Today, as a result of external pressures from a state-driven audit culture brought about by the cultural components of neoliberalism, there exists less and less space for thoughtful psychotherapeutic study and practice, and a questioning of the assumptions of our ever-shallowing field and current organizational practices. The overregulation of psychotherapy, the manualization of both treatment and training programs, and an overwhelming focus on modalities that offer little more than symptom reduction and short term fixes have cumulatively sacrificed the art of psychotherapy with deleterious consequences spanning client, psychotherapist, and culture.
For thirty years we have lived within the zeitgeist of neoliberalism – an economic paradigm that came into the mainstream in the late 70’s and proposes that human well-being is best advanced by ensuring individual entrepreneurial freedoms and skills. This is it’s economic interpretation but a growing number of scholars view and refer to neoliberalism as a political ideology, mode of governance, and form of public pedagogy that deems profit making as part of the essence of democracy, consuming a primary action of citizenship, and the market able to solve most problems and adequate to serve as a model for structuring social relations. The most prevalent cultural components of neoliberalism include hyper-individualism, the tendency to act in a manner that benefits the self without regard for or accountability to others, society, the world, or the environment; commodification, the transformation of goods, ideas, and services, into objects of trade to include those items, which are not generally considered commercial items, such as education and human capital; and market ideology, an economic or transactional way of viewing something that focuses on efficiency and potential advantage. Though each of these is not unique to neoliberalism, together they offer a comprehensive account of the sociocultural effects of neoliberalism within the United States. Although it began as an economic paradigm, neoliberal characteristics now dominate personal, public, and systemic ways of thinking and behaving in the United States and around the world.
As a result of thirty years of a pervasive neoliberal ideology, negative outcomes within the United States are evident across a variety of domains from personal to public. Individually, we see unacceptable rates of suicide, depression, and anxiety among children, adolescents, and young adults. Narcissism has risen. Empathy has decreased. In our relationships, child neglect in the United States is up while contact time with children has declined as a result of labor policies that place the market and profit over family. Institutionally, in tandem with the implementation of neoliberal policies in the 1980s, a shift began in the U.S. educational system. By adopting neoliberal policies and practices, the U.S. educational system has begun to function as a business rather than an educational institution driven by a human-centered purpose. The past 25 years have brought with them an institutional emphasis on standardized testing and most recently, the invention of value-added measures, evidence of business models and paradigms being implemented within the educational system. In the same way the cultural components of neoliberalism have influenced our relationships, families, workplaces, and educational system, so too have they influenced entire disciplines and fields of thought and practice, including psychology and psychotherapy.
Traditional, mainstream psychotherapy has adopted a hyper-individualistic ethos by focusing primarily on the individual, and addressing pervasive, systemic problems as individual problems.
I recently spent a year providing individual and group psychotherapy to a primarily adult, outpatient population at a local community mental health organization. I discovered that despite the uniqueness of each client and their conceptualization of and experience with a variety of symptoms, I really only ever heard and helped treat a handful symptoms and disorders. Of course similar symptomatology is to be expected, as it is what any diagnostic system is based upon – a more or less homogeneous group of symptoms constitutes a particular diagnosis. However, it seemed that in the same way a group of homogeneous symptoms constitutes a particular mental health disorder, the prevalence and pattern of depression, anxiety, social phobia, panic, and substance abuse in the United States constitutes a larger and more systemic problem. Enter the cultural aspects of neoliberalism.
It seems we need a sort of public health model for mental health to hit the mainstream. Nearly 50% of the U.S. population will experience a mental health disorder at some point in their lifetime, and we have higher prevalence rates of mental health disorders than any other country in the world. And yet, though millions and millions of individuals are experiencing the same afflictions, we continue to conceptualize, diagnose and treat these disorders as disorders of individual functioning.
Cognitive Behavioral Therapy is the most widely studied and utilized evidence-based treatment for a number of common disorders including depression, anxiety, PTSD and OCD. It, along with several other similar treatments (i.e. DBT, Brief CBT), has proven effective at symptom reduction. Despite its evidence base and widespread use, I and others view this modality (and those similar) as a technique that treats little more than symptoms, and as ill equipped to elicit deep and substantive change. Rollo May, refers to this type of therapy as gimmick:
“Psychotherapy is facing a very profound crisis. I think the teachings of the fathers – Freud, Jung, Rank and Adler has been, in this crisis, almost completely lost. The problem is that psychotherapy has become more and more a system of gimmicks. People have special ways of doing their own therapy. They learn which particular buttons to push. They are taught various techniques by which they can cure this isolated symptom or that. And that wasn’t the purpose at all of Freud and Jung and the rest of the really great men who began our field. Their purpose was to make the unconscious conscious and there’s a great deal of difference between that. The gimmick approach leads to a general boredom. And the reason so many new systems in psychotherapy spring up is that therapists are bored. They are bored because they deal with the minor problems of life. They patch a person up and send them out again. I don’t regard that as real therapy at all. The therapy that is important as I see it is the therapy that enlarges the person, makes the unconscious conscious, enlarges our view. It enlarges our experience, makes us more sensitive, and enlarges our intellectual capacities as well as other capacities. This is what Freud was setting out to do. It’s what Jung, Adler and Rank tried to do. These people didn’t talk about gimmicks. It just didn’t interest them. What did interest them was making a new person.”
Amen. We need to look upstream, think broader, and examine what might be going on culturally that may be causing or contributing to this epidemic.
I would go a step farther and suggest that rather than traditional, mainstream methods of psychotherapy simply fitting into and adopting an individualistic ethos, perhaps these methods were born of it and now act as its extension – as a mechanism – of the status quo. Culture seems to me a central determinant in the outcome of therapy. Perhaps it also is, and has been, a determinant of theory, methodology and practice.
In the name of efficiency, effectiveness, and protecting the public, and with insurance companies and evidence-based modalities leading the cause, traditional, mainstream psychotherapy has adopted a market ideology and an audit culture.
Managed care has infiltrated the therapeutic relationship and is dictating treatment decisions. Insurance companies insist on a diagnosis within roughly 3 sessions – far before a therapist has had the opportunity to develop a deep and meaningful understanding of the client, and their symptoms and context. Insurance companies limit the number of sessions a client can be seen and only cover treatments, interventions and techniques coined evidence based – regardless of the reasons behind why some are evidence-based and some are not, and regardless of the fact that not-yet-evidence-based does not mean ineffective.
Over the past thirty years, the field of psychology seems to have developed an inferiority complex over the fact that it isn’t a harder science. Its attempts to prove itself otherwise by myopically focusing on the use and dissemination of only evidence based treatments (EBTs) and interventions (EBIs) – have contributed to the slow death the craft of psychotherapy is experiencing.
Like Empirically Supported Treatments in the medical field, EBTs and EBIs dominate training and practice in psychotherapy. And why shouldn’t they? Increasing health care costs and inadequate health care systems mean it’s in the public’s interest to utilize only those treatments and interventions that have proven effective. Although this sounds quite reasonable, often times the golden appearance of evidence-based treatments and interventions can be determined spurious upon further inspection. Consequently, a growing number of people, including myself, believe that many EBTs and EBIs treat little more than symptoms, that they are not conducive to deep and substantive change, and that there are very real risks to focusing on them so exclusively.
First, despite what we’d like to think, we are not living in a world where all research is conducted with the public good as its highest priority, with transparency, or without funding sources that elucidate severe biases. A recent study at John’s Hopkins shows the drug and device industry funds six times the clinical trials as the federal government. So, often companies with great financial interest in the outcome of trials will have more control over what doctors and patients will learn about new treatments than the National Institutes of Health.
Allen Francis, chair of the DSM-IV Task force and part of the leadership group for DSM III and DSM-III-R is Professor Emeritus and former chair of the Department of Psychiatry at Duke University School of Medicine. In his latest book, Saving Normal, he discusses how commercial interests have hijacked the medical enterprise, putting profits before patients and creating a culture of over-diagnosis, over-testing, and over-treatment. He blames diagnostic inflation for the fact that an excessive proportion of the population relies on psychiatric medication and the myriad of subsequent problems.
- 1 in 5 adults in the United States uses at least one psychiatric drug while roughly 4% of our children are on a stimulant.
- Psychiatric meds are now the star producers for the drug companies – in 2011, over $18 billion for antipsychotics (6% of all drug sales), $11 billion on antidepressants, $8 billion on ADHD medications. Antidepressant use nearly quadrupled from 1988 to 2008.
- Primary care physicians, who have little training in psychiatric illnesses and medication and are under significant pressure from pharmaceutical companies and representatives, prescribe 80% of these.
- The misuse of legal drugs has now become a bigger public health problem than street drugs, with more emergency room visits and deaths due to legal prescription drugs than to illegal street drugs and 7 percent of our population is addicted to prescription drugs.
Second, even if it is transparent and as unbiased as is humanly possible, research done in a lab or with “gold standard” experimental methodology (a randomized controlled trial) does not mimic the complexity of real life or the unique experience of psychotherapy, nor is it adequate to reality. Their findings can only be accurately extrapolated to those individuals living within the exact parameters of the carefully designed experimental setting.
Third, EBIs and EBTs are based on statistics. The individual is not. “In the aggregate, man is a statistical certainty. But the individual is an insoluble puzzle” (Sherlock Holmes). Similarly, William James believed the uniqueness in every individual defies all formulation.
And finally, today’s EBTs and EBIs are the “best” answers we have today, with the tools, instruments, and knowledge we have today. But theories and “best” practices come and go. Let us not forget that until 1973, our best psychiatrists and psychologists believed homosexuality was a psychiatric disorder. At any given moment, we seem to think we have the best answers from the most exhaustive information, and we have far too much confidence in what we think we know.
Prior to beginning my Ph.D., I earned an M.A. from the University of Denver in International Security, and extensively studied Intelligence and Counter-terrorism. For two years I was educated to be extremely wary of relying on patterns of data and behaviors that are most ‘expected’ of a population or group. I was taught to be continually cognizant of the elusive Black Swan – an event or occurrence almost completely beyond prediction through conventional measures, that will have an immense and overwhelming impact on an individual, group, society, nation or world (i.e. 9/11). Black Swans are, in effect, outside of the “best practices” of analysis.
As a consequence of this training in a seemingly unrelated field, I have a difficult time seeing and analyzing individuals through a paradigm of statistical norms, or how “most” people experience the world and behave, and I have trouble swallowing the overwhelming weight given to EBTs and EBIs by our field. It’s dangerous to view a client – a person – through a paradigm of statistics because although means, standard deviation and other forms of statistical analysis may tell you about a small piece of a client or their story, they won’t tell you the most important pieces, and more likely than not, they will deter you from their deepest truths. I tend to liken individuals to the Black Swan and believe that in effect, every individual is one.
As a result of viewing the world through the cultural framework of neoliberalism, which positions efficiency, effectiveness, and profit top priorities in all affairs, we have packaged psychotherapy as an evidence-based, educationally sound and manualized program, effective and able to produce quick changes in behavior. Perhaps our efforts to package this as such have helped us avoid acknowledging and dealing with the variability and uncertainty inherent in the psychotherapeutic process. However, as this process and the therapeutic relationship are each a mechanism from which the client’s most salient struggles emerge, in avoiding that uncertainty, we also avoid the means of helping them find the most profound and cathartic answers they seek.
And so, in an effort to mitigate the deleterious effects of the cultural components of neoliberalism, and restore the art of psychotherapy, we must begin to view symptoms and disorders from a distance, and as indicative of larger, systemic problems and characteristics, while simultaneously viewing the individual as completely and utterly unique. We must be willing to seek with our clients rather than espouse a prescribed, and evidence-based answer. We must be willing to face uncertainty and the precarious nature of therapy and life along side those we aim to help. And we must always think critically about the extent to which the treatments and interventions we chose may or may not be an extension of a system whose goal is not the growth of our client but rather a bottom line. These qualitative shifts in paradigm combined with considerable amounts of empathy, and clinical expertise and skill will help reestablish psychotherapy as a thoughtful, rich, and deeply transformative experience.