Renouncing Psychology

Deutsch: Phrenologie (Photo credit: Wikipedia)

Well, maybe not quite yet. 

It did get your attention, though, didn't it? 

And it's true, I do have a beef with psychology. My introduction to psychology was accidental, a story many of you have heard. I wandered into a psych prof's office when I was getting signed up for a business degree, and the rest, as they say, was history. 

But these were academics. I got introduced to clinical psychology through Ann McAllister and Stuart Strenger, Ph.D.s who practiced together in Buckhead back in the '70s. They were wonderful clinicians and even better human beings, and I wanted to be like them when I grew up. 

Twenty years later, I was surrounded by so many psychologists whom I could not even like, never mind respect, that I began to wish I'd never let my counseling license go. I no longer wished to identify with the arrogance, callousness, unscientific thinking, unprofessional behavior, and outright greed that I was encountering on a daily basis. The profession, however, I still loved. I was proud of the science of psychology. 

Psychology was already changing, however, and I can't say I like the direction it has taken. So while I am not quite ready to disavow it, I do have a beef. 

Once upon a time, the scientists in psychology were all rat-runners. The psychotherapists were all theorists. And their theories generally took into account the whole human being. Psychotherapy was an emotional, intellectual, psychological -- dare I say it? -- even spiritual journey that the therapist and patient/client took together. 

And then, along came Skinner. That was the start of our slippery slope. 

Don't get me wrong: Behaviorism is a damn good theory, and behavioral therapies have some great applications. But what happened next was that, coincidentally with our long-standing desire to be taken seriously as doctors came the push to be included in insurance reimbursement, to be classed as healthcare providers. And that, my dears, was the beginning of the end as far as I'm concerned. 

 The number of mental illnesses we can diagnosis (and of course this is psychiatry's fault, not psychology's, but it stems from the same sources and we've been on board with it from the git-go) has multiplied astronomically from what it was 50 years ago. Everything's abnormal now, treatable, and most importantly from the point of view of many practitioners, reimbursable. 

The twin drives to be taken seriously and be paid as doctors has spawned the evidence-based practice movement, a child of the devil if ever there was one. Ironically, perhaps, it is also the part of the science of psychology with which I most identified in the early days. Why would we waste people's time and money, and offer false hope, for silly woo-woo therapies that don't work? Let's study what does! Sounds great, right? But somehow, in the process, we have reduced diagnosis and treatment if not to the level of the petri dish then to something scarily close to it.

Therapies are manualized. Follow this cookbook recipe with every client you have with this diagnosis, and they'll get better. It's pigeonholing clients, and reducing professionals to technicians. Everything, even assessment, is by the numbers. The person's humanity is out the window, all their experiences and dreams and complexity reduced to three symptoms from group A, two from group B, for a duration of not less than two years, and not due to some other specified disorder or circumstance listed in Appendix C.

Worse, the therapies don't work. Or they only work in the lab. One I got all excited about last year after a workshop turned out to be this sort of dud. Thirty percent of the potential participants in the big study its proponents were trumpeting were weeded out before the study ever started. They had more than one problem, or they were on medication, or whatever variation in their circumstances that normal human beings coming into clinician's offices every day exhibit. So at best, I'm thinking as I'm reading this, the new treatment works with 70% of people with this diagnosis, right?

Not so fast, Virginia. No fewer than 50% of the folk enrolled in the study dropped out! So now, if the new treatment helped every single one of the completers (which, of course, it didn't), we're talking about a therapy that is effective for 35% of the folk for whom a clinician might consider it. Thirty-five percent.

And yet this has now become the only approved therapy for this disorder.

I kid thee not. It works for maybe 35% of the population with this disorder, but if I don't deploy it with every one of them who walks through my front door, I will not be treating my people according to the standard of care, once this gets written into the standards, which it will. Mark my words.


Ironically, chasing the money has led us to fly directly in the face of the best and latest science, offering "treatments" that are absolutely proven not to work for "disorders" that are pretty much proven by now not to exist because they are lucrative. Jumping on the weight-loss bandwagon, as psychology has over the past year or two, is perhaps the best example.

I'm done.

I want to go back to sitting with my clients. And no, they're not patients. They're not sick! I want to go back to being with my clients, not sitting there trying to look attentive while running algorithms in my head or jumping ahead to what I'm supposed to say next according to the treatment protocol. I want to go back to the day when the therapeutic relationship was the primary healing factor, when my own best tool was my self, not a checklist with lines and boxes and graphs to complete to tell me what's the matter with the person. I want to go back to the day when my care was caring, not steps I followed in a manual, to a time when good therapeutic technique mattered, yes, but when there was an art to it.

Is that too much to ask?

Why I Hate Managed Care in General, and the Medical Model in Particular

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So this arrogant psychiatrist in another state, who has never met nor spoken to my patient, decides in less than 10 minutes on the phone* to deny coverage for depression and ADD because she's made only minor progress in 12 weeks of outpatient psychotherapy ("three months!" quoth he, obviously horrified).

Oh, yeah, and because she's not getting "standard" (read: "cheaper") treatment, to wit, psychotropics.

He actually asked me why I was asking for more sessions! Um, because she's still depressed? still has family issues? Still doesn't know what she wants to do with her life? After all, he says, it's not working, is it?

Yes, it is. It may be slow, but it is working. Her problems have been years in the making and we're not going to turn them around in three months. He seemed astounded by this concept.

He implied more than once that my treatment of her was substandard. She wants a non-drug solution and I'm not forcing the issue, partly because her depression is moderate, therefore not an emergency, and partly because most of it is environmental in origin, not endogenous. As for the ADD, well, it is definitely holding her back, but it's not going to kill her, and I see the decision whether to medicate or try adaptations and accommodations as a personal one. I respect patients' ability to make decisions like that for themselves, and support their right to do so.

And by the way, the standards of care are written by--wait for it--the American Psychiatric Association.

Not to mention, success with medication is hardly guaranteed. I have had dozens of patients who have not responded to medication after medication after medication. Do insurance companies then want to stop paying for any more drugs? No. This is about money, pure and simple, and it pisses me off. This, people, is why we need national health care.

So if your insurance company doesn't want to pay for ongoing psychotherapy, fine. If it doesn't fit within their definition of "medically necessary," fine. I get that, and I have no problem with it. But don't imply that my work is substandard, dude. Do not go there.

*actually, he'd clearly already made up his mind before he even picked up the phone, based on a one-page request form I'd faxed in. I suppose I should have claimed "moderate" progress on the form. Her role functioning has improved because she's learning to structure herself better ("yes, but is her concentration better?" the insurance company care manager wanted to know) and she's made one of the major life decisions she came here to make. But I really feel we're just getting started. "Moderate" to me implies that we're about halfway through. "Major" progress would be close to the end, right?

While I was writing this the care manager called to see if I wanted to appeal. You betcha! And she pointed out that this all happened because I didn't return their calls quickly enough to suit them. I got passed on for this "peer review" thingy (Do you really think he's my peer? Do you think he's got a doctoral degree in psychology and 30 years experience providing psychotherapy?) partly to punish me.

Anyways, if I had, she went on to say, she "might" have given me two more sessions!! to get the client to agree to a med consult.

Makes me want to set my head on fire.