Following the Money
Our early focus as a publication had been on the intimate drama of the consulting room and the advances psychotherapy was making as a healing craft. But as the field grew and became more of a shaping force within the culture, it became harder to ignore the larger reality: mental healthcare was a multibillion dollar business. Much as we liked to view the profession with an almost bucolic innocence—as a loosely organized collection of friendly, well-meaning grocery store proprietors quietly tending their practices, in fact, large institutional players were reshaping the nature of the profession, determining what individual therapists could and couldn’t do and limiting the financial viability of their practices. Managed care’s relentless focus on cutting mental health reimbursements, the growing power of The Diagnostic and Statistical Manual of Mental Disorders, or DSM, and the increasing popularity of pharmaceuticals as alternatives to therapeutic treatment turned private practice from a comparatively easygoing, freewheeling, well-paid profession into a besieged enterprise struggling for economic survival. Much to their collective horror, therapists, largely a profession of refuseniks from the corporate world, were finding that, by and large, if they wanted to be paid for their work, they’d have to become entrepreneurs, make business plans, and worst of all, begin (gasp!) marketing themselves.
The 1994 publication of DSM–IV—a five-pound tome that included 340 different diagnoses—gave managed care companies a particularly effective screening tool for denying coverage. No longer could therapists just scribble in the code for “adjustment reaction”, the old DSM–III pro forma diagnosis and virtual free pass for insurance reimbursement. Now therapists without a readymade caseload had to take DSM seriously, parsing its definitions like Talmudic scholars if they wanted to get reimbursed. As one therapist said, “If DSM didn’t exist, managed care would have had to invent it.”
In hindsight, it was a devil’s bargain: therapists would play the diagnosing game as if the clients they saw suffered from “medical disorders,” treating them according to the equally fictitious “medical necessity,” and by so doing, be admitted into the medical club—at least long enough to get insurance reimbursement. The bargain worked well enough for many years, until managed care threw a wrench into the system by not only limiting reimbursement to specific diagnoses, but also accepting as “medically necessary” only those diagnoses that could be cured quickly. Treatment of choice (reimbursable treatment) often meant following officially established, short-term, “evidence-based treatment guidelines”—clear, manualized, unambiguous, reproducible recipes, intended to shorten and remove all ambiguity from the practice of therapy. So much for the Carl Whitaker school of treatment! Increasingly, a major ingredient in those recipes was medication. And more medication.
Following the enormous commercial success of the antidepressant Prozac, the ’90s ushered in what could be called the “era of the magic pill” with a tsunami of new psychotropic medications literally pouring forth as the drug companies rushed to get them to market. The Networker authors, while acknowledging the genuine usefulness of thoughtfully prescribed psychotropic drugs, were dismayed by the growing tendency toward pill pushing, not just in addition to, but instead of therapy. “The rising fascination with evolutionary psychology and biological determination has led some experts to proclaim, without much evidence, that all emotional states (including depression) are ultimately based on biology,” wrote clinical psychologist Michael Yapko in 1997. “But [the] devaluation of therapy that inevitably accompanies the new emphasis on biological approaches is wrongheaded on two fronts.” Not only did “epidemiological, social and cultural data indicate that, for most people, depression is not a disease of biological origin,” but “if, as the evidence now shows, cultural and social forces contribute more to the onset of depression than does biology, medication is only a partial solution. More important, there is now abundant evidence that therapy is as effective or more effective than drugs are for treating depression, with lower rates of relapse.”
In their prescient critique “Exposing the Mythmakers,” Barry Duncan, Scott Miller, and Jacqueline Sparks anticipated an avalanche of exposés of “Big Pharma” in the years to come, marshalling an impressive array of evidence that the hard sell for biomedical interventions was mostly hot air. “In all of the healing arts, there is no single explanation or simple, infallible remedy for any of the problems that beset humankind. Yet the growing power of the biological perspective in mental health discourse and practice suggests not only that there are solely biological explanations, but perfect, fail-safe biological solutions as well—simple pills that mark finis to everything from mild depression and nervous tension to panic attacks, bipolar disorder, and full-blown psychosis and schizophrenia.” How did this grossly simplistic and distorted view “come to hold almost unchallenged sway over both public and professional opinion? . . . Follow the money, and you will begin to understand the growth of the pharmaceutical behemoth.”
Widening the Lens
In 2001, the Networker officially acknowledged something that had been apparent to readers of the magazine for some time. Our coverage had shifted as the new ideas and clinical discoveries animating the field were no longer coming from family therapy or systems thinking. In fact, rather than the consulting room, much of the inspiration for new ways of approaching the therapist’s task was coming from nonclinicians in research labs. New developments in the broader scientific community were expanding the perspective of therapists and leading to the surprising conclusion that psychotherapy’s humanistic, relationship-oriented values weren’t at odds with the findings of modern science. In fact, researchers were legitimizing concepts and methods that had previously been on the margins of respectability and dismissed as “New Agey” and “touchy-feely.” More and more, the Networker was exploring topics like the nature of human emotion, mind–body approaches, mindfulness training, genetics and temperament, technology, and so on. Finally, it seemed only natural that the magazine’s name should better reflect the increasingly variegated material it contained. Thus, with the March/April issue, The Family Therapy Networker became the Psychotherapy Networker. We got some flak for “abandoning” family therapy, but as we saw it, we were just creating room for a bigger, more diverse “blended family” of therapeutic approaches, more attuned to the sprawling identity of the field as a whole.
Perhaps the most influential development of the past decade has been therapists’ increasing interest in brain science, which injected an unexpected but powerful jolt of “growth hormone” into our understanding of how and why therapy works. Freud had dreamed that someday therapists would understand the “neurology” behind psychopathology, but ever since, therapists had found it hard enough to focus on the mind and emotions, happily leaving the brain to its own mysterious devices.
There’s a tired, old quip people make when beginning a new undertaking that they think won’t be too difficult to learn or understand—“it’s not brain science.” Well, soon we were trying, in our limited way, to understand brain science, and the process was often excruciating. We began to discuss things like the neuroscience of emotion in the Networker, using new vocabulary, like the limbic system or emotional brain, and arguing that therapy didn’t always work well because it assumes that “our rational brains are in charge of our emotions, that what distinguished Homo sapiens from so-called ‘lower’ animals is our capacity to reason before we react,” as Brent Atkinson wrote in 1999, the culminating year of the Decade of the Brain. However, “our neural circuitry programs us instead to rage and cower and collapse in grief in a nanosecond, before we ever get a chance to fashion an ‘I’ statement or otherwise think things through.” In fact, Atkinson concluded, “our cerebral topography actually favors flaming emotionality, not sweet reason.”
Perhaps the most important new insight that therapists began to incorporate about the brain was that, as Mary Sykes Wylie wrote in “Discoveries from the Black Box” in 2002, our first issue devoted entirely to exploring the clinical implications of brain science, far from being a self-defining organ isolated inside our individual heads, “much brain function is an interpersonal phenomenon. Not only do brain structures and functions provide the means by which we connect with and make sense of one another, but through relational experience, parts of the brain, literally, grow. In fact, the brain, as we know it, is inconceivable without social relationships.” Successful psychotherapy is always and primarily a neurobiology-changing relationship. Furthermore, stories and narratives of the kind revealed in therapy—all those hours clients spend making sense of their raw, emotional experience—are “fundamental to brain function and attachment.”
According to psychiatrist Dan Siegel, who helped coin the term “interpersonal neurobiology” and as much as any contributor made understandable to therapists the brave new world of brain research revealed that, “Coherent stories are an integration of the left hemisphere’s drive to tell a logical story about events and the right brain’s ability to grasp emotionally the mental process of the people in those events. . . . Psychotherapy is perhaps the area where the human brain’s capacity for storytelling is most deeply engaged.” Finally, the brain is plastic: we develop new neural connections, and even develop new neurons in response to experience. In short, old-fashioned, nonscientific, nonmedical, and mostly not even “empirically validated” talk therapy was being restored to glory by the proponents of brain science, perhaps the most rigorous and certainly the most difficult of all the biological sciences—a satisfying, if paradoxical, development, indeed.
In no arena of practice did the interest in brain science have more impact than in trauma treatment, which previously had been seen by most therapists as a bad head trip, for which the standard approach was talk therapy of some kind, group support, and perhaps a Prozac prescription. But along with the expanding interest in understanding the human nervous system came the recognition that traumatized people continually relive trauma in mind, brain, and body, in physical sensations of frozen terror and helplessness—upset stomach, pounding heartbeat, sweaty hands, chest pressure, all signs of an autonomic nervous system run amok. Neuroimaging studies showed that when deeply traumatized people try to consciously access and put language to their trauma, their thinking brains essentially shut down, making them mostly unable to profit from standard talk therapy. As Bessel van der Kolk, a champion of a more somatically oriented approach to trauma, explained it, “The trauma doesn’t ‘sit’ in the verbal, understanding, part of the brain, but in much deeper regions of the brain—amygdala, hippocampus, hypothalamus, brain stem—which are only marginally affected by thinking and cognition. [P]eople process their trauma from the bottom up—body to mind—not top down,’” he added. “‘[T]o do effective therapy, we need to do things that change the way people regulate these core functions, which probably can’t be done by words and language.’” Taking the side of longtime body-oriented therapists, and basically blowing a raspberry at the research psychology establishment, van der Kolk argued that some form of body-based approach, whether EMDR, Somatic Experiencing, Sensorimotor Psychotherapy, or something else, was required before standard verbal therapy could get off the ground. Now, many of these interventions—so “fringy” when first introduced—as well as the thinking behind them, began to move into the mainstream.
It wasn’t only the scientific discoveries from brain science that were increasingly shaping psychotherapy’s direction. Impressive evidence from the growing new field of psychoneuroimmunology was demonstrating the powerful impact of mindfulness training on mental and physical health. Jon Kabat-Zinn, mindfulness practitioner and research scientist, began publishing studies that demonstrated that far beyond being merely a woo-woo New Age practice, meditation could make an enormous difference for people living with chronic pain and illness. Mindfulness training, he suggested in a 2004 Networker interview, could help people “cultivate intimacy” with their own bodies as standard medical or psychological approaches couldn’t. “Many of us are just really encapsulated in our head and in thought, while our bodies are kind of on their own,” he said. “Then when we experience pain or disease, we may realize that we’re actually in an adversarial relationship with our own body. When our body does something we don’t like—like come down with disease—we want to drive it to the hospital and have it fixed, as if it were an automobile.” Kabat-Zinn argued that meditation offers a means of giving people access to deep inner resources for healing “that are biologically available to all of us.”
A new model of practice, what Andrew Weil has called Integrative Mental Health, now has begun to take shape. In some ways, it’s a version of systems theory of 30 years ago, but instead of staying within the sphere of linear, left-brain understanding, it incorporates what we’ve learned about the relationships among mind, body, and spirit, along with our hard-won discoveries about how families and other social systems operate. Weil has quoted Albert Einstein to describe the connection between old and new knowledge in this emerging vision of mental healthcare: “Creating a new theory is not like destroying an old barn and erecting a skyscraper in its place. It is rather like climbing a mountain, gaining new and wider views, discovering unexpected connections between our starting point and its rich environment. But the point from which we started still exists and can be seen, although it appears smaller and forms a tiny part of our broad view gained by the mastery of the obstacles on our adventurous way up.”
The Conversation Ahead
So what lies ahead for psychotherapy and for this hardy little publication dedicated to telling the story of its continuing evolution? Like human beings and human history, therapy just keeps evolving and shape-shifting into forms we never can imagine ahead of time. When we began publishing this magazine, we were still entranced by the powerful voice of the family therapy revolutionaries. It did seem almost possible that they’d bring the bad old history of human unhappiness to an upbeat end and usher in a timeless era of psychological well-being. But over time, as we listened, different voices clamored for attention from different parts of the spectrum. These new conversations multiplied, overlapping and overriding each other, creating an unholy din at times. The upshot was that the answer to “What is good therapy?” didn’t grow simpler and more straightforward, but more complex—richer and more varied to be sure, but also more ambiguous.
The old top-down mode of conversation within our field is clearly a thing of the past. Since tapping into the worldwide community and the potential for instant communication through the Web, the potential for exchange within our field—the exponential increase in new voices, diverse ideas, ongoing arguments—seems almost unlimited. The question now is, How can we determine which voices, which conversations, will really contribute to psychotherapy’s store of genuine wisdom, and what can safely be dismissed as mere chatter?
Some years ago, after it had become glaringly obvious that we probably hadn’t discovered the single secret to human happiness after all, nor would we, I fastened on what became my favorite, catchall, security-blanket of a phrase, particularly useful in the face of facile truths, grandiose Big Ideas, or wildly popular fads. I discovered there’s hardly a case conference or a meeting about a Networker article or just about any occasion when it’s inappropriate to pause meaningfully, assume a wise look and say: “It’s more complicated than that.”
In fact, if editing this magazine has taught me anything about the multiple realities of human nature and the inherent difficulties of psychotherapy, it’s that, as a field, we must always be aware of our limitations, particularly when we’re broadcasting the latest, miraculous, one-size-fits-all model. That’s why it’s always important to listen to the critics along with the inventors of this or that fabulous new entry into the psychotherapy miracle-cure sweepstakes. Notice, I didn’t say we’d shun exciting new stuff. Who’d want to read us? But we always need to maintain a certain capacity for self-correction, which means, of course, always keeping the conversation going, no matter how loud and raucous it can sometimes get. In the meantime, given the endless variables of human beings and the infinite ways in which we can make ourselves miserable—and therefore in need of a good shrink—I wait for and wonder about what great new thing will bubble up next from the heaving collective consciousness of psychotherapy, and what will be found wanting about it.
As we step forward into the uncertain future of the field and this publication, I still take my guidance from Sal Minuchin, my first hero and today, at 90, still training young therapists and offering workshops around the world. According to him, no matter what the case he’s seeing or how much he continues to learn about what works in psychotherapy, one thing remains the same: “I’m always saying to people, in one way or another, ‘There are more possibilities in you than you think. Let us find a way to help you become less narrow.’” At another time, reflecting on the ups and downs of his own long career, he said, “I have failed in many ways, as most clinicians do. But when you fail, your certainty is transformed into questioning. I still see myself as an expert, but I know my truths are partial truths and my style of intervening is partial. Perhaps real wisdom is the uncertainty of the expert.”
Richard Simon, Ph.D., has been the editor of this magazine for 30 years. He’s the coeditor of The Art of Psychotherapy: Case Studies from the Family Therapy Networker, and the author of The Evolving Therapist: Ten Years of the Family Therapy Networker and One on One: Conversations with the Shapers of Family Therapy. Contact: email@example.com. Tell us what you think about this article by e-mail at firstname.lastname@example.org, or at www.psychother apynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine.