The Lessons of the Masters—1982
The early editions of what was then called Around the Network—in a publication then titled The Family Therapy Networker—reflected this magazine’s efforts to grasp what the exciting new field of family therapy was all about. Who were its leading lights? What set them apart? What could they teach the rest of us about the mysteries of therapeutic alchemy? Truth to tell, there was a lot of hero worship in the field in its infancy, as everyone looked hopefully to Virginia Satir, Milton Erickson, Murray Bowen, Carl Whitaker, and others to show them the way.
But ever the skeptic, Atlanta psychiatrist Frank Pittman stood a bit outside of the profession’s collective enthusiasms, fads, and groupthink. He was our provocateur-in-residence and for 26 years, until his retirement in 2009, the author of Screening Room, his always-quotable, bimonthly review of the latest movie offerings. Here’s a nugget of penetrating wisdom from Frank that appeared, not in a film review, but as a Networker Quote of the Month in one of our 1982 issues:
I should not presume to explain the phenomenon of a master therapist like [Carl] Whitaker. But a master therapist is likely to be better at doing therapy than at explaining it. When any of us explains what we do as therapy, we may notice only those things we work at doing and may overlook those things that come naturally.
John Hinckley’s Leaving Home—1983
As the boomers swelled the ranks of the therapy profession and became the psychologically-minded consumers of the burgeoning profession of psychotherapy, our field received increasing mainstream coverage through the late ’70s and early ’80s. Then John Hinckley’s shocking assassination attempt on Ronald Reagan focused attention on the quality of treatment Hinckley had received and his therapist’s use of the “leaving home” strategy, commonly employed at that time with troubled young adults struggling to start a life independent of their parents. Bringing even more tension to the drama was the spectacle of every therapist’s ultimate nightmare—a malpractice lawsuit in the glare of national publicity.
Former Presidential Press Secretary James Brady along with the Secret Service agent and D.C. policeman who were also wounded in John Hinckley’s attempted assassination of Ronald Reagan have filed a 14 million dollar malpractice suit against Hinckley’s former psychiatrist John Hopper. The suit charges that Hopper misdiagnosed Hinckley’s condition (Hopper’s diagnosis was “acute anxiety”); provided treatment under which Hinckley actually got worse (Hopper prescribed valium and had his client go through biofeedback relaxation procedures), and should have hospitalized Hinckley (as his parents requested).
Commenting on the suit, Joel Klein, General Counsel for the American Psychiatric Association, maintained that if Hopper loses there will be a tremendous increase in the number of difficult patients who will be hospitalized by therapists out of “self-defense.”
[The case was ultimately dismissed on the grounds that Hopper couldn’t have known that Hinckley, who never threatened anyone, was capable of such violence.]
The Profession Booms—1986
With the growth of the therapy profession throughout the 1980s, increasing numbers of psychologists, social workers, counselors, and marriage and family therapists found their way into private practice. With liberal reimbursement from insurance providers and managed care not yet a factor, the era is recalled fondly by many private practitioners today. This item from our May/June 1986 issue clarifies the actual fee structures of the era, which seem generous for the time. Unfortunately, for many, these fees haven’t changed all that much since then.
According to an annual survey of therapist fees conducted by Psychotherapy Finances (PF), the median individual fee for all therapists is now $65 (up $5 from 1984). Among the 1500 psychotherapists surveyed, the average income from full-time private practice is $47,000 with 13 percent having an income over $80,000. Average fees charged varied according to training. Psychologists in the PF survey charged $70 per hour while the average fee among social workers, pastoral counselors and marriage counselors was $60. The survey also indicated substantial income differences between male and female practitioners. While women therapists had an average income of $38,000, men reported mean earnings of nearly $50,000.
The Roots of Depression—1987
In its focus on the immediate encounter in the consulting room and skepticism about inborn determinants of behavior, the family therapy field embraced a kind of interactional determinism. Fixated on the power of social context, especially the family, to shape behavior, the field largely rejected diagnostic formulations and theories that it believed underestimated the human capacity for change. But throughout the ’80s, researchers kept publishing studies that challenged this blank-slate view of human development and the belief that the age-old nature–nurture debate had finally been unequivocally resolved in favor of nurture. It was, as usual, “more complicated than that.”
In 1987, psychiatrist Janice Egeland and colleagues from Yale and M.I.T. released a groundbreaking study identifying bio-chemical anomalies on the chromosomes of one extended Old-Order Amish family with disproportionately high rates for manic-depressive illness. Egeland and her associates, using molecular gene-mapping technology on blood samples drawn from each of the 81-member clan, found DNA markers on a dominant gene conferring a predisposition to manic-depressive illness in the family. Egeland’s research enlivens psychology’s classic “nature vs. nurture” debate. Her study provides the strongest evidence so far for a link between manic depression and a specific bio-chemical factor, something in the blood or “siss im blut,” as the Amish say.
–Mary Sykes Wylie
The Changing of the Guard—1988
By the end of the decade, many of the leading lights who’d pioneered family therapy and been the role models setting the tone for the field had begun to pass on. As the Networker paid its respects to the trailblazers who’d ignited the clinical imagination of a generation of therapists—people like R. D. Laing, Murray Bowen, and Carl Whitaker—there was a palpable sense of the changing of the guard. But it was perhaps the passing of Virginia Satir that stirred the deepest resonance among clinicians who’d been viscerally influenced by her work, which anticipated so much of the mind-body orientation of many approaches today.
Virginia Satir, path-breaking family therapist, writer, teacher, and world-traveling peace advocate, died of cancer September 10th at her home in Menlo Park, California. She was 72. . . .
Satir was an inspired therapist and teacher whose charismatic vitality and extraordinary gift for reaching people made her an inspiration to thousands of students and colleagues. During the ’40s and ’50s, while Freudian psychoanalysis dominated clinical thinking, she was one of the first therapists to work with whole families. In a profession dominated by men, she was the first and, for a long time, the only woman to achieve eminence. According to Frederick Duhl, co-director of the Boston Family Institute, Satir was “the most gifted therapist in the field. She knew human systems with her fingertips. Virginia probably trained more people than any other family therapist alive.”
–Mary Sykes Wylie
While what Lynn Hoffman called “The Great Originals” of family therapy influenced the mental health field largely by their iconoclastic force of personality and fierce sense of conviction about the new perspective they were offering, the therapeutic profession of the 1990s cast a more skeptical eye at new methods that claimed clinical effectiveness. A sufficient research infrastructure had developed in the field that new models were expected to actually offer some data to support their claim, and innovators realized that charisma alone wasn’t enough—they needed to offer empirical evidence if they hoped to convince the sophisticated clinician of the value of their approach.
For the first time, therapists may have a procedure to quickly and effectively desensitize clients to their traumatic memories. When psychologist Francine Shapiro first published her initial study on Eye Movement Desensitization and Reprocessing (EMDR) in 1989, many clinicians were skeptical, but since then some of the most eminent therapists in the trauma and behavior therapy fields have become convinced that EMDR is an important discovery. Among these is behavior therapist Joseph Wolpe, creator of systematic desensitization—one of the most influential methods in the history of psychotherapy. “Shapiro’s technique seems to work with remarkable efficacy in cases of post-traumatic stress disorder [PTSD],” says Wolpe. “While it still has not been studied in a controlled way, the preliminary results have been dramatic. It is much better than anything else we have for treating trauma.”. . .
In contrast to many other promising interventions that never get examined beyond the clinician’s office, EMDR is being closely studied in a number of separate research projects in the United States and in England. It should soon be clear whether EMDR is snake oil or an important addition to the therapist’s armamentarium.
Clinton Becomes Therapist-in-Chief—1993
It would be hard to underestimate the sense of identification within the mental health field that accompanied the election of Bill Clinton and Al Gore, both of whom seemed steeped in the language and sensibility of pop psychology in a way that was unprecedented for our national leaders. As the first boomer president, Clinton, with his celebrated ability to “feel your pain,” embodied a style of leadership different from that of anyone who’d previously occupied the Oval Office. Here’s an entry from March/April 1993 at the very beginning of the Clinton administration, that captured the sense of new possibility of what now seems like a long-ago era.
It is no secret that President Clinton and Vice President Gore bring to office a familiarity with the language and concepts of psychology, as well as a deep interest in the welfare of children. Clinton, it has been noted by the media, not only participated in a therapeutic family intervention with his substance-abusing brother, but even speaks with some fluency the language of popular psychology. At times, he worked his successful presidential campaign less like an old pol than like a John Bradshaw clone. Clinton spoke publicly about his stepfather’s violent alcoholism, and often used themes from the recovery movement (the phrase, “the courage to change,” for example, from the Serenity Prayer used by Alcoholics Anonymous) in campaign speeches.
–Mary Sykes Wylie
The False Memory Controversy—1995
By the mid-1990s, it was becoming increasingly clear that the therapy field that had started out with such promise, creating a haven to talk safely and openly about previously ignored or taboo topics like gender inequality, incest and sexual abuse, violence in the family, and racism, might have seriously overreached itself on the issue of recovered memories of childhood abuse. At the height of the controversy, “Divided Memories,” a four-hour PBS Frontline documentary on the subject, coming on the heels of an avalanche of negative stories in newspapers and magazines around the country, shone a spotlight on some of the worst excesses within our field, and became a source of sobering reflection for many therapists.
Therapists’ reactions to the documentary ranged from embarrassment to outrage to approval. “I was ashamed for my profession,’” says one Washington, D.C., psychologist. Harvard psychiatrist and trauma researcher Bessel van der Kolk, who was interviewed on the show, wrote to Bikel [the show’s producer] to say she had ignored scientific research validating traumatic amnesia and held trauma victims up to ridicule. Christine Courtois, psychologist and author of Healing the Incest Wound, says that the documentary used bizarre practices to discredit work done in the clinical mainstream. . . . But Atlanta family therapist and psychiatrist Frank Pittman, who contends that practically all delayed recall of childhood sexual abuse is iatrogenic, said the documentary was an enormous relief. “Finally, somebody is catching on,” he says. “I think repressed and recovered memory is a giant hoax that has had an absolutely disastrous effect on the mental health field and our credibility. It’s an expression of our terrible distrust of families and of how enamored we are with the concept of victimhood.”
The World Goes Digital—1996
Our first article on therapists and the Net appeared in March/April 1996, and seems soooo outdated today. Does anyone even remember how we tried to grapple with the Web’s unimaginable capacity by linking it to something familiar, resulting in the anachronistic-sounding “information superhighway”? And what about the “techno-creative people” using graphics on the Web?
To access the Internet, you need four things: a computer, a modem, a phone line and a service provider. And that’s it. You’re connected and ready to go. . . .
When we think “Internet,” most of us have in mind the World Wide Web. It’s the greatest adventure on the Internet, the pavilion at the state fair where amazing kitchen contraptions, encyclopedias, organic herbs, cotton candy, tarnish removers, social service organizations, gourmet food, snake oil salesmen and reclining chairs exist side by side. Because the Web can inexpensively create and transmit graphics as well as text, it has attracted the techno-creative people and entrepreneurs. It is virtually unregulated and full of opportunities and excellent resources, but there are also dangers. Whenever you hear people express reservations about the trash on the Internet, they are usually talking about the Web. . . .
Many therapists and social workers, for reasons ranging from altruistic to self-promoting, have begun their own home pages on the Web—like having a roadside stand on the information superhighway. You can put whatever you wish on your home page: you can list your resume, practice specialty, opinions and writings; you can try to sell things; you can set up discussion forums; or you can use your home page to point and link people to other resources on the Internet that you think are worthwhile.
The Decade of the Brain—1999
Within the psychotherapy field, the Decade of the Brain led to an enhanced understanding of the role of neural processes—previously relegated to the Black Box—in both comprehending the difficulties that brought people to treatment and developing tools for bringing about therapeutic change. The Networker was typical of many therapy publications in having a dramatic upsurge of articles about brain research findings and their relevance for clinicians. The dispatch below, published in 1999, was a harbinger of many more articles that turned the long-neglected topic of brain science into one of the most influential areas of therapeutic inquiry today.
A surprising new study overturns the long-held assumption that the human brain stops growing after about the age of 6 and opens the door for the prospect that physicians may someday be able to replace brain cells lost to disease, strokes or injury. According to a study by a team of Swedish and American neurologists, the hippocampus region of the brain—the center of learning and memory—continues producing new cells for as long as we live.
Several years ago, scientists discovered that this lifelong cell creation goes on in the hippocampus of birds, mice and monkeys. But the marker used to track new brain-cell production in the animals is toxic and had not been tested on humans. Then the Swedish and American research team, led by neurobiologist Fred Gage of the Salk Institute in La Jolla, California, realized that this marker chemical, despite its toxicity, is used to track the spread of cancer in certain patients. They received permission from five terminally ill cancer patients who had been injected with this tracer to examine their brains immediately after their deaths. The patients, whose ages ranged from 55 to 70, received the tracer injections at periods ranging from two years to three weeks before they died. The results of the researchers’ examinations showed that every patient’s brain had continued to produce new cells until his or her death.
Now that we know that brain-cell production occurs throughout life, Gage speculates that with increased knowledge about biochemical processes, we may someday be able to control the process of brain-cell division. This would enable future patients to grow new, healthy brain cells to replace those damaged by disease, trauma or aging. “The door,” Gage says, “has been opened.”
The Business of Psychotherapy—1999
As the millennium approached, economic shifts that had been long feared within the mental health field had finally begun to affect therapeutic practice. The impact of managed care and the increased emphasis on medications in treating psychological problems were taking a demonstrable toll on the therapists’ incomes.
During the 20 years that the monthly newsletter Psychotherapy Finances has kept track, therapists’ incomes have risen every year through 1996. In 1997, the trend reversed: counselors, psychiatrists, psychologists and social workers all reported making less than the year before, with only marriage and family therapists reporting an increase. The figures ranged from a high of $96,000 for psychiatrists to a low of $48,000 for professional counselors. Now, newsletter publisher Herb Klein is processing the numbers for 1998, and it looks as if all therapists’ incomes have dropped.
The numbers reflect the fact that therapists are getting smaller and smaller slices of the managed health care pie. Health Care Plan Design and Cost Trends, a report from the consulting firm Hay Group, found that in the decade from 1988 to 1998, behavioral health care benefits dropped from 6.1 percent of managed health care companies’ total health care costs to 3.2 percent.
History of Psychotherapy in a Nutshell—2000
While Clinician’s Digest largely focused on weighty matters like the important trends shaping the field and studies with interesting clinical implications, it still occasionally included items that encouraged therapists not to take themselves too seriously.
In May, we asked readers to condense the history of psychotherapy (from the cave to the new millennium) into 75 words or less, promising an award of a one-year gift subscription to the Family Therapy Networker to the top entry. First place, for her precise, accurate tracking of the profession’s progress from ascription of blame to acceptance goes to Sykesville, Maryland, social worker Wendy Smith:
B.C-1945 A.D.: It’s God.
1950: It’s your parents.
1960: It’s you.
1980: It’s them.
1990: It’s us.
2000: It is.
Unmasking Big Pharma—2001
Under the direction of contributing editor Garry Cooper, a repeated subject of Clinician’s Digest was exposing the pharmaceutical companies’ control and manipulation of research findings on psychotropic drugs to highlight positive studies and obscure negative findings. Here’s just one example of the critical examinations of the data supporting medications’ effectiveness that Garry wrote over the years.
According to an article in the November 14, 2000, issue of Newsday, during the 1990s, pharmaceutically funded research increased six times faster than government funded research. At the Duke University Medical Center alone, for example, corporate-sponsored biomedical research increased nearly 70 percent in two years, jumping from $63 million in 1997 to $107 million in 1999. Richard Horton, editor of the British medical journal The Lancet, says that his peer reviews reject 9 out of 10 studies of new drugs submitted to the journal because the research has been designed to produce results favorable to the medication. In a September 9 article, the Canadian newswire service Canadian Press reports that companies have also withheld data necessary to answer peer reviewers’ questions and, in some instances, withheld negative data, even from the researchers who reported the results.
Companies have also required researchers to sign agreements that prohibit the scientists from publishing negative findings or discussing such findings with the press. A series of articles in the April 10-15 Hartford Courant reveals that academic researchers are even paid to put their names on articles actually written by ghostwriters working for pharmaceutical companies.
It Ain’t Necessarily So—2002
Another important role this department has played is as a regular debunker of the field’s certainties, alerting readers to studies challenging the conventional wisdom and reporting on emerging debates. In 1996, a task force in the American Psychological Association’s Division of Clinical Psychology began the effort to distinguish between treatment approaches founded in scientific evidence and the unregulated range of methods being applied in the name of “psychological healing.” The result was a list of approved treatments, consisting almost entirely of behavioral treatments, which sought to bring more of a sense of discipline, coherence, and professionalism to psychotherapy. But many critics remained unconvinced that the collection of supposed empirically supported treatments really worked.
Many therapeutic regimens for treating depression, panic disorder, and generalized anxiety disorder (GAD) have earned the imprimatur of an American Psychological Association task force charged with identifying “empirically supported” treatments. These therapies must be scrutinized in carefully controlled, replicable studies that demonstrate their effectiveness. But a new metanalysis of many of the studies says that these treatments may not work so well in everyday clinical practice.
In December’s Journal of Clinical and Consulting Psychology, Boston University researchers Drew Westen and Kate Morrison say many of the studies that purportedly demonstrate the efficacy of a treatment are based on samples so pure as to bear little resemblance to real-world treatment populations. For example, they found that many studies excluded subjects diagnosed with more than one disorder. . . .
When Westen and Morrison factored in the subjects who had been excluded from the samples, the success rates of the treatments declined significantly—from 54 percent to 37 percent for the depression treatments, 52 percent to 44 percent for GAD, and 63 percent to 54 percent for panic disorders.
Westen and Morrison found that empirically supported treatments may not work so well in the long term, even for the samples on which the studies are based. . . . Putting the best face on the findings, Westen and Morrison conclude that about half the people who complete the empirically supported treatments will benefit from them, primarily in the immediate reduction of symptoms. However, they caution that the average person who completes these treatments will remain clinically depressed or anxious.
The Most Discredited Therapies—2007
The Networker has always offered critical perspectives on clinicians’ excesses and blind-spots. In a profession where therapeutic fads have long exerted a disproportionate influence on practice without any relationship to demonstrated results, it’s seemed crucial to regularly look at not only psychotherapy’s successes, but our failures. The following represented an unusually systematic attempt to attach warning labels to a wide variety of treatment methods, some still commonly used.
With the increasing focus on evidence-based therapies, psychologist John Norcross decided it would be worthwhile to identify some of the most discredited therapies. Along with current American Psychological Association President Gerald Koocher and doctoral student Ariele Garofalo, he combed the literature and asked hundreds of mental health professionals to nominate what they considered “discredited treatments and tests that have been used professionally within the last 100 years for mental health purposes.”
After the list was compiled, a panel of 101 researchers, journal editors, and therapists were asked to rate each method on a 5-point scale from “not at all discredited” to “certainly discredited” (raters could also choose “not familiar with”). Using the Delphi survey method, his team then sent the panel members the results of the survey, minus those techniques that less than 25 percent of the members had rated, and asked them to rate them again. In the end, the expert panel rated 89 treatments and assessment methods.
Part of the list of discredited methods, presented in the October Professional Psychology: Research and Practice, reads like an amalgamation of medical horrors and New Age ideas: prefrontal lobotomies, crystals, and pyramids. Other treatments listed comprise a historical tour of psychotherapy: Freudian dream analysis, Jungian sand trays, past lives, future lives, primal scream, Erhard Seminar Training, Bettelheim’s model for treating childhood autism, family therapy for schizophrenia based on the double-bind theory, marathon encounter groups, and holding therapy for attachment disorders.
More recent controversial treatments on the list that garnered highly discredited ratings were reparative therapy for homosexuality, rebirthing, and Thought Field Therapy. Other recent therapies, like EMDR for trauma, psychosocial therapies for AD/HD, thought-stopping for excessive rumination or worry, and laughter or humor therapy for depression, were deemed credible. Several older methods, including J. L. Moreno’s psychodrama and Wilfred Bion’s psychoanalytically oriented group analysis, also garnered respectable ratings.
Norcross stresses that a discredited ranking of any treatment should primarily be construed as a call for more research on it, not as a condemnation, that experts “can and have been wrong,” and that therapists shouldn’t be afraid to be innovative and trust their intuition. Nevertheless, he says, the study has generated considerable controversy, including protests from many psychotherapists who pointed out that they themselves have successfully used some of the most “discredited” treatments like the Lüscher Color Test for personality assessment. “I don’t know how to answer them,” he says. “If something’s helped them, I want to be respectful of their experience. At the same time, we know from research that placebos work about a third of the time.”
We’re always on the lookout for intriguing findings that may not initially get much public attention, but suggest unrecognized changes in people’s attitudes and beliefs. One of the most interesting that we came across recently was a phenomenon that’s made the job of researchers looking for significant treatment effects harder than ever.
What are they putting into placebos, those supposedly inert pills with no medicinal effect that have long been the benchmark against which the effectiveness of new medications are measured? Something’s going on, because placebos are getting stronger. An intriguing metanalysis in the November 2009 Journal of Affective Disorders, for example, found that the potency of placebos has nearly doubled between 1985 and 2005. How can that be? . . .
As brain-imaging technology has revealed that people’s expectations produce actual brain reactions, the key to understanding placebos has shifted from the notion that their effect is purely imaginary to a new appreciation of their real psychological impact. Silberman speculates that the pharmaceutical companies may be victims of their own multimillion-dollar advertising successes. Press reports and mass advertising have led us to believe increasingly in the power of medications, so critical trial subjects and raters (whose unconscious biases often influence results) may have developed higher expectations that pills will work.
The End of the Psychotropic Era—2010
The pharmaceutical industry—“Big Pharma”—has long been a bugaboo of our profession. We like to see ourselves as idealistic Davids pitted against soulless corporate Goliaths that dispense pills instead of expanding awareness. For those of us long grown accustomed to the idea that the continued triumph of these Goliaths goes without question, the very idea that their business might experience a downturn was an invitation to gloat that many of us couldn’t resist.
By now, we’ve gotten accustomed to expecting successive new waves of psychotropic medications to make their much ballyhooed appearance on the market, each set of drugs accompanied by claims that they’re far more effective than their predecessors, with fewer side effects.
Antidepressant tricyclics gave way to SSRIs, which have more recently led to SSNRIs (which affect norepinephrine levels as well as serotonin); the first generation of antipsychotics was followed by the atypical antipsychotics. But beginning last winter, a series of surprising announcements indicated that even the mighty psychopharmaceutical industry has hit hard times. Claiming that researching and developing psychotropics has becomes too expensive and unprofitable, both GlaxoSmithKline and AstraZenica said they were suspending or curtailing research on drugs targeting depression, anxiety, and other psychiatric conditions.
The Battle Over DSM-5—2011
As the Networker moves into the next stage of covering the important developments within our profession, one thing seems sure: no story will have more far-reaching implications for the future of the mental health field at every level than the already tumultuous struggle brewing over the next edition of the Diagnostic and Statistical Manual, the “bible” of therapeutic practice.
Despite delays, the American Psychiatric Association (APA) is now firmly committed to bringing out psychology’s revised bible, DSM–5 by 2013. Nonetheless, an unprecedented outcry from past DSM lead editors and members of DSM–5 work groups has been highly critical of the compilation process, of several proposed new diagnoses, and of a major new diagnostic procedure. They say that the work groups are too quickly making decisions that aren’t supported by the research. Not mincing words, Allen Frances, lead editor of DSM–IV, fears the 2013 deadline is becoming “a rush to produce an inferior product.”
The increasing impact of the DSM can’t be underestimated. Originally intended primarily to create a more coherent taxonomy of mental disorders, it now helps shape insurance coverage, lawsuits, criminal prosecutions, and even how we think of ourselves and others. When homosexuality moved from a disorder to a normal expression of sexuality, for example, the attitudes of many gay and straight people shifted, which then influenced social legislation and cultural norms. Its inclusion of PTSD led to a wide range of groundbreaking research and opened the door to millions of dollars in lawsuits and disability payments. From an economic standpoint, its diagnostic categories have led to the increasing use of psychotropic medications, making it a treasure trove for the pharmaceutical industry.
Like earlier editions, DSM–5 will be a blend of hard science, political compromises, educated guesses, and research biases. Frances knows firsthand what this combination can create. . . . [Those concerned about the production process warn] of the unintended consequences of rushed deadlines that force decision-making ahead of good science and, however well-intentioned, subvert the fundamental medical principle of doing no harm. “We used to say proudly that DSM was never on the leading edge, but always on the following edge,” says [Columbia University psychiatrist Michael] First. As DSM–5 rushes toward its 2013 deadline, critics are trying to ensure that, if they can’t slow it down, they can at least help make the final decision-making more conservative.