Tuesday, July 9, 2013

Nicholas Cummings -- Time for Psychotherapy to Take on Pharmacotherapy

An impassioned plea from former APA President Nicholas Cummings. This one line really grabbed me: "How long has it been since you have seen a patient who came to you who had not already been medicated by the primary care physician or a psychiatrist?" This is such a striking observation that you don't realize it at first because it is so "normal." That is, it is normal for a primary care physician to begin "treating" a patient for anxiety or depression even before a thorough psychological assessment has been made by a mental health specialist. They write the prescription and then they refer for psychotherapy (if they refer at all, which they rarely do).

"We are seeing in the second decade of the 21st Century two forces converging that create both an imperative and a golden opportunity for psychology. The first is the continued steady decline of psychotherapy which has been largely replaced by psychotropic medication. How long has it been since you have seen a patient who came to you who had not already been medicated by the primary care physician or a psychiatrist? Antidepressants are ubiquitous, prescribed not only for the Monday morning blues or any degree of sadness, but also for such off-label conditions as erectile dysfunction, smoking cessation, obesity, obsessive compulsion, and even bereavement, with the latter practice unfortunately interfering with and severely prolonging nature’s healing process. It did not used to be that way prior to the medicalization of mental health. Rather, the patient first saw a psychologist, psychotherapy was the first line intervention, and in those instances when the psychologist determined medication was necessary, it was arranged through a cooperating psychiatrist. But the psychologist’s evaluation always came first. 


Psychotherapy was not only effective, numerous researches over decades repeatedly revealed it saved medical/surgical dollars. There was a high regard for our services among the general public, which was heralded in the media, movies and government sponsored programs such as the community mental health centers. It was usual for highly sought psychotherapists to have long waiting lists of those who clamored but patiently waited for their services, not only because of need, but also for self-improvement. Psychiatrists medicalized because they wanted tobe “real doctors.” They abandoned psychotherapy, and became essentially a prescribing and hospitalizing profession, thus making psychology the booming, preeminent psychotherapy profession. The American Psychiatric Association cleverly responded by joining Big Pharma with its grants, subsidies, and other goodies, and then captured the National Institute of Mental Health (NIMH) with a sweeping “changing of the guard” at the highest levels. The DSM threw out all psychopathology to fit into the new theories of serotonin and dopamine receptor imbalances in the brain. It promised to cure mental illness through a rapidly evolving series of psychotropic meds. On the basis that medication would thus solve the problem, our state hospitals were deinstitutionalized by releasing hundreds of thousands of schizophrenics with nowhere to go and only a supply of medication. Overnight the street and the prison became our de facto mental hospitals and remain so to this day in spite of new generations of highly touted antipsychotics.

The second force is the rapidly developing backlash among the public resulting from mounting and often serious side-effects, the over-prescribing of medication for minor conditions and especially for children, revelations of tampering with clinical trials by throwing out studies with negative or neutral findings, and, worst of all, psychiatrists conducting the research and those promoting various drugs have been subsidized or even directly hired by the pharmaceutical companies. Additionally, the cherished “brain chemical imbalance” theories are being called into question by numerous studies and are chronicled in two best-selling books published in 2010. The DSMs have successively abandoned any validity to actual brain diseases, becoming arbitrary collections of symptoms that are grouped into syndromes given clinical-sounding names, and with every syndrome needing a medication or class of medications. Psychotherapy is disdained as ineffective and even irrelevant “talk therapy.”

But now Big Pharma has never had a lower public image, giving us an opportunity made in heaven for us to make a comeback. This is the time to mount an extensive campaign to educate the American public on the effectiveness of psychotherapy and to restore it as the first line intervention in behavioral health. Such a campaign would not only be directed through the media, but it would involve the most recent communication innovations such as YouTube. Can we afford to do this is not the question. Rather, it is, “Can we afford NOT to do this?” If we miss this golden opportunity psychotherapy will continue to decline and psychology as a direct service profession will become a relic that someday economic paleontology can unearth and dissect, seeking to answer why the most admired profession of the 20th Century died in the 21st."



Carlat, D.J. (2010). Unhinged: The trouble with psychiatry - A doctor's revelations about a

profession in crisis. New York: Free Press.

Whitaker, K. (2010). Anatomy of an epidemic. New York: Crown.

(Reprinted by the author from
The National Psychologist, 20(1), p. 8, January/February 2011.)


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