety. However, it isn’t so much better that it’s worth the risk of a potentially fatal disease.

This March, I offered all patients the option of telephone or video sessions instead of meeting in person. Most readily accepted. One or two had no private place to speak with me other than my office, so I continued to see them in person. Even our strict Shelter in Place order in San Francisco allows supermarket shopping, picking up take-out food, and visiting the dry cleaner or hardware store. Sharing my office for 50 minutes with one person quietly sitting eight feet away, when both of us are asymptomatic and I handle the doorknobs, didn’t seem out of line with these other common exposures; it was also permitted under the law. This week I decided to wear a cloth mask when seeing the rare such patient in the office.

Most patients opted for video. I tried FaceTime and Zoom before settling on Doxy.me. I found the three services essentially interchangeable, despite raging debates about HIPAA compliance and privacy. Audio and video quality varied a lot, though, depending on internet bandwidth. The calls improved substantially when I replaced wifi with wired ethernet at my end. But there were still occasional frozen video feeds and garbled audio. Once or twice it was so bad we switched to telephones mid-session. Conversely, when everything was going well, which was usually, the technology receded into the background.

Well, except that I was, and am, still conscious of positioning myself correctly in the camera frame, modulating my voice, attending to my facial feedback, confirming the novel payment arrangements, and asking about the transmission quality at the other end. I imagine all that improves with practice.

I considered charging less for phone and video sessions, maybe even less for phone than video. To my mind, I wasn’t offering as much virtually as I do in a “real” session. But I ended up keeping my usual fee, on the theory that my time and expertise are equally valuable no matter how it’s delivered. Of note, many insurers don’t see it that way. As of this writing, Medicare just started covering video therapy, but not telephone therapy (yet).

When the crisis is over, I plan to resume in-person services and retire the remote options. I fear others will not — that therapists and patients will have learned to accept glitchy transmissions and the other distractions of tech as normal. I worry, too, that therapists will no longer value the subtleties lost online: the quiet sighs, sly glances, and fleeting hesitations that add music and meaning to the words.

To my surprise, even the American Psychoanalytic Association blog argues that “online therapy can be just as effective as being in the same room with your therapist.” (This is not APsaA’s official position.) I wonder if this is a counterphobic reaction to psychoanalysis suffering a behind-the-times reputation for generations. Curiously, their argument is based on online music being emotionally moving. However, as noted by the general manager of New York’s Metropolitan Opera, the fact that online music is moving doesn’t mean it equals a live performance. The interaction between artist and audience animates the latter.

So it is with psychotherapy. If we reduce therapy to mere information transfer — complaints, feelings, and recollections in one direction, reframing, support, and/or interpretation in the other — then virtual therapy does a pretty good job. But if we see therapy as co-constructed, it’s more than information transfer. It’s “being with” each other in relationship. It’s intimacy. It’s closeness and trust.

Can this be approximated online? Sure. At a time when the viral risks of in-person treatment almost always outweigh its benefits, we should use the technology available to us. And third party payers should cover such sessions, which currently many don’t.

But when the dust settles, we’d be shortchanging our patients and ourselves if we settled for what we’re forced to champion now. The inconvenient truth is that physical exams are often important in medical diagnosis, and can’t be replicated online. Likewise, in-person psychotherapy enjoys advantages that distance therapies can’t touch. There’s no shame in admitting that, while advocating for a little less right now.

Image courtesy of Ambro at FreeDigitalPhotos.net

Dopamine fasting

Dopamine

Taking a break from technology is a fine idea, but we don’t need a pseudoscientific new name for it: dopamine fasting.  Launched with viral Silicon Valley memes, online reports, and articles in the New York Times and elsewhere, dopamine fasting is now a thing.  Basically, the idea is to temporarily deprive oneself of the usual stimulations of life — largely electronic these days — in order to re-sensitize one’s brain.

Since several parties popularized the term, they wrestle over its definition.  Some take an ascetic, global view of stimulation-avoidance, while others limit the fast to electronic media.  Getting too excited over these battles stimulates dopamine, of course.  Perhaps it’s best not to worry about it.

Neuroscientists point out that the name is misleading.  Dopamine isn’t uniquely implicated in habituation to stimuli or behavioral addictions (although it is certainly involved), and naming the neurotransmitter doesn’t advance our understanding of the process.

Consequently, it’s no surprise pundits debunk the idea as repackaged common sense.  Sure, it’s refreshing to step away from the rat race and attention-grabbing tech.  But we already have names for that: relaxing vacations, a “mental health day”, picturing your happy place, meditating, taking a walk to clear your head, the sabbath, sabbaticals, retreat weekends, and so on.  The concept is as old as humanity.  This, in turn, leads proponents to defend their baby with heartfelt but not entirely rational distinctions between dopamine fasting and these other activities.

I’m in the debunking camp.  I agree with one of the vocal proponents of dopamine fasting, Cameron Sepah, who concedes: “The term is technically incorrect, but ‘stimulus control 101 for dealing with addictive behavior’ just doesn’t have the same ring to it.”  In other words, the term “dopamine fasting” is hype, referring (with false, dopamine-inducing excitement) to an old, well-understood behavioral practice.

It’s also the latest example of misleading the public with whiz-bang neurobiological language.   This is rampant in modern psychiatry, where the mere existence of functional brain imaging (allowing us to visualize metabolic activity in the brain) makes the field “biological” — even though our biological treatments haven’t improved as a result, and remain wholly symptomatic and empirical.

Attach a “neuro-” prefix or a brain chemical to your field of interest, and the world beats a path to your door.  I recently joked that if we re-cast psychotherapy as “verbal neuromodulation” the field would enjoy newfound popularity and research funding.  This is essentially what the advocates of dopamine fasting did.

Selling products with pseudoscience isn’t new.  Old-time cigarette ads, believe it or not, touted their health benefits.  Athletic clothing has been over-hyped to the tune of multimillion-dollar false-advertising settlements.  Cosmetic ads frequently invoke essentially meaningless scientific terms.

The difference now is that social media has made the “marketplace of ideas” a real marketplace.  Popularizing ideas, and by extension oneself, now demands the same promotional tactics previously used to sell cigarettes and soap.  Can you, in some convoluted way, tie your idea to neuroplasticity?  dopamine?  cellular regeneration?  If so, you’re well on your way to becoming an influencer.  Yes, you’ll be pandering to the attention economy, and presumably stimulating and thus depleting everyone’s dopamine in the bargain.  But don’t let that stop you.

Verbal neuromodulation: old wine in a new bottle

Neuromodulation is a hotly studied field.  Research groups worldwide are exploring genetic and epigenetic modulators, inflammatory processes, optogenetics, dietary effects, and other modalities.  Although neuromodulation can influence many non-psychiatric conditions, one tantalizing hope is that by modifying critical brain physiology and the connectome we may someday attack the root causes of mental illness, a global scourge of human suffering.

It may surprise the reader to learn that this tantalizing promise is, right now, an under-appreciated reality.

Neuromodulation is not a new idea; it has progressed over many decades with advances in medicine and technology.  Thanks to expenditures of many millions of dollars and fervent international effort, brain research now produces complex genetic maps and colorful three-dimensional depictions of metabolic activity known as functional brain imaging.  These visually engaging results suggest that we are closing in on the cellular substrate of the psyche.  Yet the linking of bench research to actual patient outcomes remains elusive.  When it come to psychological suffering, translational medicine seems so close and yet so far.

Oddly neglected in this juggernaut of neurobiological research is verbal neuromodulation.  Transmitted via phylogenetically primitive afferent auditory pathways, verbal signals enter along the eighth cranial nerves, then stimulate limbic and cortical brain centers in highly complex ways.  Simpler (nonverbal) auditory neuromodulation has been used successfully in treating tinnitus, i.e., ringing in the ears, and preliminary research has found that ultrasound can affect intact brain circuits.  But the neurobiological implications of higher-level auditory interventions have been overlooked — perhaps even denigrated — in a field beholden to high-tech reductionism.

In contrast to most neuromodulatory techniques, the verbal variety, historically known as “psychotherapy,” boasts a low-tech high-touch interface similar to everyday dialog.  Most human subjects have conversed since childhood and find the experience somewhat familiar and relatively non-invasive.  Generally well-tolerated and with a good safety record, psychotherapy has been shown to alter functional brain imaging and even brain microstructure, reflecting improved signaling in essential brain pathways.  Moreover, verbal neuromodulation is both “precision medicine” and “patient-centered,” concepts currently deemed crucial to patient care, not to mention academic advancement and publication in peer-reviewed journals.

While verbal neuromodulation has been shown to be highly effective in numerous studies, its mechanism of action is still not well understood.  At the neurostructural level, dialogic reflection may enhance bidirectional signal transduction between the limbic system, which mediates emotion, and cortical areas, which mediate cognition and self-awareness.  By bringing limbic and cortical centers into greater synchrony, the entire brain may work more harmoniously to realize its goals.  This synchronization is presumably mediated by enhanced dendritic arborization, resulting in a fuller connectome, and/or neuronal protein synthesis, allowing the consolidation of new memories.  Further research is surely warranted to delineate the fundamental mechanisms at play.

Verbal strategies to affect emotional well-being are not new.  Friends, family, clergy, counselors, and psychotherapists have conducted such interventions for generations.  Yet, in the 21st century, the “talking cure” has been supplanted by empty promises from neurobiology, while sufferers make do with dubious symptomatic treatments and quick-fix smartphone apps.  Re-casting dowdy, outmoded “psychotherapy” as verbal neuromodulation optimizes research grant support and may spark excitement in the public.  It may encourage more sufferers to reap the benefits of a brain-modifying treatment that long ago made the leap from theory to evidence-based practice.

Those of us who offer verbal neuromodulation should legitimately present it as the leading technology to target and modify specific brain activity in the service of relieving emotional suffering.  Of course, outside the earshot of pundits, academics, and a public entranced by high-tech, we may still call it psychotherapy.  Just as long as no one hears us.

Graphic courtesy of geralt at pixabay.com

Dialectics in psychotherapy

The word “dialectic” has a long history, from ancient Greek philosophers, through Hegel and Marx, and to the present day. Its meaning has changed over the centuries, and according to different thinkers. In psychotherapy, “dialectic” is almost wholly associated with dialectical behavior therapy (DBT), where the term identifies a particular type of treatment — even though most clients don’t know what the word means. In reality, dialectics as used in DBT is a feature of all schools of psychotherapy.

Broadly speaking, a dialectic is tension between two contradictory viewpoints, where a greater truth emerges from their interplay. Socratic dialog, in which philosophers mutually benefit by finding defects in each other’s arguments, is a classic example. In the early 19th century, Georg Wilhelm Friedrich Hegel described a universal dialectic, commonly summarized as “thesis, antithesis, synthesis.” His esoteric philosophy holds that every thesis, or proposition, contains elements of its own negation. Only by considering both the thesis and its contradiction (antithesis) can one synthesize a greater truth. This process never ends, as the new synthesis itself contains antithetical elements. The term veered in meaning with Marx’s dialectical materialism, and in yet other directions with more contemporary writers. But DBT uses the Hegelian sense, and that is our focus here.

Marsha Linehan faced a problem as she developed DBT in the late 1970s. Her behavioral strategies implicitly pathologized those she sought to help. Clients thought: “If I need to change, there must be something wrong with me.” To avoid re-traumatizing them, she turned to Zen Buddhism’s self-acceptance and focused on clients’ strengths. But this, in turn, downplayed their real need to change. Dr. Linehan and her colleagues eventually realized they would have to integrate change (thesis) and acceptance (antithesis) into a larger truth that incorporates both (synthesis).

This is the fundamental dialectic of DBT, although there are others. For example, the therapist is trustworthy and reliable, but he or she also makes mistakes. The client is doing his or her best but wants to do better. Although worded here using “but” for clarity, DBT teaches clients to use “and” instead (e.g., the therapist is reliable and makes mistakes). In doing so, the therapeutic task is to embrace the truth of both propositions at once, not to choose one over the other.

An uneasy tension between acceptance and the need for change exists in all psychotherapy, not just DBT. Indeed, this tension underlies a question commonly posed to new clients: “What brings you in now?” Therapy begins only when emotional discomfort and the perceived need for change outweigh the inertia (i.e., acceptance), reluctance, and other factors that precluded it before. Then, once in therapy, change versus acceptance is often an explicit struggle. File for divorce or work on one’s marriage? Learn to be bolder or accept that one is shy by nature? Change physically through exercise or plastic surgery, or become more comfortable with the body one has?

When clients grapple with such questions, therapists of any school should refrain from choosing sides or giving advice. Except in extreme cases, we simply don’t know which option is best for the individual in our office.

However, it goes further than this. As Hegel wrote, a clash of thesis and antithesis may result in a new third way, a synthesis that incorporates, yet transcends, both sides of the argument. This “union of opposites” was first described by pre-Socratic philosophers (and by Taoists, as in the well-known Yin-Yang symbol of interdependence). The concept was later adopted by alchemists, who observed that compounding two dissimilar chemicals can result in a third unlike either parent (e.g., sodium, a highly reactive metal, plus chlorine, a poisonous gas, produces table salt). Carl Jung, who studied alchemy, weaved the union of opposites into various psychological writings. It forms the basis of his “transcendent function” that leads to psychological change; an accessible introduction to this concept can be found here.

The shuttling to and fro of arguments and affects represents the transcendent function of opposites. The confrontation of the two positions generates a tension charged with energy and creates a living, third thing… a movement out of the suspension between the opposites, a living birth that leads to a new level of being, a new situation.

Collected Works of C. G. Jung, Vol. 8. 2nd ed., Princeton University Press, 1972. p. 67-91.

One need not be a Jungian to recognize creative, “third-way” processes in therapy. Instead of being caught on the horns of a dilemma, it often helps to take a step back and appreciate the validity of both positions: It is valid to seek autonomy and relatedness. It is valid to be serious and to play. And it is certainly valid to accept oneself while also striving to change. Insight is our term in depth psychotherapy for achieving synthesis: a position that reconciles and transcends thesis and antithesis, makes sense emotionally, and works in one’s life. In this way, dialectic tension generates all creativity and psychological growth.

Image courtesy of digitalart at FreeDigitalPhotos.net


"Evidence based" psychotherapy

When a mental health clinic, online referral service, or private practice offers “evidence based” psychotherapy, that certainly sounds like a selling point.  It suggests solid science supports the therapy offered — and that competing services lack this support.  But what does this phrase really mean?

“Evidence based medicine” first appeared in the medical literature in 1991.  It cast doubt on physicians’ clinical intuition and anecdotal experience, reminding them that science should guide medical practice.  (The term was new, the warning was not.)  Acceptable scientific evidence included clinical epidemiology, bench research, published case reports, and so on.  However, the randomized controlled trial (RCT) soon emerged as the gold standard, the best evidence that a treatment works.

In a RCT, subjects who all suffer the same disease are randomly assigned either to the treatment under study, or to a control group.  The latter receives an inactive placebo, or sometimes an active comparison treatment.  Ideally, RCTs are “double blind”: neither the subjects nor those rating them know who is in which group.  This minimizes psychological effects such as confirmation bias, where both researchers and subjects tend to rate more improvement where they expect to see it.  If the treatment group then fares better on average, this is taken as strong evidence of treatment efficacy.

RCTs are powerful tools — with limitations.  Best for studying a single treatment applied to a single disease, the method becomes impractical when studying patients with multiple or ill-defined conditions, or when assessing treatments with nuanced variations.  It can be hard to find a suitable placebo or comparison treatment, and sometimes it proves impossible to create double-blind conditions.  For a variety of reasons, there is still an important role for evidence aside from RCTs.

In the field of psychotherapy, the paradigm in the first half of the 20th century was psychoanalysis and its offshoots.  Its prominence was largely due to intellectual elegance and compelling case reports, not RCTs.  But by mid-century, critics began questioning the broad claims of psychoanalysis.  New medications and psychotherapies were introduced.  And in 1980, psychiatry’s Diagnostic and Statistical Manual was revised.  It would thereafter define mental disorders not narratively, but by symptom criteria.  With the right set of symptoms, a patient would “meet criteria” for one or more diagnoses.

Drug developers and the newer schools of therapy, especially cognitive behavioral therapy (CBT) and short-term structured therapies, were eager to prove they could reduce these symptoms and, by definition, relieve psychiatric disorders.  Many RCTs were done, and indeed these studies showed, on average, that symptoms were reduced.  This led to FDA approval for the medications, and to “evidence based” claims for the therapies.

Yes, CBT and other symptom-focused therapy is “evidence based.”  But that’s only part of the story.  Left unsaid is that a great deal of scientific evidence finds traditional, psychoanalytically based therapy effective as well.  This includes group studies using standardized measures — even RCTs — as well as patient satisfaction surveys, a myriad of case reports, and other lines of evidence.  Although there are fewer RCTs of analytic therapy than CBT, often the amount of improvement (the statistical “effect size”) is greater in the former.

“Evidence based” also glosses over why people seek therapy.  Many hope to decrease concrete symptoms: to feel less anxious, to have a brighter mood, to sleep more soundly.  Here the evidence supporting CBT and similar treatments is very solid.  But others are motivated by vague complaints that arise only in the context of close relationships.  Or by a lack of meaning in life.   Or by unwitting self-sabotage.  Not uncommonly, they really can’t say what is wrong.  No RCTs exist for such problems, as there is no diagnostic group to randomize, no concrete symptoms to treat.

It reflects a fundamental misunderstanding — or false advertising — to promote “evidence based psychotherapy” for these sufferers.  There is no such evidence, if by that we mean RCTs.  Yet if evidence is more broadly construed, as it was in the original conception of “evidence based medicine,” it is psychoanalytic therapy, not CBT, that is supported by far more evidence.

“Evidence based therapy” has quickly become an empty phrase that slights the competition.  The evidence is real, but its relevance often is not.  This false narrative has misled insurers, government agencies, and many patients into believing certain approaches to psychotherapy are inherently superior when they are not.

Cognitive, highly structured, symptom-focused therapies certainly help many people.  Psychoanalytic therapies, and other therapies that rely on depth and relatedness, do as well.  The best choice for an individual depends on factors unique to that person, starting with his or her presenting complaints and preferences.  It may or may not be relevant that a particular therapeutic approach works against specific symptoms as tested in RCTs.  “Evidence based” is mostly sales-talk, not a blanket scientific endorsement.  All mainstream psychotherapy is evidence-based.

Image by Gerd Altmann from Pixabay