{"id":1615,"date":"2022-08-07T23:54:59","date_gmt":"2022-08-08T06:54:59","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=1615"},"modified":"2024-01-10T10:10:56","modified_gmt":"2024-01-10T18:10:56","slug":"dr-tom-insel-scorns-traditional-psychotherapy","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=1615","title":{"rendered":"Dr. Tom Insel scorns traditional psychotherapy"},"content":{"rendered":"
\n
\"Dr.<\/figure>\n<\/div>\n\n\n

When one of America\u2019s most prominent psychiatrists expresses deep disdain for depth psychotherapy, especially when that criticism is misinformed and hopelessly outdated, it should concern all of us.<\/p>\n\n\n\n

Dr. Tom Insel directed the National Institute for Mental Health (NIMH) from 2002 to 2015.  Formerly a psychiatric researcher \u201cat the <\/a>cellular<\/a> level<\/a>,\u201d he studied<\/a> medications and neuroscience.  Insel admits<\/a> that under his directorship the NIMH didn\u2019t improve care for those with serious mental illness (SMI):<\/p>\n\n\n\n

\n

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\u2014I think $20 billion\u2014I don\u2019t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.<\/p>\n<\/blockquote>\n\n\n\n

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 \u201cbehavioral health czar\u201d to Governor Gavin Newsom of California.<\/p>\n\n\n\n

Even at age 70, Insel apparently hasn\u2019t 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<\/em> (Penguin Random House, 2022).<\/p>\n\n\n\n

The book\u2019s main message is that we can already help most people with SMI.  We \u201cmerely\u201d 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.<\/p>\n\n\n\n

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\u2019s all perfectly sensible, if unsurprising.<\/p>\n\n\n\n

Unfortunately, there\u2019s a glaring bias in Insel\u2019s narrative.  Throughout the book, and confirmed in a recent interview<\/a> with the New York Times<\/em>\u2019 Ezra Klein, Insel repeatedly denigrates psychoanalysis, psychodynamic therapy, and all psychotherapy that is not symptom-focused or \u201cskills based.\u201d<\/p>\n\n\n\n

Insel claims such therapies are “eminence-based care” in contrast to \u201cevidence based\u201d [pg 103], and that psychoanalysis is \u201cnot by itself a treatment for mental illness\u201d [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\u2019s 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:<\/p>\n\n\n\n

\n

That\u2019s not what you get with talk therapy that\u2019s not focused. It doesn\u2019t have an evidence base. So I\u2019m 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.<\/p>\n<\/blockquote>\n\n\n\n

In his book Insel falsely claims that Victor Frankl developed logotherapy, a type of existential psychotherapy, in reaction \u201cto the introspection and self-absorption of psychoanalysis\u201d [pg 174]. (Logotherapy aims to be more positive<\/a> than Freudian analysis, not less introspective.)  Writing about ELIZA, an early computer program designed to (roughly<\/a>) mimic client-centered Rogerian therapy, Insel treats ELIZA\u2019s simple algorithmic responses as though they accurately reflected Carl Rogers himself: \u201cOf course, the Rogerian therapist, with this obnoxious reflexive response, was hardly better than a robot and certainly an easy form of \u2018natural language\u2019 to automate\u201d [pg 204].  In rushing to condemn such therapy, Insel conflates a primitive computer program with a real therapist who was neither obnoxious nor reflexive.<\/p>\n\n\n\n

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 \u201ccouches\u201d and \u201cchildhood stuff\u201d of traditional Freudian analysis, as well as their updated vision of therapy larded with strategies and jokes:<\/p>\n\n\n\n

\n

I\u2019m 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]<\/p>\n<\/blockquote>\n\n\n\n

\n\n\n\n

There\u2019s a lot to look at here.  First, mental illness, including SMI, is very heterogenous.  Schizophrenia, bipolar disorder, and OCD count, but by Insel\u2019s 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.<\/p>\n\n\n\n

Most psychiatrists (but not<\/a> all<\/a>) agree there is little direct role for insight-oriented, depth psychotherapy in the treatment of schizophrenia<\/a>, bipolar<\/a> disorder<\/a>, or OCD<\/a>.  Nonetheless, even in these conditions, therapies of \u201cdepth<\/a>, insight, and relationship<\/a>\u201d can help a sufferer come to terms with his or her debilitating condition, reflect on issues of self-identity and life\u2019s meaning, improve treatment adherence, and provide emotional support.  In other words, even when such therapy doesn\u2019t treat the problem itself, it can help the patient deal with feelings about the problem.  The relationship can be stabilizing and very valuable.<\/p>\n\n\n\n

It\u2019s a far different matter when it comes to depression, PTSD, borderline personality, and many other potentially devastating conditions.  Here we see much<\/a> stronger<\/a> evidence<\/a> for<\/a> the<\/a> benefits<\/a> of in-depth psychotherapy.  Insel is plainly mistaken when he implies that such psychotherapy lacks the evidence of efficacy that other therapies have:<\/p>\n\n\n\n

\n

\u2026 for many issues (e.g., depression, anxiety, eating disorders, PTSD) there are specific therapies that have been validated empirically \u2014 sometimes called empirically supported treatments. [pg 252]<\/p>\n<\/blockquote>\n\n\n\n

It is a widely-held but false<\/a> belief<\/a> 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.\u201d They clearly are.<\/p>\n\n\n\n

Perhaps worse are the outdated stereotypes he uses to denigrate such therapy.  Yes, many decades ago psychoanalysts blamed \u201crefrigerator mothers\u201d for autism and \u201cschizophrenogenic\u201d mothers for schizophrenia.  Dismissing current analytic practice for these old errors is just as silly as dismissing modern biological psychiatry for previously using lobotomy.<\/p>\n\n\n\n

Contemporary analytic therapy doesn\u2019t 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\u2019s an influential speaker and writer, it would be good if his prejudices evolved too.<\/p>\n\n\n\n

By far the most ironic twist is Insel\u2019s newfound emphasis on the importance of people (\u201cpeople, place, and purpose\u201d) 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:<\/p>\n\n\n\n

\n

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]<\/p>\n<\/blockquote>\n\n\n\n

Why hasn\u2019t 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 \u201cmove the needle in reducing suicide, reducing hospitalizations, [and] improving recovery.\u201d  Finding out probably won’t cost anywhere near $20 billion, yet it still awaits serious attention by NIMH.<\/p>\n\n\n\n

\n\n\n\n

Page numbers refer to Insel T, <\/em>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<\/a>.<\/em><\/p>\n\n\n\n

<\/p>\n","protected":false},"excerpt":{"rendered":"\n

When one of America\u2019s most prominent psychiatrists expresses deep disdain for depth psychotherapy, especially when that criticism is misinformed and hopelessly outdated, it should concern all of us.<\/p>\n

Dr. Tom Insel directed the National Institute for Mental Health (NIMH) from 2002 to 2015.  Formerly a psychiatric researcher \u201cat the cellular level,\u201d he studied medications […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[4,8],"tags":[52,45,53],"class_list":["post-1615","post","type-post","status-publish","format-standard","hentry","category-current-events","category-psychotherapy","tag-neuroscience","tag-psychiatric-research","tag-psychodynamics","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1615","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1615"}],"version-history":[{"count":7,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1615\/revisions"}],"predecessor-version":[{"id":1691,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1615\/revisions\/1691"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1615"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1615"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1615"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}