Dodos In Rehab: What’s Effective Therapy (part three)

So what do I mean by Dodos? Those familiar with decades-old arguments within the Balkan states of psychotherapy know the meaning of this allusion to Alice In Wonderful. It has something to do with games in which there are no winners. Lewis Carroll’s absurdist Dodo bird declares, “Everyone has won, and all must have prizes.” With respect to psychotherapy or mental health treatment in community settings, the Dodo bird theory posited that outcome studies for different therapies are surprisingly equivalent, or that patients were as likely to manifest positive change without receiving any kind of mental health treatment at all.

This was the conclusion of Singer and Luborsky (1975), among others. You’d think this would lend itself to less territorial disputes among professionals; less competitiveness or fewer tiresome pronouncements about what works with consumers of mental health treatment, and what doesn’t. Well, you’d think that, but you’d be wrong. I wasn’t a psychotherapist in the 70s or 80s, so I wasn’t around for the supposed arrogance of that generation’s psychoanalytic patriarchs. I work in a state containing some 30,000 licensed Marriage and Family Therapists (compared to a third less just five years ago!), which doesn’t include the thousands of other therapists operating under other licenses, or at a pre-licensed level. Waiting lists? Maybe a few therapists have ’em–those at the top of the food chain. But these days there are plenty of options for the consumer, and the consumer base demands access to care for a diverse population with diverse means. Managed care companies, who are the brokers of this access, demand concrete evidence of what is effective: behavioral change, a medical model’s reduction in symptoms, externally observed–a teleological framework. Hence the DSM and the ubiquity of reductionist thinking.

In my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment, I chronicle my observations of this trend, among others, during my own career in community mental health from the mid-nineties to the end of the last decade, roughly. The trend away from psychoanalytically-derived models is apparent in the rhetoric of providers, program directors, glib administrators–those who pronounce the efficacy of cognitively-based models, and implicitly decry as “alternative” that which has been subject to a lesser volume of affirming research. The passages in my book that depict training scenarios in which psychoanalytic models are mocked: those are real. Trainers really do say things like “we’re not here to do Freud stuff” to clucks of amusement from sycophantic listeners who don’t know any better. The bullet points of their presentations really do assert the greater effectiveness of their chosen models, without even bothering to explore the confounding factors in such research, despite the glaring obviousness of those factors.

On one level, I don’t begrudge the advocates of CBT and other short-term treatment models. Their methods do indeed lend themselves to quantifiable measures, and those looking for a threshold of care that addresses short-term goals deserve to find providers who specialize in implementing short term models, with a focus on present-day stressors and needs as well as a philosophy that draws as much attention to a person’s strengths as it does their deficits. This, after all, is the promise of the latterly heralded strength-based movement, now prominent in schools, special needs programs, and among social workers and in community mental health settings. In these respects, I’d say that shorter term models of mental health treatment have done more to reach more people in the community, though in my opinion, the potential (and precedent) exists for the strength-based model to be integrated with a psychodynamic focus across all levels of care, as long as care is taken not to allow excitable positive thinking to obscure painful realities.

The spirit of the Dodo bird pronouncement is one of humility and mystery: a statement of not knowing that should prevail whenever the subject is the meaning of an individual’s life. There are plenty of perspectives vying for attention at the treatment planning table, and if the need for cohesion is why diversity of thought must be contained, then so be it. Those who find themselves in the right places at the right times can pick their models, the colleagues that will echo them, and be in charge for the time being. But such victories of timing should not hoodwink the public at large: the disengenuous pronouncements of those making sales pitches in this business will whither sooner or later, and those looking for more than what short term psychotherapy models have to offer will at some point stop coming back, to paraphrase a popular saying. The parallels with society’s food debate are apparent: principals of supermarket chains might credibly argue that their products cost less; that they are accessible to a wider range of people with various levels of income; that they feed more people. There is a faction of organic farmers in mix, now asking, “yes, but are you feeding them well?”

* Luborsky, L., Singer, B. (1975) Comparative studies of psychotherapy. Archives of General Psychiatry, 32, 995-1008.

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