Dr. Tom Insel scorns traditional psychotherapy

Dr. Tom Insel.  National Institute of Mental Health, Public domain, via Wikimedia Commons

When one of America’s most prominent psychiatrists expresses deep disdain for depth psychotherapy, especially when that criticism is misinformed and hopelessly outdated, it should concern all of us.

Dr. Tom Insel directed the National Institute for Mental Health (NIMH) from 2002 to 2015.  Formerly a psychiatric researcher “at the cellular level,” he studied medications and neuroscience.  Insel admits that under his directorship the NIMH didn’t improve care for those with serious mental illness (SMI):

I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.

After NIMH, Insel led the mental health initiative at Verily, the Google-spawned health science company; co-founded Mindstrong Health, a digital mental health company focused on SMI; launched Humanist Care, a recovery-oriented online therapeutic community; and served as “behavioral health czar” to Governor Gavin Newsom of California.

Even at age 70, Insel apparently hasn’t found a comfortable place to settle down.  But having learned a thing or two, he wants everyone to know.  Thus his book Healing: Our Path From Mental Illness to Mental Health (Penguin Random House, 2022).

The book’s main message is that we can already help most people with SMI.  We “merely” lack the social and political will to make it happen.  He grossly downplays these social and political challenges, offering only a roadmap, not policy proposals.

The roadmap, though, is fundamentally sound: comprehensive biopsychosocial care.  In other words, the biological treatments Insel knows so well, plus skills training, peer and family support, therapeutic communities, a shift from incarceration to treatment, and so forth.  It’s all perfectly sensible, if unsurprising.

Unfortunately, there’s a glaring bias in Insel’s narrative.  Throughout the book, and confirmed in a recent interview with the New York Times’ Ezra Klein, Insel repeatedly denigrates psychoanalysis, psychodynamic therapy, and all psychotherapy that is not symptom-focused or “skills based.”

Insel claims such therapies are “eminence-based care” in contrast to “evidence based” [pg 103], and that psychoanalysis is “not by itself a treatment for mental illness” [pg 51]. He believes that traditional psychotherapy blames parents and families for mental illness, and that only by discarding these outmoded approaches, families can now be part of a patient’s support team.  He derides analytic therapy as dwelling on childhood, not current life.  By contrast, according to Insel, evidence-based therapy focuses on learning skills:

That’s not what you get with talk therapy that’s not focused. It doesn’t have an evidence base. So I’m a huge proponent of psychotherapy, but it has to be psychotherapy that actually involves those kind of skills learning that has a kind of scientific basis to it with people trained to do it in the way that works.

In his book Insel falsely claims that Victor Frankl developed logotherapy, a type of existential psychotherapy, in reaction “to the introspection and self-absorption of psychoanalysis” [pg 174]. (Logotherapy aims to be more positive than Freudian analysis, not less introspective.)  Writing about ELIZA, an early computer program designed to (roughly) mimic client-centered Rogerian therapy, Insel treats ELIZA’s simple algorithmic responses as though they accurately reflected Carl Rogers himself: “Of course, the Rogerian therapist, with this obnoxious reflexive response, was hardly better than a robot and certainly an easy form of ‘natural language’ to automate” [pg 204].  In rushing to condemn such therapy, Insel conflates a primitive computer program with a real therapist who was neither obnoxious nor reflexive.

Finally, Insel praises Woebot, a chatbot that provides a version of CBT.  He quotes Woebot (actually, its programmers), apparently sharing their sneering disdain for the “couches” and “childhood stuff” of traditional Freudian analysis, as well as their updated vision of therapy larded with strategies and jokes:

I’m here for you 24/7.  No couches, no meds, no childhood stuff.  Just strategies to improve your mood.  And the occasional dorky joke.  [pg 215]

There’s a lot to look at here.  First, mental illness, including SMI, is very heterogenous.  Schizophrenia, bipolar disorder, and OCD count, but by Insel’s reckoning, so do major depression, PTSD, and borderline personality disorder.  This broad category of SMI obscures a wide variation in the applicability of various psychotherapies.

Most psychiatrists (but not all) agree there is little direct role for insight-oriented, depth psychotherapy in the treatment of schizophrenia, bipolar disorder, or OCD.  Nonetheless, even in these conditions, therapies of “depth, insight, and relationship” can help a sufferer come to terms with his or her debilitating condition, reflect on issues of self-identity and life’s meaning, improve treatment adherence, and provide emotional support.  In other words, even when such therapy doesn’t treat the problem itself, it can help the patient deal with feelings about the problem.  The relationship can be stabilizing and very valuable.

It’s a far different matter when it comes to depression, PTSD, borderline personality, and many other potentially devastating conditions.  Here we see much stronger evidence for the benefits of in-depth psychotherapy.  Insel is plainly mistaken when he implies that such psychotherapy lacks the evidence of efficacy that other therapies have:

… for many issues (e.g., depression, anxiety, eating disorders, PTSD) there are specific therapies that have been validated empirically — sometimes called empirically supported treatments. [pg 252]

It is a widely-held but false belief that only symptom-focused psychotherapy, usually cognitive behavioral in nature and sometimes manualized or algorithmic, is evidence based.  Insel should know better.  There is a large evidence base for analytic, depth therapies, particularly for depression and anxiety.  Consequently, he is also mistaken when he declares these therapies are not by themselves “a treatment for mental illness.” They clearly are.

Perhaps worse are the outdated stereotypes he uses to denigrate such therapy.  Yes, many decades ago psychoanalysts blamed “refrigerator mothers” for autism and “schizophrenogenic” mothers for schizophrenia.  Dismissing current analytic practice for these old errors is just as silly as dismissing modern biological psychiatry for previously using lobotomy.

Contemporary analytic therapy doesn’t blame parents or anyone else, nor is it trapped in endless rehashing of childhood.  It tackles plenty of present-day, pragmatic concerns.  But it does so while revealing underlying thoughts, wishes, fears, and more complex emotions, and while closely attending to the relationships the patient forms with the therapist and others.  Like everything else, psychoanalysis has evolved in the past 50 years since Insel experienced it.  Since he’s an influential speaker and writer, it would be good if his prejudices evolved too.

By far the most ironic twist is Insel’s newfound emphasis on the importance of people (“people, place, and purpose”) and especially relationships for recovery from SMI.  This was his big insight in moving from a strictly biomedical view at NIMH.  While peer groups and clubhouses certainly provide support, the healing value of a close relationship with a caring therapist has been well known for at least a century.  The therapists Insel belittles have certainly known it all along.  His ultimate hypocrisy is complaining about, and failing to take responsibility for, the woeful dearth of research in this area:

But social connection is not simply the absence of loneliness.  Connection, experienced as support, attachment, or love, has a power that has not been studied sufficiently.  [pg 163]

Why hasn’t this power been studied sufficiently?  Surely, one guilty party is the former director of our premier mental health research agency, the NIMH.  The power of connection, experienced as support, attachment, or love, may very well “move the needle in reducing suicide, reducing hospitalizations, [and] improving recovery.”  Finding out probably won’t cost anywhere near $20 billion, yet it still awaits serious attention by NIMH.

Page numbers refer to Insel T, Healing: Our Path From Mental Illness to Mental Health, Penguin Random House, 2022, Kindle version. Quotations without page numbers are from the New York Times interview transcript.

14 comments to Dr. Tom Insel scorns traditional psychotherapy

  • The article cited below addresses widespread misunderstandings about existing research that clearly demonstrates the efficacy of psychodynamic psychotherapy. It also points to two other important factors related to outcomes in psychodynamic psychotherapy. (1) Effect sizes are larger later at followup than at the conclusion of therapy and (2) there are significant psychological/developmental benefits of psychodynamic psychotherapy beyond symptom reduction, which accounts for the larger effect sizes at followup.

    Shedler, J. (2010) The Efficacy of Psychodynamic Psychotherapy. American Psychologist, 65(2): 98-109.

    • Hello, and thank you for highlighting this article. Dr. Shedler provides the full text on his own website, so I assume he doesn’t mind if others share it. It’s linked to the word “stronger” in the phrase “much stronger evidence for the benefits” above, and here it is again.

  • Alicia

    As someone who has personally engaged in various therapy modalities for PTSD and Depression, I applaud your validation for psychotherapy. We should be challenging the growing belief of empirically based models (such as CBT), being the only solution to aiding in mental health recovery.

    While CBT was indeed helpful, I personally have seen the most significant shifts engaging in relational psychodynamic therapy. In my opinion, an effective mental health professional will utilize multiple skills and/or therapeutic modalities to help a client.

    I see it as a puzzle. When starting out, it’s helpful to start with the outside pieces and corners which we could view as the therapeutic tools. Then you start putting together clusters inside the puzzle, slowly integrating the clusters until the puzzle is complete, which would be the psychodynamic component.

    Thank you for the thought-provoking piece, challenging a biased and far too simple way of viewing the road to mental health recovery.

  • I just read your piece on Psychology Today. I could not agree more with the power of relationships. If a genuine, empathic relationship is not present, even learning skills may not have the same impact. I often think that the drive for time-limited protocols like CBT approaches is driven more by insurance companies directing how many sessions they will pay for… and if the ‘evidence-base” says in “X” sessions there is an improvement, it does not consider other factors like poverty, racism, etc… it is ironic that someone who headed up the NIMH is now denigrating the professions that have been leaders in paying attention to those who have been marginalized because of mental illness.

  • Chris

    With regard to eating disorders, Insel has a point. In 2014, a scientific experiment was published testing psychoanalysis as treatment for bulimia nervosa. Half the patients were treated with 100 sessions of psychoanalytic psychotherapy, the other half with 20 sessions of CBT. After two years, 44% treated with CBT were recovered, but only 15% of those treated with psychoanalysis were recovered. In other words, psychoanalysis had 1/3 the effectiveness and five times the monetary cost. Poulsen, A Randomized Controlled Trial of Psychoanalytic or Cognitive-Behavioral Therapy for Bulimia Nervosa, Am J Psychiatry 2014 Jan: 171(1): 109-116
    For anorexia nervosa, CBT was quicker and led to greater improvements in psychopathology as compared with Psychodynamic Psychotherapy,
    Zipfel, Psychodynamic Therapy, Cognitive-Behavioral therapy and Optimized Treatment as Usual . . ., Lancet, 2014 Jan 11, 383 (9912); 127-37
    For children. and teenagers with anorexia nervosa, FBT outperformed psychodynamic therapy in the leading randomized controlled clinical trial, Lock, Randomized Clinical Trial Comparing Family-Based Treatment with Adolescent Focused Individual Therapy for adolescents with Anorexia Nervosa, Arch Gen Psychiatry 2010 Oct; 67 (10); 1025-32

    • Hi Chris,

      There are certainly issues to raise in the studies you cite: Poulsen et al admit that “this is the first trial of the present version of longer-term psychoanalytic psychotherapy for bulimia nervosa.” That is, they developed the version themselves, and this is the first time they used it in a study. Zipfel et al found no statistically significant differences between the study groups. And Lock et al compared two treatments both developed by Lock; the one you are calling psychodynamic therapy is actually “adolescent-focused individual therapy,” described as combining dynamic, cognitive, and other approaches.

      Nonetheless, it wouldn’t surprise me if CBT really does reduce eating disorder symptoms faster than analytic/dynamic therapies. After all, CBT is tailor-made to reduce concrete behavioral symptoms, and it often does a good job with this specifically.

      I never claimed that Insel was mistaken to suggest that other treatments are sometimes (or even often) preferable. For example, I agree that medications lead to faster symptom reduction in acute psychosis or mania, and that CBT and behavioral treatments like “exposure and response prevention” are superior treatments for OCD. My objection is his wholesale rejection of analytic/dynamic therapies as lacking evidence of efficacy when that is plainly false, and demeaning such therapies using obsolete stereotypes.

      • Chris

        There is growing doubt that one of the eating disorders — anorexia nervosa — is actually a mental illness or susceptible to mental health treatments. A huge international study, The Anorexia Nervosa Genetics Initiative, has found evidence that genes involving metabolism may underlie anorexia nervosa. At the same time, the professional consensus (I’ve been a member of the Academy for Eating Disorders) is that professional psychotherapies have limited effectiveness treating the condition. We might draw a similarity with peptic ulcers, once blamed on psychological factors, now known to be caused primarily by bacteria and better treated with antibiotics than with psychotherapies.

        • The Academy for Eating Disorders emphasizes that eating disorders, including anorexia nervosa, are “serious mental illnesses” that include psychosocial risk factors. A strong genetic diathesis argues for likening anorexia nervosa to schizophrenia, not peptic ulcers. Both nature and nurture play a role.

          Like schizophrenia, the primary treatment for anorexia nervosa may someday be pharmacological (or genetic). When that day comes, psychotherapy will be secondary, but still potentially helpful, as I argue in the post regarding schizophrenia.

          But I’m left curious: your first comment touts the superiority of one type of psychotherapy, CBT, while your second casts doubt on psychotherapy in general. It seems to me that with effective biological treatment, there will be no need for symptom-focused CBT, yet still a place for in-depth exploration of self-image and relational issues.

        • Chris

          It is not surprising that the Academy for Eating Disorders classifies anorexia nervosa as a “mental” illness. That’s because the majority of members of that organization are psychotherapists. However, that classification is questioned by those who study the biology of anorexia nervosa. Other professional organizations involved with anorexia nervosa, including the Eating Disorders Research Society (considered by many to be more prestigious) tend to emphasize the biology of AN.

          The best treatment for anorexia nervosa does involve a biological agent — food. In other words, food is medicine. Semi-starvation has demonstrated effects on the structure, functioning, and even size of the brain, as shown by brain scans of those with the condition. When the sufferer from AN has been fully weight-restored for a substantial period of time, the biological functioning of the brain normalizes. Talk therapy while the brain is starving has been shown to be of limited effectiveness.

          CBT has shown better results than psychoanalysis. I haven’t said it’s the best treatment for AN, only that it’s better than psychoanalysis.

          There is no demonstrated need or role for self image or relational issues therapy after a sufferer has been fully weight restored and has re-established normalized patters of eating behavior.

          Thanks for the opportunity to comment on your blog.

  • Julia

    Viktor, spelled incorrectly in the article, Frankl did develop logotherapy as a therapy that directed individuals to find meaning in life- not because it was more positive. Frankl didn’t feel that the motivation behind the meaning in one’s life needed to be positive. He developed it as a result of his experience in the nazi concentration camps.
    Psychotherapy has been proven in study after study to be an integral part of the healing and wellness process. There is a new understanding in the importance of addressing the biopsychosocial model. It sounds like Dr.Insel has arrived at this conclusion.

    • Hi Julia,

      True, Frankl developed logotherapy from his concentration camp experiences. However, he considered logotherapy to be more positive than Freudian psychoanalysis. In the blog post, I linked to the website of the Viktor E Frankl Institute of America, which I took to be a definitive source. Here’s a quote:

      In contrast to Freudian traditions of depth psychology, Frankl referred to logotherapy as height psychology. Depth psychology is oriented towards the past and the dark, unconscious mysteries of an individual. There are times when this may be appropriate, but it reduces problems of living to something similar to a disease that needs to be cured. This approach puts the therapist in a position of authority and treats the patient as someone with a disability. Frankl once wrote, “Logotherapy declares war on pathologism” because of its orientation towards the future and the belief that humans have the capacity to move beyond inner and outer obstacles.

      I agree that Tom Insel embraces the biopsychosocial model. And that I misspelled Frankl’s first name. Thanks for writing.

  • What “Chris” wrote on August 22, 2022 regarding Anorexia Nervosa is the sheerest nonsense and sophistry. There is every reason to believe that psychodynamic therapy for work on self and relationships is helpful to patients who are recovering from eating disorders. I have known such people. Their emotional, family and characterological challenges certainly contributed heavily to their eating disorder – which could hardly be attributed solely to “starving brain.” I’m always amused when myopic reductionists read some studies and think they can dismiss the profoundly helpful role of depth therapy, even as an adjunct to CBT or meds.

  • Linda Meneken

    Hello. I am a senior physical therapist and have been practicing since 1975. I have treated patients in all age groups, from infants with torticollis to 90 year olds with strokes. I am so interested and fascinated with the World of Psychology, Psychotherapy, and Psychiatry…And, I totally believe in the mind-body connection, of course. In our PT curriculum, we had one course (yes, ONE only) on Abnormal Psychology. I truly feel that today’s PTs need MUCH MORE basic psych training in our teaching institutions. When men and women (particularly women) patients were relaxed lying on my treatment table, there were many episodes where they were revealing deep, heartfelt feelings and emotions, about their families, their work, their marriages (yikes!), their divorce, their childhood, etc. Of course, I would try to reassure and to redirect them back to why they should be improving their posture or stretching their hamstrings. However, in many cases, I would gently refer them to counseling. No wonder many people never seem to improve physically if they are not mentally or emotionally stable and sound! Thank you all for the great work that you do, in helping people attempt to see any Light at the end of a despairing, Dark Tunnel.

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