Q&A: A Yale Psychologist Calls for the End of Individual Psychotherapy
Is individual therapy overrated and outdated?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.]
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.
Exposure Therapy for Anxiety Disorders
Over a quarter of the people in the US population will have an anxiety disorder sometime during their lifetime. It is well established that exposure-based behavior therapies are effective treatments for these disorders; unfortunately, only a small percentage of patients are treated with exposure therapy. For example, in the Harvard/Brown Anxiety Research Project, only 23% of treated patients reported receiving even occasional imaginal exposure and only 19% had received even occasional in vivo exposure. In part, this may be a lack of well-trained professionals, because most mental health clinicians do not receive specialized training in exposure-based therapies.
Another factor may be that many health care professionals do not understand the principles of exposure or may even hold (usually unfounded) negative beliefs about this form of treatment. Surveys of psychologists who treat patients with PTSD show that the majority do not use exposure therapy and most believe that exposure therapy is likely to exacerbate symptoms. However, individuals with trauma histories and PTSD express a preference for exposure therapy over other treatments. Furthermore, exposure therapy does not appear to lead to symptom exacerbation or treatment discontinuation.10 Indeed, a wealth of evidence indicates that exposure-based therapy is associated with improved symptomatic and functional outcomes for patients with PTSD.11
The available research literature suggests that exposure-based therapy should be considered the first-line treatment for a variety of anxiety disorders. Here we review a handful of the most influential studies that demonstrate the efficacy of exposure therapy. We also discuss theoretical mechanisms, practical applications, and empirical support for this treatment and provide practical guidelines for clinicians who wish to use exposure therapy and empirical evidence to guide their decision making.
Exposure therapy is defined as any treatment that encourages the systematic confrontation of feared stimuli, which can be external (eg, feared objects, activities, situations) or internal (eg, feared thoughts, physical sensations). The aim of exposure therapy is to reduce the person’s fearful reaction to the stimulus.
Open house to discuss anxiety disorders
The Psychiatry Department will hold an open house at 5pm on Thursday to discuss signs and symptoms of anxiety disorder.
The lecture and open discussion will be led by Hamad Medical Corporation’s psychology supervisor, Mariana Barrancos, whose areas of expertise include adjustment disorders, anxiety and depression, trauma and cultural diversity.
Anxiety is one of the most common psychological disturbances and its frequent symptoms may include excessive worries and fear, nervousness, irritability, shortness of breath, insomnia, a racing heartbeat, nausea, dizziness and shaking.
Other symptoms may manifest as gastrointestinal problems, insomnia and headaches which increase the patient’s level of discomfort.
In addition, anxiety disorders may coexist with other psychological disturbances, such as depression and an increased risk for substance abuse.
The lecturer will also discuss how to understand the multiple risk factors of anxiety symptoms as will describe different types of anxiety disorders, treatment options and healthy strategies to help people manage it.
Barrancos’s institutional work focused on the prevention and treatment of multiple forms of abuse, trauma and emotional deprivation in children, adolescents and adults.
The lecture is part of a series of open days held on the second Thursday of every month throughout 2011, which aim to educate the public on various aspects of mental illness and mental health.
However, the Psychiatry Department, which is planning a slew of activities to mark this year’s World Mental Health Day on October 10, will also hold a symposium on new advances in mental health mid-December.