I can still remember the excitement in the air at the first Psychotherapy Action Network (PsiAN) conference held in San Francisco at Golden Gate University in December 2019. As I write this, that was almost exactly one year ago, but it feels like it was in an altogether different world: a time when people came together in person without worrying about COVID-19. It was at this event that I first met the three remarkably dedicated women who developed and co-lead PsiAN – Nancy Burke, Ph.D., ABPP, Linda Michaels, Psy.D., MBA, and Janice Muhr, Ph.D.
Only a year previously I had learned about their vision for PsiAN. Inspired by this, when I discovered they were searching for a location to hold a conference in the Bay Area, I immediately reached out to offer space at Golden Gate University, knowing that we’d have plenty of room after students returned home for the winter holiday. The conference, entitled “Advancing Psychotherapy for the Next Generation: Rehumanizing Mental Health Policy and Practice,” was a huge success, drawing attendees from all over the country, each of whom shared a passion for preserving, promulgating, and elaborating dynamically-informed, relationship-based treatment.
The present issue attempts to capture the spirit of both this event and its predecessor held in Chicago two years prior. Many of the contributors were, in fact, presenters at one or both of the aforementioned conferences, whereas others have been involved with PsiAN in other ways. All of the authors express, each in his or her own idiosyncratic way, ideas that are integral to the mission of the larger organization. That mission recognizes that while depth-based psychotherapy is alive and well, it is also under attack. Insurance companies are reluctant to cover substantial treatments. Psychology training programs are increasingly constrained to teach manualized, behaviorally-oriented treatments. Public policy is similarly biased toward short-term, structured interventions and medications. The shared vision of organizing to “push back” against medicalization, managed care, instrumentalization, and reductionism unites the present group.
In our lead article, Psychotherapy Action Network: Seeing Beyond the Crossroads, Nancy Burke, Linda Michaels, and Janice Muhr – the three co-chairs of PsiAN – offer a lovely meditation on many of the issues that animate the work of the organization and that will be discussed in later articles in this special issue. They emphasize the importance of recognizing the environments in which our patients are embedded, including the financial, ideological, and cultural forces that impinge upon them and upon the therapeutic work that occurs (or fails to occur) in our treatments with them. Therapies of depth, insight, and relationship are in the “cross hairs,” they insist, and their survival depends upon the strength of our advocacy on their behalf. In this vein, they describe the origins of PsiAN, the principles that form the backbone of its mission, and its three main audiences: policymakers, the general public, and mental health professional organizations. They describe, too, some of the organization’s main efforts over the past several years which, as readers will soon see, have been substantial and far-reaching. It is surely a hopeful beginning.
In our second article, Diagnosis and Its Discontents: Reflections on Our Current Dilemma, Nancy McWilliams reflects on contemporary diagnostic conventions in mental health and their impact on clinical practice, describing the historical evolution from diagnosis that is inferential, dimensional, contextual to descriptive and categorical ways of characterizing mental suffering and the unfortunate consequences for the field entailed by this shift. With a view informed by the history of our field, she highlights the consequences upon diagnosis and treatment of efforts at cost containment, the interests of pharmaceutical companies in mental health, and the sweeping changes in the academic landscape. Finally, McWilliams describes the international project of creating and improving the Psychodynamic Diagnostic Manual, an effort to restore a clinically useful diagnostic sensibility that values inference, dimensionality, context, and meaning.
Farhad Dalal, in his article CBF: Cognitive Behavioral Fallacies, delivers an impassioned critique of the Cognitive Behavioral Therapy (CBT), including its underlying philosophy and “facile understanding of the human condition,” the flawed research protocols that have been used to develop its so-called evidence based, the neoliberal and managerialist political surround in which CBT prospers, and the delivery of CBT in the United Kingdom’s health system. He astutely traces the philosophical origins from Jeremy Bentham’s utilitarianism, which quantified the notion of happiness and drove psychology toward positivism with its insistence that only what can be observed and measured is real. This fundamentalist ideology, by which psychology today is still gripped, can be described as follows: “Only the countable counts. And that which happens to be countable is MADE TO count. And that which cannot be counted, is simply discounted” (p. 582). This ideology, naturally, led to the ascension of behaviorism, descriptive psychiatry, and research paradigms that are fundamentally tied to the diagnostic categories of the DSM. His critique of these research paradigms is devastating and unveils the vested interests, sleights of hand, and abhorrently compromised standards that characterize much of the so-called “evidence” for CBT.
Enrico Gnaulati, in his article Relational Healing in Psychotherapy: Reaching Beyond the Research, argues for a humanistic revival in the education and training of psychotherapists in an effort to help clinicians-in-training to acquire the relational repertoire, self-expansion, and ethical know-how that is an essential aspect of the clinical profession. It is now a well-known fact that the alliance between therapist and patient is one of the strongest predictors of treatment outcome. In addition, while relatively neglected in the current evidence-based zeitgeist, therapist qualities, such as the capacity for empathic immersion and genuine, authentic care, have long been recognized as essential in the psychodynamic, existential, and humanistic therapeutic traditions. In his article, Gnaulati definitionally and descriptively unpacks key aspects of alliance building, therapist empathy, and therapist authenticity and genuineness for pragmatic learning purposes. His effort, it is hoped, will serve clinicians-in-training who are attempting to develop these fundamental capacities and more seasoned clinicians who are revisiting and honing them as well.
Santiago Delboy and Linda Michaels, in their article Going Beneath the Surface: What People Want from Therapy, share the results from their extensive qualitative and quantitative research. They listened deeply to the general public and assessed attitudes, beliefs, biases, motivations and concerns regarding therapy, therapists and mental health. Importantly, they found that a sizeable percentage of the public wants what depth therapy has to offer and has an intuitive understanding that their symptoms can be superficial, transitory, and meaningful. People also understand that changing repeating patterns and opening up new choices takes time, and they are willing to make the investment of time, money and emotion, for they feel both that therapy is a worthy endeavor and they are worthy of its benefits. It is heartening that the public seems receptive to learning more about therapies of depth, insight and relationship, and their research provides the blueprint for revitalizing these therapies in the mind of the public. Yet much work will need to be done, as the public experiences a dearth of resources and clear information.
Susan Lazar, in her article The Cost-Effectiveness of Psychodynamic Therapy: The Obstacles, the Law and a Landmark Lawsuit, provides an overview of the research and laws that demand the provision of psychodynamic psychotherapy. In this effort, she describes how psychodynamic psychotherapy has been poorly supported by insurance in spite of the fact that the Mental Health Parity Act mandates benefits for mental health care at parity with other health care and that the Affordable Care Act lists mental health care as an Essential Health Benefit. She draws out the consequences of limiting insurance support for psychotherapy upon poorer patients and those with a range of chronic and co-morbid conditions. Finally, Lazar describes the 2019 class action lawsuit against United Behavioral Health for declining to cover research-backed standards for mental health care and of a subsequent California state law mandating sufficient insurance coverage.
In The Exclusion of Psychoanalysis in Academic and Organized U.S. Psychology: On Voodooism, Witch-Hunts, and the Legion of Followers, Oksana Yakushko turns an eye toward the precarious place of psychoanalysis in American psychology throughout its history. In spite of its influence upon the wider culture, psychoanalysis has been marginalized and excluded in academic psychology, with notable consequences including a lack of psychoanalytic ideas in psychology academic training, practice guidelines, grants, and scholarship. Yakushko attempts to understand this exclusion within the historical context of values embraced by American psychology since its inception. After surveying the attitudes toward psychoanalysis of important figures such as William James, John Watson, B.F. Skinner, Albert Ellis, and Martin Seligman, among others, she turns to the socio-historical origins of the attitudes toward psychoanalysis within the academy. Here she cites the influence of the eugenics movement on American psychology, whose assumptions were incompatible with those of psychoanalysis in fundamental ways as well as the organizational dynamics of the American Psychological Association from its inception.
In our final article, Two Perspectives of Mental Distress, drawing on his real-world experience as a psychiatrist and psychoanalyst, John Thor Cornelius reflects upon the tension between two perspectives on mental distress: the “broken brain,” which understands mental distress from a localized, mechanistic perspective and as caused by discrete mechanical failures of organic brain function, and the “symphonic” perspective, which sees mental distress as a non-local, wholistic, and distributed process spread across the entirety of the mental capacity and as resulting from the impact of tragic life events upon the normally functioning mind. Despite their overlaps, these two perspectives lead to dramatically different ways of relating to, and attempting to ameliorate, suffering. While the “broken brain” perspective has been prominent in recent decades, he highlights questions about its scientific validity and relation to clinical outcomes. The “symphonic” perspective, he suggests, is buttressed by emerging scientific evidence of its theoretical credibility and clinical efficacy.
In our epilogue, Stepping Towards the Future: PsiAN’s Vision, Linda Michaels, Janice Muhr, and Nancy Burke remind us of the essential and vital role for psychotherapies of depth, insight, and relationship and revisit some of the central themes from this special issue, highlighting both the reasons for hope and the threats to the overarching vision expressed here. As they suggest, and as I want to reiterate in this introduction, the ideas discussed by our contributors have real-world import and urgently demand our attention. Our thoughtfulness about these complex issues, efforts toward advocacy in the public and professional spheres, and the important work of community building have the potential to make an enormous difference in the wider world and in the lives of our patients. It is work worth doing.
Tom Wooldridge, Psy.D., ABPP, CEDS-S
Issue Editor
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Notes on contributors
Tom Wooldridge
Tom Wooldridge, Psy.D., ABPP, CEDS-S, is Chair in the Department of Psychology at Golden Gate University as well as a psychoanalyst and board-certified, licensed psychologist. He has published numerous journal articles and book chapters on topics such as eating disorders, masculinity, technology, and psychoanalytic treatment. Two of his articles were chosen as the “Top 25” published in the past 25 years in the journal, Eating Disorders: The Journal of Treatment & Prevention. His first book, Understanding Anorexia Nervosa in Males, was published by Routledge in 2016 and has been praised as “groundbreaking” and a “milestone publication in our field.” His second book, Psychoanalytic Treatment of Eating Disorders: When Words Fail and Bodies Speak, an edited volume in the Relational Perspectives Book Series, was published by Routledge in 2018, and has also been well reviewed. In addition, Dr. Wooldridge has been interviewed by numerous media publications including Newsweek, Slate, WebMD, and others for his work. He is on the Scientific Advisory Council of the National Eating Disorders Association, Faculty at the Psychoanalytic Institute of Northern California (PINC) and the Northern California Society for Psychoanalytic Psychology (NCSPP), an Assistant Clinical Professor at UCSF’s Medical School, and has a private practice in Berkeley, California.