The Story of Psychology (110 page)

Of all the ways in which psychology influenced Americans during the past three quarters of a century, none has been more pervasive than the change it brought about in how they think of and deal with emotional and mental disorders. Many miseries, failures, disabilities, dissatisfactions, and misbehaviors that their forefathers attributed to weakness of character, wickedness, or Fate came to be seen by most Americans as psychological disorders that could be treated by mental health practitioners.

Acting on this conviction, in recent years some 10 million Americans made 86 million visits to psychotherapists annually, and in-patients in mental hospitals and psychiatric wards of general hospitals accounted for another several million sessions. Cumulatively, nearly one out of three persons—80 or 90 million—have had some experience with psychotherapy.
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About a third of these “consumers” of psychotherapy were treated by psychologists, about a third by physicians (but probably more of the total visits were made to psychologists than to physicians, since many users visited a physician only once to receive medication rather than talk therapy). The rest of the visits were made to clinical social workers, clinical mental health counselors, lay (nonmedical) analysts, and pastoral counselors. (Dr. Abe Wolf, current president of Division 29—psychotherapy—of the American Psychological Association, ruefully says in a recent online message from his division, “Psychologists struggle to maintain a distinct identity, competing with other professionals who all practice psychotherapy.”) Most of the above professionals (except for the physicians dispensing medication), despite their dissimilar backgrounds and allegiance, practice therapies that are psychological, as distinguished from such other approaches to mental illness as the physiological, social, and religious.
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The rise in the use of medication, however, has been notable; the nonmedical therapists now often refer their clients to a physician for medication (to be taken along with talk therapy), and many emotionally or mentally ailing people ask their own family physicians for mood-influencing medications. Some psychotherapists believe that medication has somewhat reduced the practice of psychotherapy, though they have no hard data on the issue. But Dr. Mark Olfson, an associate professor of clinical psychiatry at Columbia University and the lead author of the latest survey of psychotherapy usage, recently told Erica Goode of the
New York Times
, “With all the attention given to antidepressants and
other medications, the role of psychotherapy can be easily overshadowed… but [it is] clear that psychotherapy continues to play an important role in the mental health care of many Americans.”
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Psychology was not originally an applied science, and its training centers produced not “health care providers” but researchers and theorists. The discipline grew rapidly after World War II, as did all the sciences, with the number of science Ph.D.’s granted yearly increasing more than tenfold between 1945 and 1970. But then the baby boom of undergraduates ebbed, new degree holders had difficulty finding teaching positions, and doctorate production declined steeply in all the sciences—except psychology, which kept growing.

By the 1970s, however, psychology was growing not as a pure science but as several forms of applied science, of which health care was far and away the largest. The total output of Ph.D.s in psychology grew steadily from 1966 to 2000, with only a slight drop off to 2004, but the percentage of research psychologists fell off sharply after the mid-1970s while the output of health care providers (clinical, counseling, and school psychologists) continued to increase. Although the absolute number of research psychologists has grown since 1970, it has steadily shrunk as a percentage of the discipline and now comprises a small minority of all doctoral and master’s level psychologists. Clinical and counseling psychologists, most of whom practice psychotherapy (the rest do primarily testing and assessment), now make up about half.
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Despite the growing numbers of clinical psychologists, about two thirds of the demand for psychotherapy is, as already mentioned, met by others: two thirds of the nation’s 45,000 psychiatrists who spend much of their time in private practice; 96,000 clinical social workers, most of whom practice some psychotherapy in agency and hospital settings but some of whom do so in private practice; 80,000 certified clinical mental health counselors; 3,000 pastoral counselors; and an unknown number of other people who call themselves psychotherapists—the use of the term is not controlled by law in most states—and who have anywhere from a fair amount of training to none at all.
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Psychotherapists in all these disciplines now treat a far broader spectrum of patients than ever. (“Patients” is the term used by psychiatrists and psychologists; many other therapists call them “clients” to avoid the medical connotations of the word “patient.” The terms in this context are synonymous.)

Formerly, psychotherapy was used chiefly with people whose contact with reality was unimpaired but who suffered from anxiety, phobias,
obsessions and compulsions, hysteria, hypochondriasis, physical problems of psychological origin—in short, all those said to have neuroses.
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Today, many people seek psychotherapeutic help for marital conflict, parent-child problems, job-related troubles, loneliness, shyness, failure to succeed, and indeed anything that comes under the general heading of “problems of living.”

In addition, psychotics, who used to be treated by prolonged soaking in tepid water, insulin or electroconvulsive shocks, and even lobotomy but rarely by psychotherapy—which often couldn’t reach them—are now brought back to reality or lifted out of the depths of depression by psychoactive drugs and thereby enabled to benefit from psychotherapy. In the 1950s, well over half a million people were locked away in the nation’s state mental hospitals; since the introduction of chlorpromazine and other psychoactive drugs in the middle of that decade, the number has declined radically, to fewer than 44,000.
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A majority of the kinds of patients who formerly were confined now live in the community, and their mental disorders are treated in community mental health centers by means of medication and psychotherapy.

Although psychotherapy has thus grown vastly in influence and acceptability, it has long been assailed both by those who regard psychology as a spurious science and those who regard psychotherapy as a spurious healing art.

One line of attack has stressed that clinical psychologists and other psychotherapists themselves admit that what they do is more intuitive than rational, more an art than a science. Many academic and research psychologists have therefore long held that psychotherapy is unworthy to be called a part of their science. In 1956, a psychologist, David Bakan, wrote in
American Psychologist
, a publication of the American Psychological Association:

A few years later the psychologists Marvin Kahn and Sebastian Santostefano wrote, again in
American Psychologist
, that clinical psychology was “in a state of anxiety, great ambivalence, insecurity, and self-doubt. Clinical psychology states that it is a science, and then says that it is an art.”
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In 1972 and again in 1986, E. Fuller Torrey, himself a psychiatrist, devoted an entire book to the thesis that psychotherapists were akin to witch doctors and medicine men, and achieved changes in their patients by comparable nonscientific means.
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Attacking psychotherapy as nonscience has continued ever since, the attackers ignoring or belittling the many hundreds of controlled studies and meta-analyses of those studies validating aspects of the discipline that have been performed over the decades (we’ll hear about them later). Typical of such attacks is one of the latest, an op-ed piece in the
New York Times
in 2006 by Adam Phillips, a British child psychoanalyst:

Thomas Szasz, a perennial gadfly to his fellow psychiatrists and other psychotherapists, made a different and radical attack on clinical psychology. Mental illness, he charged, is a “myth” fabricated by clinicians who, acting as lackeys of the establishment, diagnose forms of socially disapproved deviant or individualistic behavior as mental disorders.
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Still others have charged that psychotherapists falsely claim therapy to be useful against a wide variety of disorders although, these critics assert, it is helpful against only a limited number. In 1983 Bernie Zilbergeld, an Oakland psychologist and psychotherapist, said in his
Shrinking of America
that psychotherapy is effective for a few problems but that for most others it is of little or no value and is inferior to drugs or simply talking to a friend.
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Another favorite criticism in recent years has been that a number of conditions psychotherapists say they can treat are actually of physiological origin and are poorly remediable by psychotherapy but far better dealt with by medications.

Clinical (severe) depression, for one, has been shown to be of biological origin in many cases. Particularly in elderly people, it is often associated with an age-related imbalance in certain neurotransmitters. Research studies of recent years have shown, according to current information from SAMHSA (Substance Abuse and Mental Health Services Administration), that antidepressant drugs “chemically restore the balance and relieve the depression… [and] are effective across the full range of severity of major depressive episodes in major depressive disorder and bipolar disorder. [The named drugs are the tricyclic and hetero-cyclic antidepressants, MAOIs (monoamine oxidase inhibitors), and SSRIs (selective serotonin reuptake inhibitors.)]… The mode of action of antidepressants is complex and only partly understood. Put simply, most antidepressants are designed to heighten the level of a target neurotransmitter at the neuronal synapse.”
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Tourette syndrome—uncontrollable tics, grunts, barks, often the compulsive repetition of foul language—was long attributed by psychotherapists to profound psychological disturbances and interpreted as having hostile and anal meanings, but psychotherapy consistently failed to help. What
has
helped is the administration of dopamine blocking agents, which suggests that the disorder is due to a dopaminergic excess of organic origin.
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Compulsive gambling and other forms of sensation seeking have been seen by psychotherapists as disorders for which psychotherapy is appropriate, but by 1989 studies based on urinalysis and spinal taps showed that compulsive gamblers and sensation seekers have a chronic deficit of the neurotransmitter norepinephrine. That deficit, it was hypothesized, leads to a low level of alertness and a feeling of boredom, which victims try to alleviate by seeking danger—a condition in which the brain produces extra norepinephrine and which, though it makes most people extremely uncomfortable, makes these people feel good.
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Obsessive-compulsive disorder, in which certain obsessive ideas cause such persistent senseless actions as washing the hands dozens of times a day, has also been found by means of PET scans to be associated with abnormally high rates of glucose metabolism in the basal ganglia, a region of the brain between the limbic system and the cerebral cortex. By the late 1980s, clomipramine, an antidepressant, was found to
sharply reduce the symptoms over a period of weeks, but it had unpleasant side effects, including sleepiness, difficulty starting urination, dry mouth, and a drop in blood pressure when rising from a seated position. Currently, therefore, the medication of choice is usually one of the SSRIs—fluvoxamine (Luvox), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), or citalopram (Celexa). If an SSRI does not work, clomipramine is the fall-back treatment.
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(Another SSRI now coming into favor is escitalopram oxalate [Lexipro]).

Given the long-standing derogation of psychotherapy and the many assertions that it is not science but, at best, a form of magical belief and, at worst, fraud, how can we account for its vast growth and wide acceptance? Some people offer sweeping social explanations: We live in a disconnected and alienated age; we seek sources of comfort and reassurance and turn to those who offer them for pay; in a secular age, psychotherapy takes the place of religious belief and is a secular sanctuary. And so on.