Medical treatment

Psychotherapy as medical treatment

REMARK

With the development of modern psychotherapy by Sigmund Freud in the 1890s, a new method of treating psychopathology was born. A neurologist by training, Freud was above all a doctor who, in 1895, wrote that he wanted to create with psychoanalysis “a psychology that would be a natural science”.1 Throughout his career, Freud maintained his belief that future advances in neuroscience would validate his ideas about the unconscious, and that later modifications in psychoanalytic technique might make it effective for more serious mental illnesses like schizophrenia.

Yet over the past 50 years, and particularly the past 30 years, we have witnessed the concept of psychotherapy applied to a multitude of endeavors unrelated to the treatment of psychopathology. These areas include marital, family and relationship therapy; career and business advice; positive psychology and general self-improvement; New Age Energy Healing; and, more recently, life coaching. It is conceivable that the current number of therapists in the United States working in areas such as those listed above exceeds the number of therapists primarily interested in the treatment of psychiatric disorders.

The current definition of psychotherapy from the American Psychological Association is as follows:2:

“…any psychological service provided by a trained professional who primarily uses forms of communication and interaction to assess, diagnose and treat dysfunctional [disordered] emotional reactions, thought patterns and behaviors.

Yet, among some modern psychoanalysts and existential therapists, there is a tendency to view psychotherapy as a process entirely independent of the concept of mental illness (that is, not as a form of treatment for illness, but rather as a business undertaken for other reasons), a position that deviates significantly from the psychiatric and psychoanalytic conceptualization of psychotherapy for the vast majority of the 20th century.

Although this demedicalization of psychotherapy coincides chronologically with the growth of lay analysis (that is, the practice of psychotherapy by non-physicians), I argue that it is not due solely to this postman. Psychiatric social workers were the first non-physicians to practice psychotherapy beginning in the early 20th century, engaging in the practice long before it was adopted by the fields of psychology and counseling, but psychotherapy remained primarily focused on treating the mentally ill during this time.3 Renaming psychotherapy as a non-medical enterprise unrelated to psychopathology has had many negative consequences.

The consequences of demedicalization for patients

I argue that there are 3 main consequences of demedicalizing psychotherapy:

1. Psychotherapy is devalued compared to other forms of psychiatric treatment, despite its proven effectiveness for a range of mental disorders.

2. Access to psychotherapy as a treatment for mental disorders is becoming more difficult as fewer therapists choose to specialize in the treatment of psychiatric patients and instead focus on other forms of therapy or counselling.

3. Educational requirements for psychotherapists continue to relax, so many graduate therapists have had little or no exposure to patients across the spectrum of psychiatric diagnosis.

Although the 3 points are essential, I want to comment briefly on number 3, which I consider to be particularly disturbing. Training standards for psychotherapists in this country have been falling for decades. For example, some clinicians graduate without ever having assessed a patient with schizophrenia or bipolar disorder. Practicum sites can be located in a variety of non-clinical settings. Without adequate training in the assessment and treatment of mental disorders, non-medical therapists are less likely to choose to work with these patients and may put them at risk of harm if they do.

These factors have led to a nationwide shortage of properly trained psychotherapists. In my own metropolitan area of ​​over 3 million people, there are only a handful of private therapists who work with patients with serious mental disorders, such as schizophrenia. Yet online therapy directories are filled with listings of therapists who specialize in relationship issues and life coaching. The sad reality is that the patients who need the most help are the least likely to find it. The demedicalization of psychotherapy is becoming a barrier to accessing competent mental health care.

By saying that psychotherapy is primarily a form of medical treatment, I am not suggesting that its practice should once again be limited to physicians. In a broad sense, a whole range of medical interventions are provided by non-physicians, such as nurses and physician assistants, and I argue that psychotherapy is one of those interventions. As noted above, psychiatric social workers practiced psychotherapy within psychiatric departments beginning in the 1910s. During this time, psychotherapy remained a medical treatment for psychiatric disorders.

Likewise, I am not suggesting that these non-medical extensions of psychotherapy, such as helping businessmen to climb the corporate ladder, are not legitimate activities that serve a useful purpose. It is simply to say that these other endeavors, however worthy (and lucrative) they may be, distract us from the primary goal of psychotherapy: the alleviation of human suffering caused by mental illness. What we are left with is psychotherapy that works for the wealthy and healthy, not the sick and disabled.

The consequences of demedicalization for the field of psychotherapy

The demedicalization of psychotherapy is not only bad for psychiatric patients, but also for psychotherapy itself. When psychotherapy is perceived by the general public – and by some mental health professionals – as something other than treatment (for example, as simple conversation to cope with the difficulties of daily life), it becomes an intervention of secondary or tertiary importance in the psychiatric arsenal. If psychotherapy is seen as not really treating mental disorders (“Drugs treat illness, psychotherapy just helps people cope”), then its use will gradually fall out of favor in favor of other, usually biological, treatments. Yet we know that psychotherapy is the treatment of choice for a range of mental disorders, including personality disorders, post-traumatic stress disorder, mild depressive disorder and others.4

Even in cases where psychotherapy is not indicated as monotherapy, such as in the treatment of bipolar disorder or schizophrenia, its use is not merely supportive in nature and is still reflective of a form of treatment. When conceptualized through a biopsychosocial lens, even complex illnesses like schizophrenia have a psychosocial component, and psychotherapy can legitimately be seen as addressing this element.5

While much of the demedicalization of psychotherapy has been the result of innocuous motives, there is also an antipsychiatric push to view psychotherapy as something other than treatment. This line of argument goes something like: “Mental illness does not exist and therefore psychotherapy does not treat illness.” Szasz made such a claim in his 1978 book The myth of psychotherapy,6 but his conclusions were based on a misinterpretation of the concept of disease.seven You don’t have to be a psychotherapist, or even value psychotherapy very much, to see the problems inherent in this type of reasoning.

Finally, conceptualizing psychotherapy as a medical treatment does not require or imply a theory of the biological causation of psychiatric disorders. Psychoanalysts of mid-century American psychiatry certainly viewed psychotherapy as treatment in the literal sense, but few viewed psychiatric disorders as biological illnesses. Although a thorough discussion of the meaning of “disorder” in psychiatry is well beyond the scope of this article, suffice it to say that mental disorders can be conceptualized as genuine medical illnesses due to the suffering and disabilities associated with them., regardless of any known or imputed biological abnormality.seven

Final Thoughts

Freud’s original goal for psychoanalysis was a method of treating mental illness. Psychotherapy remained, for many decades, primarily a form of medical treatment, even when practiced by non-physicians. Attempts to define analysis – and, by extension, psychotherapy – in other ways historically deviate from its original and primary intent. The more recent application of psychotherapy to problems unrelated to psychopathology dilutes the value of psychotherapy, relaxes training requirements, and leads to unnecessary barriers to care.

Dr. Ruffalo is Instructor of Psychiatry at the University of Central Florida College of Medicine in Orlando, FL, and Adjunct Instructor of Psychiatry at Tufts University School of Medicine in Boston, MA. He is a psychoanalytic psychotherapist in private practice.

The references

1. Freud S. Scientific Psychology Project. Standard edition. Hogart; 1966: 295-397.

2. American Psychological Association. Psychotherapy. APA dictionary of psychology. Accessed June 20, 2021. https://dictionary.apa.org/psychotherapy

3. Harrington A. Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness. Norton; 2019.

4. Shedler J. The effectiveness of psychodynamic psychotherapy. American psychologist. 2010;65(2):98-109.

5. Ruffalo M. Understanding schizophrenia: towards a unified biological and psychodynamic approach. Psychoanalytic social work. 2019;26(2):185-200.

6. Szasz T. The myth of psychotherapy. Anchor Press/Doubleday; 1978.

7. Pies R. On Myths and Counter-Myths: More on Szaszian Errors. Arch Gen Psychiatry. 1979;36(2):139-44.