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Rat race and the twilight of psychotherapy

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This is the second in the series of introductory articles on the Multidimensional Model of Change and Emotional Safeness Therapy (a modular group treatment for recurrent depression, successfully implemented and run at the Akershus University Hospital in 2015-2018).
The introductory text had become so long that I decided to chop it into smaller blog posts to make more digestible.

In order to understand a broader context of the development of Multidimensional Model of Change, it’s useful to understand the gap between clinicians and researchers in how both groups approach psychotherapy. While researchers attempt to continually produce something new in order to get published and to justify their existence, clinicians look for something reliable and solid. Emotional Safeness Therapy has been developed by clinicians, working in public mental health services, guided by a strong commitment to create nothing new. The idea was to reuse existing stuff in new configurations, and to sort out what’s solid from the crypto-marketing noise. Now it’s up to the readers to evaluate whether we succeeded in that.

After clarifying the difference between researchers and clinicians, let’s take a look at the history of psychotherapy research. Empirical studies on psychotherapy as a distinct branch of applied science can be traced back to Eysenck’s work in the early 1950’s. Yet, the mainstream research has quickly abandoned professional distinctiveness of psychotherapy as a separate discipline. Many psychotherapy researchers turned towards the bio-mechanistic approach to health. Their ambition was to mimic the clinical research of somatic medicine and this ambition gradually became the mainstream scientific approach not only to somatic but also to mental health.

I call this approach a “billiard model” because it investigates any clinical intervention (including psychotherapy) as if it was a billiard game. According to the mechanistic approach to health, the use of a certain therapeutic intervention or procedure (let us say: taking a pill) can be compared to striking and setting in motion the first bill in the game. Its impact should cause some changes within the next bill (let us say: reduction of the bacteria population) which was hit indirectly. Those changes, in turn, are aimed at affecting health outcomes or, using the billiard metaphor, hit the “recovery bill” and score final points. The intervention which scores the highest number of points wins the competition.

The main rules of the game are set by the research design called double-blinded randomized trial, in which an active intervention is compared to an undistinguishable placebo (neutral) intervention. If the real intervention is more efficient than placebo, we can assume that something more than just clients’ expectations was involved in healing.
Double-blinded means that neither patients nor those who deliver the intervention have any idea about who receives the real treatment and who receives placebo, because this knowledge would contaminate the results.

This design is hardly applicable in the psychotherapy research. Firstly, it’s difficult to make a neutral placebo-psychotherapy, because we’re not quite sure through what processes psychotherapy works. For example, in order to eliminate therapeutic relationship, we had to deliver intervention via channels that exclude any involvement of human beings, like the internet, . This would seriously limit populations to which the treatment would be applicable (you can’t, for instance, treat people at risk of suicide in this way). Moreover, results of such interventions can’t be generalized to other contexts, like face to face therapy. Secondly, can you imagine a trial where therapists have no idea what kind of psychotherapy they deliver? However, the RCT design became THE standard in psychotherapy research – yet in a flawed version.

Those who adopt the mechanistic approach to health problems believe that there are specific pathological processes located within the organism (biological or psychological) that, under certain circumstances, cause a disorder. These processes should be identified, targeted by an appropriate intervention and reversed. Mechanistic approach assumes a straight, causal relationship between the intervention and the outcome, and reminds me of the mechanism of hydraulic breaks: (1) you push the pedal, (2) the brake fluid in the cylinder gets higher pressure and (3) it pushes brake pads against the spinning rotor to produce the breaking effect at the other end of the mechanism. In the mechanistic clinical research, the brake fluid is called the mediator of change.

The mechanistic clinical research seems to have worked pretty well for the somatic branches of medicine. It brought about more efficient drugs and technologies. There is no doubt that we have better medicine now than thirty years ago. But can we say the same about psychotherapy?

Status presens

Since randomized controlled trials have been adopted as the golden standard in psychotherapy research their most visible impact on the field was the launch of the continuous rat race between various therapeutic schools. Sometimes it makes an impression that outperforming others became more important than being helpful for those who need our help. Results of flawed clinical trials have been commonly oversold and used as crypto-marketing tools to promote particular training programs, sell books, gain new grants and kick competitors off the market. In the meantime, … let’s have a look at the field.

Depression, which just a few years ago had the fourth place in the sad ranking of the Global Burden of Disease, will climb up to its first place by 2030, according to the WHO. By that time the amount of disability and life loss due to depression will be greater than that of any other medical condition, including cancer, stroke and heart diseases. In the last 45 years suicide rates have increased by 60 percent worldwide and they continue rising, despite the fact that our field has produced an impressive number of empirically supported treatments and RCTs. Research shows that two out of three people who commit suicide are clinically depressed at the point of their death. While the WHO reports gradual improvement of global somatic health, the same can’t be said about mental health.

And here is a paradox: while mental health in western countries seems to be in decline, the market of easy-to-chew self-help books is rapidly growing. Only in United States its value is estimated at 10 billion dollars per year. That’s more than the budget of some countries. And what if there is a direct link between the growth of this market and the decline of mental health?

And another question is how the current clinical research strategy improved clients’ confidence in our work. I claim that it didn’t. Looking around the world we can notice that only in the United States, from 1998 to 2007, the number of patients in mental health care receiving psychotherapy fell by 34 percent, while the number receiving medication as a stand-alone treatment has increased by 23 percent. Even when people can afford it, 85% of those who need psychotherapy choose not to go to a therapist, and 56% of those who go, choose to discontinue the treatment after the first visit. Those numbers have increased in the recent years. In western countries people who experience emotional troubles are still more likely to seek help from a healer or a fortune teller than turn to a professional. This is not the case with somatic problems.

Psychotherapy is a potentially lifesaving and life changing interaction between humans, but – without jumping to more specific conclusions – something obviously went wrong in our field in the last three decades so that its potential fails to be utilized. The rat race between psychotherapeutic approaches did not make things better, and certainly not for those who need help.

Looking at the field from a clinician’s perspective: while listening to some prominent psychologists who vow to create a new and better reality I just notice their extraordinary ability to ignore the existing one.

To integrate or not to integrate – this is the great question

Actually, the question’s not so great. The majority of clinicians have already found the answer: they deliver eclectic interventions. While academic tribes (read: labs) continue their war with RCTs, clinicians tend to tailor interventions to users by combining therapeutic strategies from different, sometimes competing traditions. Eclecticism became a very common, perhaps predominant psychotherapeutic approach, which is a natural and understandable phenomenon. It just reflects the clinical wisdom and experience of mental health providers: no intervention is omnipotent and universal. Even those trained in very comprehensive therapies tend to borrow something from outsiders.

However, although the question whether to integrate different approaches seems to have been answered by clinicians, the question “how to integrate” remains open. The art of blending techniques would be difficult to defend if it only remained an art. The risk of functional incoherence (more about this issue in my previous article) is real in our field. Clinicians need a kind of integrative road map and the Multidimensional Model of Change, which I’m discussing in my next blog post, was meant as a such.

Contextual approach to psychotherapy

Our team chose a contextual approach to psychotherapy as an alternative to the hydraulic, mechanistic view of mental health. (You can read more about the difference between contextualism and mechanism in one of my previous blogs.)

Although clinical researchers generally share the view that there are many paths into a mental disorder, at the same time many of them behave as if there was only one path out: psychodynamic vs CBT, third wave vs second wave, alliance vs technique, context vs content, genes vs environment, pharmacotherapy vs psychotherapy, you name it.

We decided not to engage in futile disputes, and our view on psychotherapy (and mental health) can be summarized in the following points:

  1. Symptoms, like any psychological events, cannot be meaningfully separated from their context. It’s the context that establishes their function and meaning. So, conceptualization of clinical problems must always be done in all relevant contexts.
  2. Psychotherapy is a potentially powerful social interaction that occurs in a certain, complex context (biological, historical, cultural, political, social, economic etc.). The context of any intervention establishes its function and should be viewed as its inseparable part.
  3. Therapeutic change occurs simultaneously via multiple paths, which interact and mutually moderate each other. These paths are not alternatives, so none of them can be dismissed by the therapist. They can only be ignored, or acknowledged and addressed, when possible.

These three points laid the foundation for our work on the development of MMC/EST and can be viewed as the theoretical manifesto of our team.

A variant of the contextual model of psychotherapy has been lately promoted by Bruce Wampold and his colleagues. Our team did not adopt their model as a ready-to-wear conceptual product. There are some aspects of the model that sounded disputable to us due to definitional and operational issues, like downplaying the role of therapeutic strategies and techniques (more on that in a separate article). However, we viewed their work as a great inspiration and as the most promising direction in psychotherapy research up to date.

In my next article I’m presenting the Multidimensional Model of Change itself, with a discussion on its clinical applications. Stay attuned!

If you have any questions about the possibility of training, research collaboration or implementing MMC/EST at your place, feel free to contact me.

CC BY-NC-ND 4.0 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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licensed clinical psychologist, psychotherapist, researcher, peer-reviewed ACT trainer
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