Earlier this month, my hometown newspaper (The Washington Post) published an opinion piece by a young associate professor of psychology at the University of Kansas, Dr. Stephen Ilardi. Titled “5 myths about psychology,” Dr. Ilardi cast light, as well as some shade, on various aspects of our profession and myths surrounding it, much to the consternation of numerous psychologists on professional listservs. The efficacy of psychotherapy was taken to task; not surprising as the opinion piece was subtitled “No, talking about difficult things isn’t always helpful.”
In fairness to Dr. Ilardi, authors of opinion pieces usually do not write the titles for their submissions. Editors, in constant search of eyeballs, both electronic and organic, try and come up with attention-grabbing titles designed to enhance readership. But whether Dr. Ilardi wrote the title for the article is somewhat beside the point. Keeping in mind that the opinion piece was written for a lay audience, not a professional one, let’s take a dispassionate look at what he says and see how well the mythological shoe fits.
To give Dr. Ilardi credit, he is hardly publishing a dissertation on the efficacy of psychotherapy. In the 1,000 words or so he was allotted, he dealt with five common misconceptions, with only three short paragraphs dedicated specifically to psychotherapy. He started with Freud and ended up with Critical Incident Stress Debriefing, wise choices if one’s point is to illustrate the shortcomings of talk therapies.
Let’s Take Our Own Look at These Shortcomings
Although some tenets of Freudian practice live on in the form of psychoanalytic and psychodynamic treatment, Freudian theory itself has fallen victim to numerous debunkers. The most cogent debunkment is provided by Richard Webster whose exhaustive—and at almost 700 hefty pages, exhausting—critique was provocatively entitled Why Freud Was Wrong (Basic Books, 1996). It goes without saying that Webster’s take on Freud fell somewhat short of total adulation, as did a fairly contemporaneous, well-publicized popular critique: In the Freud Archives by Janet Malcolm (Penguin, 2002). But Freudian theory and practice created a tectonic shift in medicine, if not the “most significant medical movement in the whole of human history” as Webster described it. Clinical psychology was a fledgling, if purely laboratory-based profession when Freud published Studies on Hysteria in 1896, and psychiatry, then usually known as alienism, had existed as a recognized specialty for nearly 100 years. Asylums were burgeoning in the 19th century, though generally filled with the victims of tertiary syphilis, the most prevalent form of madness in those times.
Talking cures have existed for millennia. Mentioned in classical philosophy and by Robert Burton (writing as Democritus Junior) in The Anatomy of Melancholy (1628), the benefits of unburdening oneself to an empathetic other of fears, secrets, and perceived shortcomings have long been known. With the advent of systematic investigation and the mid-20th century development of the randomized clinical trial, its benefits have been quantified. We all know the hazy guesstimate known as the “rule of thirds”: about a third of participants in psychotherapy get better, about a third remain the same, and a smaller number get worse. As Bruce Wampold has often reminded us with his famous “Dodo-bird hypothesis,” any active, credible form of psychotherapy (including psychoanalysis and psychodynamic treatment) is as good as any other credible, active form of psychotherapy. But it took Freud, and arguably more importantly Carl Rogers, to lay the foundations of a systematic psychotherapy with acknowledged benefits. We also know that the benefits of psychotherapy and pharmacotherapy are roughly equivalent, at least for depression and anxiety disorders. Effect sizes are modest for both treatments, but regardless of which treatment is received, about the same proportions of patients get better, stay the same, or deteriorate. An important aside here is provided by Totura, Fields, and Karver (2018) who performed a meta-analysis of studies that looked at the therapeutic relationship as a covariate in pharmacological treatment and found an overall average weighted effect size of z = .30—indicating that the therapeutic relationship in treatment with medication has a significant, albeit modest, influence on treatment outcome. So whether it’s psychotherapy or psychotropics, the quality of the relationship predicts who gets better.
As to the treatment once known as Critical Incident Stress Debriefing (CISD), and later called Critical Incident Stress Management, among other less savory things, well, perhaps the less said the better. CISD was ardently promoted as an effective intervention in the military and among first responders in spite of the total absence of an evidence base supporting efficacy. Particularly in its earlier, more aggressive manifestations, it had real power to do harm in that the model mandated verbalization, in group settings, of individuals’ behavior and subsequent psychic responses to traumatic events. Although the model was later modified to do away with the mandatory disclosure component, decompensation was a known risk of CISD. Parenthetically, CISD presented a nightmare scenario for accident investigators. Because the model called for it to be conducted on-site, and as soon as possible after an incident, group disclosure of an individual’s actions in responding to the crisis irretrievably contaminated post-incident investigation.
It is important to ask why an unvalidated intervention mandating potentially involuntary disclosure became so popular in the early 1990s. While aggressive marketing certainly had a role, I suspect it is more likely that agencies were becoming increasingly aware of the cumulative effects of involvement in traumatic events on first responders, and in the absence of validated alternatives readily adopted this apparently credible intervention. Caveat emptor.
Returning to Dr. Ilardi’s Article
So how should we judge Dr. Ilardi’s reference to a claim that only 50% of patients improve with talk therapy? Given what we know, I think he is fairly generous in his estimates. Talk therapy is not a panacea, and unproven treatments and unskilled practitioners can do real harm, so there is no cause to fault his iteration of this conclusion. Where Dr. Ilardi does err, I believe, is his apparent belief that psychotherapy failures result from ignoring evidence-based techniques. As noted above, all active, credible psychotherapies are of generally equal efficacy, and as the lifelong student of psychotherapy—Professor John Norcross—reminded us in a recent National Register webinar, it is the quality of the relationship, rather than any specific technique, that accounts for most of the variance in psychotherapy outcome.
Professor Ilardi addresses several other common popular misconceptions in his op-ed piece. There is no truth to assertions that humans only utilize 10% of their brains, that patients with OCD are by nature hyperorganized neat freaks rather than essentially paralyzed by their obsessive thoughts or compulsive rituals, or that pharmacotherapy works by correcting chemical imbalances in brain. But these are public misconceptions and not professional ones, and Dr. Ilardi provides a service by addressing them in a forum aimed at seekers of psychological services rather than those who provide them.
So let’s not rush to Lawrence, Kansas with buckets of hot tar and sacks of feathers. Professor Ilardi has accurately pointed out some common misconceptions about mental health and psychological treatments, and in doing so has provided a service to the public. Our treatments don’t work for everyone, and we often don’t know the active components of the ones that do. As credible scientist-clinicians, we should readily endorse these shortcomings while at the same time strive to improve our knowledge and its application. Let’s recall what André Gide suggested more than a century ago: “Believe those who seek the truth. Doubt those who find it.”
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Totura, C. M. W., Fields, S. A., & Karver, M. S. (2018). The role of the therapeutic relationship in psychopharmacological treatment outcomes: a meta-analytic review. Psychiatric Services, 69(1), 41–47. doi: 10.1176/appi.ps.201700114