The Rise and Fall of PaxMedica - Page 3

Cognitive-behavioral therapy (CBT) was one answer. During the 1970s, psychiatrist Aaron Beck developed his CBT approach and used the methods of social science research to establish its indisputable empirical effectiveness. Many therapists disdained the social science research methods that underlay psychotherapy outcome research, what there was of it, but Beck viewed the use of research as an opportunity to build scientific credibility for CBT. For potential customers, the method had instant appeal. In contrast to psychoanalysis, CBT was fast (12-16 sessions), focused, pragmatic, optimistic, rational, and unconcerned with deep, subconscious motivations. It was a sunny field to psychoanalysis's dark cave.

Like other therapists of the time, Beck ignored the brain and made only rudimentary assumptions about how the mind worked. For him, a precisely defined and designed technique was what mattered most, not complicated theories about the inner processes of the mind. But he did consider himself a physician, the people who saw him patients, and his therapy a mental health treatment.

Beck's work dovetailed seamlessly with a new version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). In it, the editor, psychiatrist Robert Spitzer, identified what were to become some of psychiatry's "greatest hits": panic disorder, AD/HD, and major depression. In a field fraught with complexity and ambiguity—and in a world where enormous amounts of money were at stake—Spitzer offered mental health professionals some peace, simplicity, and the comfort of a renewed faith in authority. His tome rapidly became the "bible of psychiatry" for insurance companies, the disability and criminal justice systems, and researchers seeking government approval for new drugs.

The collective influences of Spitzer, Beck, and the pharmaceuticals resulted in a compromise vision of what the "mental health profession" should be and do, which has dominated the field since the late 1970s. This Pax Medica stipulates that in psychotherapy, as in dermatology or orthopedics, diagnosis—which assumes a specific pathology—is vital to evaluating a patient and planning treatment. In standard medicine, in the absence of observable causes—lesions, virus, or bacterium—treatment targets the symptoms. Likewise, the new view of therapy required clinicians who were formulating treatment plans for their patients to ameliorate the symptoms associated with specific diagnoses to determine medical necessity.

As an indication of how thoroughly the medical model penetrated mainstream psychology, in the mid-1990s, the Society of Clinical Psychology of the American Psychological Association (APA) established a task force on "empirically validated treatments." To earn the designation "empirically validated," a treatment had to be shown superior to placebo or comparable treatment in two separate randomized clinical trials. The intervention had to be reducible to a clear and teachable manual. Eighteen DSM-III disorders were seen as candidates for this process; almost all the methods that initially qualified as "evidence based" were variations on CBT.

There were soon rumblings of skepticism and discontent with the established regime that was Pax Medica. In 1980, just four years after the publication of the DSM-III, three little-known academics—therapy researchers Mary Lee Smith, Gene Glass, and Thomas Miller—combined and analyzed the results of many well-designed studies on the benefits of therapy and reached two unexpected conclusions: notwithstanding its bad rap, psychotherapy was robustly effective. Even more startling—and totally at odds with the spirit of the times—the actual technical methods—considered aside from the impact of the therapeutic relationship itself employed by therapists—seemed to have no significant effect on outcome. Since then, the 80 to 90 percent of psychotherapy research examining the efficacy of specific methods for specific disorders has corroborated their findings. Overall, skepticism about the singular importance of diagnosis and method has increasingly taken root since the 1980s—even the alleged superiority of CBT is being questioned by a sturdy body of dissidents within the profession.

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