Is Psycho-Social Psychotherapy falling into oblivion at the most critical time?
An article in The New York Times reflects upon a psychiatrist lamenting on the fact that he can no longer do Talk-therapy with his patients as it is by large no longer covered by health insurances in the US. (see link here: http://www.nytimes.com). But this is not all. To put another nail in the coffin of psychoanalytic psychotherapy:
A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since.
This is indeed shocking news and it is also echoing an article by the APA about a year ago, recording a big fall in the proportion of pshychiatrists who see patients in liaison with other members of the multi-disciplinary team
However Michael J. Owen, member if the DSM5 Work Group on Psychotic Disorders have been part of writing an article where it is evident that the glass-house is tumbling down in terms of genetic medical research into psychosis and schizophrenia but is it too little too late? I will reflect on this in this article which is written from the perspective of being an Occupational Therapy student who also happens to be a member of ISPS (The International Society for the Psychological Treatments of the Schizophrenias and other Psychoses). As Owen, et. al. writes in their new article in The British Journal of Psychiatry:
“In particular the evidence from family, twin and adoption studies has suggested that schizophrenia is not merely highly heritable, but that there exists a specificity of genetic risk with respect to other major psychiatric syndromes. However, recent findings pose severe challenges to this view, and suggest that schizophrenia might more usefully be seen as a member of a much wider group of overlapping syndromes to which neurodevelopmental abnormalities contribute, and which are not restricted to psychotic, or even psychiatric, disorders.”
I have been part of coining a term for this kind of writing. In Future Science we call such language for ‘the backwards gallop’. Imagine a knight in shiny armor riding his horse. He is shaking his head violently in total denial while the horse is galloping backwards. He is trying to fend off any obstacles but he cannot see them as there is a clear schism in the direction of attention between himself and the backwards galloping. Salvation comes from insight, not from trying to fit reality to your own purpose. I do not mean to make it laughable or to mock the authors of the article as I believe it is a serious article. However I do believe that there is a case of denial in terms of it being late and the magnitude of neglect towards the whole psychosocial approach – which has been existing for many centuries. So it is, as if the Roman nobles are indeed falling on their swords. I would believe the process of change would require the noblemen to actually publicly appreciate ‘the other side’ (for lack of better words) rather than to try and re-fit their old dogma into a new frame claiming they always had the right answers and that it is only minor adjustments to what they already knew. That is how I interpret this article. Everyone is of course entitled to learn from ones ‘mistakes’ (or claims based on assumptions caused by lack of evidence) but I do think that in order to do that you have to come to terms with it as being faulty or insufficient in the first place. Did they realize that earlier assumptions were splitting psychiatry in two?
“Aetiological research, including genetics, should now end its exclusive love affair with DSM and ICD categories. The goal now must be to relate research on aetiology and pathogenesis to specific psychopathological syndromes and phenotypes defined by studies of cognition and neuroimaging, and to place these in a developmental context.”
I think there is a song-text by Alanis Morissette that goes along the lines of: “Isn’t it ironic”. If you want to really change things you have to start with the language… As the late Lars Thorgaard was such a brilliant mind for seeing this in terms of medical terminology being obstacles in itself for recovery I might point to his work rather than getting myself wound into an explanation that I might not yet have thought thoroughly through. However I can say that I have written on this in a project about the theoretical terminology used in Palliative Care at an earlier time. I believe the same critique can be directed towards psychiatry. If you want patients to understand you have to start with something they can understand and relate to. My point is that this starts already when someone writes down theory, thesis and research articles because this is what is going to form the language that is used in praxis too. And certainly the internal language between psychiatrists themselves is going to affect the attitude towards clients.
“Recent findings suggest that we now need to go further and view the functional psychoses as members of a group of related and overlapping syndromes that result in part from a combination of genetic and environmental effects on brain development and that are associated with specific and general impairments of cognitive function.”
Too little too late? Why do I find Cullbergs description of psychosis as similar to crisis reaction much more valid and generally valuable for the patient? The whole problem of course from my point of view is that DSM and ICD are reflecting onto other branches (like OT) effectively preventing us from taking a holistic approach to our work with the patients. Also I would like to point out that this article might be seen as revolutionary internally (in the psychiatrist world-wide community), but is it really? Or is it just the shortest step possible when it could have been a series of giant steps (to use a Coltrane term). If non-medical staff like OT’s (see the mail about Drugs and psychotherapy) are required to ask that managers would hire psychiatrists with a psychoanalytic or psycho-social approach then we would have to be able to point to a bigger population than 11% of psychiatrists and that requires a change in the ranks of psychiatrists. Otherwise we will not be taken serious. It is a major breakthrough when the major UK centre for genetic research admits ‘we were wrong’, but in order for that to even make a ripple in the surface out where the patients are treated in day-to-day praxis the language will have to follow through in order to change the general attitude and THEN – then we can start to ask the management to follow through on psycho-social long term person-centered mental health care which would be in concordance with Occupational Science and Occupational Therapy. What we are facing here is the general extinction of psychoanalytic psychotherapy approaches while everyone is suddenly coming to realize that it was the better approach. In praxis it may be too late before the ripples hit the shore.
I hope I do not come through as overly provocative.
Michael J. Owen, PhD FRCPsych, Michael C. O’Donovan, PhD FRCPsych, Anita Thapar, PhD FRCPsych andNicholas Craddock, PhD FRCPsych (2011). Neurodevelopmental hypothesis of schizophrenia. http://bjp.rcpsych.org/cgi/content/full/198/3/173
For the magnitude of this scientific revolution contrast this article from Sept 2005 by the same authors:
M.J. Owen, N. Craddock and M.C. O’Donovan (2005). Schizophrenia: genes at last? Department of Psychological Medicine, Wales College of Medicine, Cardiff University, Henry Wellcome Building, Heath Park, Cardiff, UK, CF14. http://tinyurl.com/5wx2vex
Genetic epidemiological studies suggest that individual variation in susceptibility to schizophrenia is largely genetic, reflecting alleles of moderate to small effect in multiple genes. Molecular genetic studies have identified several potential regions of linkage and two associated chromosomal abnormalities, and evidence is accumulating in favour of several positional candidate genes….
Wake-up call for British psychiatry
See the full text of the abstract and note the polarised assertion that the