Talk Therapy: Longer-Term Models No Longer Viable?

When you measure client progress not in terms of symptom reduction, but in terms of improved social and emotional well being, there really is a positive dose-response curve. In other words, the more therapy received the better clients get. Given that only about 9 percent of clients attend twenty or more psychotherapy sessions—a number which in itself is much less than what the average anxious/depressed client needs to fully recover—to me it is indisputable that we have a psychotherapy drop-out crisis. Enrico Gnaulati, PhD, author of Saving Talk Therapy (Psychology Today interview)

From the publisher’s description of clinical psychologist Enrico Gnaulati‘s Saving Talk Therapy: How Health Insurers, Big Pharma, and Slanted Science are Ruining Good Mental Health Care (2018): “In recent decades there has been a decline in the quality and availability of psychotherapy in America that has gone largely unnoticed—even though rates of anxiety, depression, and suicide are on the rise.”

Factors cited include Big Pharma’s pushing of psychotropic medications directly to prospective clients via TV and other ads, the ability to get such medications from one’s physicians versus having to see a mental health practitioner, and health insurers’ preference for quick treatments.

Although he tells Ryan Howes, PhD, in a Psychology Today interview that talk therapy isn’t exactly “dying,” he does believe it’s “seriously under threat; at least as it applies to varieties of talk therapy that are relatively non-directive, time-intensive, in-depth, and exploratory in nature—typically under the psychodynamic and humanistic umbrellas of care”:

These are the approaches where clients are allowed ample time and space to settle in and emotionally unburden themselves—to think the unthinkable, feel the unfeelable, and say the unsayable—with a therapist who truly embodies that all-important blend of empathy, patience, discernment, serenity, and forthrightness.

The newer trend is to provide “evidence-based” treatments, which according to Gnaulati are “CBT-type, short-term psychotherapies supposedly tailored to reduce the symptoms associated with a given diagnosis.” Having reviewed the literature, he believes that studies that tout such treatments tend to be misleading, however:

Evidenced-based treatments such as these are problematic because they measure progress strictly in terms of symptom reduction over the short term, not greater social and emotional well-being over the long term.
It turns out that evidenced-based really is evidenced-biased because the bulk of current empirical evidence substantiates that ‘contextual factors’ in psychotherapy are most predictive of positive outcome—empathy, genuineness, a strong working alliance, good rapport, favorable client expectations. And when you survey clients they overwhelmingly want a therapist who is ‘a good listener’ and who has a ‘warm personality,’ not someone skilled in the latest techniques.  So, CBT-type evidenced-based treatments should not be monopolizing the field right now in the way they are.

Fifteen Facts About Mental Health That Show Why We Need to Save Talk Therapy” has been posted by Gnaulati’s publisher, Beacon Press. A sampling:

  • 90% of people claim they would rather meet with a therapist to talk about their problems than take medications
  • Only about 3% of Americans ever enter psychotherapy, even though roughly half the population meet lifetime criteria for a serious emotional problem
  • Of the approximately 49,000 psychiatrists in the United States, the overwhelming majority exclusively prescribe medications. Fewer than 11% now provide talk therapy to their patients
  • 58% of emotionally troubled people take medications only, with no psychotherapy. About 10% of such people attend psychotherapy only and opt out of medication usage
  • 50% of research articles in the field of psychiatry are ghostwritten in some shape or form, penned by outsiders and published under the names of prominent academics, all whom draw paychecks from pharmaceutical companies

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