Thomas Insel, M.D., former director of the National Institute of Mental Health, in his most recent book, “Healing: Our path from mental illness to mental health” (1) argues that our mental health crisis is more an instance of our failing to provide the treatments that work to the illnesses that our clients (or patients) experience. Insel cites a number of examples of this, including how there is strong evidence to support Family-Based Therapy for eating disorders for adolescents (2), but how this model is not being consistently utilized. Insel’s point appears to be that one aspect of the crisis in mental health is the failure of providers to consistently utilize the most effective treatment models. While some of his arguments in this regard may be subject to debate (for example, his arguments for the benefits of medication based treatments and what he refers to a neuroscientific treatments, such as TMS may not be as well supported as he asserts) this does not detract from his point that we as a field are not consistently utilizing the most effective treatments in a consistent fashion. Insel also focuses on problems in delivery of care. His critique includes the fragmentation of care, specifically providers not coordinating care, as well as the quality of training mental health professionals receive. In addition, Insel is critical of what may be considered biological reductionism, the tendency to view mental illness as a solely or primarily biological problem. Insel argues that many of the simplistic biological explanations of mental illness are far from sufficient, and acknowledges that there has been an overfocus on neuroscience focused research and an inadequate focus on clinical research. Insel is far from alone in this critique. For example, Johann Hari has written a thought provoking critique of the biological model of depression (3) which has been discussed in previous blogs. In sum, Insel offers a thoughtful and thought provoking discussion of challenges we face in understanding and more effectively treating mental illness.
A recent article in Wired Magazine (not my usual reading but it appeared in my newsfeed) provocatively titled, “Why Therapy is Broken” (4) raises similar concerns about the state of mental health care, with a much more specific focus on psychotherapy. The first concern identified involves the popularization of therapy and misconceptions that people may have about what therapy does and what is necessary for therapy to be helpful. Ironically, a second article (5) in my news feed discussing the rise of Tik Tok videos on ADHD highlights this issue. Specifically, the article notes that while the discussion of ADHD increases awareness of this disorder it also contributes to the spread of inaccurate information about ADHD and the possibility of overdiagnosis, which is an increasing concern (6). A second issue concerns the proliferation of models of therapy and how many so-called Evidence Based Therapies (those models supported by research) really may not all be effective. A related concern is how many therapists tend to draw from multiple models in their work and thus are not actually providing the treatments as they were designed. The authors cite a meta review (an analysis of multiple studies) that finds that the evidence supporting Evidenced Based Therapies is far less consistent and far less adequate than the label, evidenced based, implies (7). Third, the article notes that consumers of therapy services really do not have a good way to find the right therapist for their problems. The article notes that listings of therapists on Websites such as Psychology Today really do not offer useful information to consumers. This point is painfully obvious to anyone who searches for a therapist in a location where there are many therapists. Similarly, online providers such as Better Help which offer a smorgasbord of options including text messaging as a type of therapy, are clearly not an improvement or a solution. Ezra Klein, a podcast host and writer, makes this point as well, in his interview with Insel. He notes that in trying to select a therapist that he was unsure how to proceed, other than to ask friends (8). He and Insel note that this problem is less challenging for those seeking medical care in that one is likely to find higher quality services through physicians at the top rated teaching hospitals. Fourth, the article notes that there is a shortage of available mental health providers which clearly appears to be a valid concern. Unfortunately, the article goes on to make the exaggerated claim that most private practice clinicians are only self-pay. Finally, the article highlights that therapists are not typically utilizing outcome measures (an approach I have discussed previously) despite consistent evidence that the use of these measures improves therapy outcome (9). In a related point the authors also note that there are a number of people who drop out of therapy, “ghost” their therapists and that there is a small, but notable, percentage of people who do more poorly, deteriorate, during the course of therapy. Scott Miller and his colleagues have highlighted this concern previously, noting that this is an often neglected but serious challenge to therapists.
The above is not to suggest that therapy is not helpful. In fact there is evidence that therapy does help a large number of people who seek therapy services. Rather, it is to suggest that there are multiple challenges that we face as a field if we wish to improve our practice. First, is to educate our clients about what therapy involves and the work that therapy entails. Second, is to educate ourselves: are we really using the most effective models and practice in our work with our clients. Third, and perhaps most challenging, is that therapists need to recognize that even the best of us cannot be all things to all clients. If we are not helping someone, we need to talk about this with our clients and re-evaluate our work together and consider alternatives that might benefit our patients. It also means that we need to have and support difficult conversations with our clients about the lack of progress, their feelings about how therapy is proceeding, and their concerns about our work with them.
- Insel, T, Healing: Our Path from Mental Illness to Mental Health, Penguin Press, 2022.
- For reviews of this book please see: https://www.psychiatrictimes.com/view/the-uphill-path-to-mental-health-a-book-review
- Sasha Gorrell, PhD,a Katherine L. Loeb, PhD,b and Daniel Le Grange, PhDc,d,*, Family-based Treatment of Eating Disorders. Psychiatr Clin North Am. 2019 Jun; 42(2): 193–204. and Published online 2019 Apr 3. doi: 10.1016/j.psc.2019.01.004.
- This article details how evidence supports an Eating disorder specific family therapy as the first-line treatment of adolescents with anorexia nervosa (AN) and as a recommended treatment of adolescents with bulimia nervosa (BN).
- Hari, Johann.
- Hari offers a detailed, if not somewhat overstated, critique of the medical model of depression, and the overreliance on medication.
- Cummins, Eleanor, “Why therapy is broken”, https://www.wired.com/story/therapy-broken-mental-health-challenges/?utm_source=pocket-newtab
- The article detailing the limitations of the research supporting so called Evidenced based therapies: Evaluating the Evidential Value of Empirically Supported Psychological Treatments (ESTs): A Meta-Scientific Review *John Kitchener Sakaluk University of Victoria Robyn E. Kilshaw University of Utah *Alexander J. Williams University of Kansas Kathleen T. Rhyner Canandaigua VA Medical C. Journal of Abnormal Psychology, 2019. A link for the summary and to access the article: https://psycnet.apa.org/record/2019-43757-004
- An interesting website, noted in the Wired article, focusing on problems in the provision of therapy: https://www.verybadtherapy.com/
- The link to the article on ADHD on Tik Tok: https://www.self.com/story/tiktok-adhd?utm_source=pocket-newtab
- The overdiagnosis of ADHD: Is Adult Attention-Deficit Hyperactivity Disorder Being Overdiagnosed? Joel Paris, MD,1 Venkat Bhat, MD,2 and Brett Thombs, PhD The Canadian Journal of Psychiatry. 2015 Jul; 60(7): 324–328. doi: 10.1177/070674371506000705. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500182/
- See Ezra Klien’s podcast, The Ezra Klien show, episode dated Jul 22, 2022 for his interview with Thomas Insel.
- This article provides a summary of the research supporting the value of routine outcome measurement in psychotherapy: The effects of routine outcome monitoring (ROM) on therapy outcomes in the course of an implementation process: A randomized clinical trial Heidi Brattland 1, John Morten Koksvik 1, Olav Burkeland 2, Rolf Wilhelm Gråwe 1, Christian Klöckner 3, Olav Morten Linaker 1, Truls Ryum 3, Bruce Wampold 4, Mariela Loreto Lara-Cabrera 2, Valentina Cabral Iversen in the Journal of Counseling Psychology, 2018 Oct;65(5):641-652
- The link for this article is: https://pubmed.ncbi.nlm.nih.gov/30113180/