Wednesday, September 21, 2011


Although I'm skeptical of anything written in Time magazine, this article is full of very interesting and somewhat radical information.  I am always looking for information on ways of improving the transmittal of mental health care.

My comments and observations are continued on another post.

Q&A: A Yale Psychologist Calls for the End of Individual Psychotherapy

By Maia Szalavitz Tuesday, September 13, 2011

Is individual therapy overrated and outdated? Yes, says Alan Kazdin, a professor of psychology and child psychiatry at Yale University, writing in the leading journal Perspectives on Psychological Science.

Kazdin contends that treatments for mental health issues have made great strides over the last few decades, but the problem is that these evidence-based therapies aren't getting to the people who need them. Nearly 50% of the American population will suffer some kind of mental illness at least once in their lifetimes, but the mental health field, which relies largely on individual psychotherapy to deliver care, isn't equipped to help the vast majority of patients.

TIME spoke with Kazdin about his views and recommendations for change.

Q: Why did you decide to speak out about this issue?
A: For me, it's like an emperor's new clothes situation. All these people — including me — do very expensive controlled trials of therapy and yet we see that most people aren't getting treatment at all. Something is wildly, drastically wrong.

In Manhattan, which has no shortage of therapists, I've asked for referrals for evidence-based treatments like cognitive behavioral therapy and several times had high-level professionals be unable to provide one.

Totally! [It is hard to get] evidence-based treatments. Among the many reasons is that scientific innovation in any field normally takes a decade or two to filter down to the public. It's somewhat sad, but normal. Most people practicing who are 50 years old or older weren't trained in them and they don't know how.

Many therapists say they want to be "eclectic," rather than trying any new treatment system that has been proven to work.

That's a red herring: I individually tailor treatment specifically for you. The research shows that no one knows how to do that. [And they don't know how to monitor your progress.] Think about if you went to your physician and had a blood test, but they never read the results. They don't have any idea if you're getting better. It's ridiculous.

So why aren't patients clamoring for better therapy?

This is a very sad commentary for me. When I was starting out, I thought that the public would be an ally, but research shows that satisfaction with therapy is not very much related to getting better. [So, they don't necessarily realize they are not getting good treatment.]

MORE: Study: How Chronic Stress Can Lead to Depression

What do you think should be done?

The first thing we need is the commitment of professionals to really help people. We need very different ways of giving treatment. Many of them are out there already. For example, there are online treatments. There's self-help that could reach millions of people in need, if we did things other than one-to-one New Yorker cartoon psychotherapy. We should have more guidelines [about what to do therapeutically] — that would offend the profession, but benefit the public.

I'm proselytizing only because someone has to look at this inertia. Right now in time zones all over country, someone is getting evidence-based treatment but there are eight or nine other people who aren't getting anything.

But if you don't have professional guidance, there's lots of self-help that is ineffective or even harmful.

Here's what's really hard. The self-help literature has a pile of evidence-based treatments that are well-studied in randomized controlled trials. But the poor public has no chance. You go to the bookstore or look online, and 99% of what you get is someone winging it. Those are not usually evidence based.

The profession should be out there taking the moral high ground [and providing appropriate guidance].

There are a couple of online cognitive behavioral treatments for clinical depression that have been shown to work in randomized controlled trials. The profession should be proselytizing, telling people that there's online treatment that's free or inexpensive, and if that doesn't help, then maybe you should see a therapist.

But what about the studies suggesting that it's the relationship between the therapist and the client — not the technique — that matters?

There's no real evidence for this. Yes, a good relationship is related to clinical outcome but it plays no causal role whatsoever. Some new therapies don't require a relationship at all. For example, there's essay-writing therapy for trauma. It's a set of self-administered treatments, there's no relationship there — it's not even an essential condition.

It's way overplayed. We did a study showing that the relationship isn't so special. The quality of the relationship [between therapist and patient] relates to how social the patient was before treatment. It may be correlated to effectiveness of treatment, but the relationship has not shown to be causally involved.

If you want to get over an anxiety disorder, do graduated exposure. But sit down and relate to me or love me like your mom and dad? There's no evidence for that.

MORE: The Third Wave of Therapy

Don't people need some sort of social support, though?

Social support is needed. The feeling of isolation is related to immune system [dysfunction] and early death. Sometimes, that's all therapy is. There was a 1986 book called Psychotherapy: The Purchase of Friendship. So, what am I coming for? It might well just be to chat; that's beautiful, but don't come for anxiety or depression.

How about to mobilize people's own support systems?

That's not what therapists are talking about. It's me, my wonderful relationship to you is going to change your whole life? It's way outdated.

So, who's going to help people find treatment? A general practitioner?

It's unrealistic to ask GPs to do it. It might be handled by professional authorities, or government could help people find the appropriate consortium of online services. You could have some sort of decision tree. Right now, we're missing most people who need care. There could be an app for this...

And how do you let people know about the help that could be available?

That itself needs a portfolio of communications. There could be pamphlets and brochures available when you go to the doctor's office. In [Scandinavian countries,] when they want to get rid of bullying, they do things like put information on milk cartons. But that's a marketing, communications, business school issue. It's a challenge for psychology, but we also really need to get collaborators involved and bring in the expertise of other fields to make it happen.

What do you think people can do to help change the mental health system?

We should unite in some way to try to bring together a critical mass of people who would have a voice to educate the public and serve at least as triage.

Won't psychologists see this as a threat to their livelihood?

They're already not doing too well. And if professional and public priorities come into conflict, the only way to go is to [favor] the public, to take the moral high ground. People are genuinely suffering.

MORE: Timely Treatment for Depression Is Hard to Get, Even for the Insured
Maia Szalavitz is a health writer at Find her on Twitter at @maiasz. You can also continue the discussion on TIME Healthland's Facebook page and on Twitter at @TIMEHealthland.

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