The Faltering APA

As I prepare a lecture for the class I teach, I am reminded of all the reasons I have to shake my head the current state of mental health care in America. Some years ago, George Albee wrote a commentary for The National Psychologist entitled "The decline and fall of the American Psychological Association." In it, he outlined the history, the present, and the inevitable future of the APA (assuming it continue to follow the same trajectory). Well, it does continue to follow that trajectory and I suspect Dr. Albee was right.

Regardless of how you may feel about my former posts and my opinions on these matters, it is hard to ignore 1) the history of mental health missteps in American history and 2) the absence of evidence to support the claims being made. I think we all pay lip service to 'how influential the media is' in shaping our opinions and beliefs about things, but if you are reading this, you probably actually care about people, want them to be healthier, and are upset when mistruths (or outright lies) are told that masquerade as truth. The irrefutable truth is that the media, funded by pharmaceutical money, lies to the American public. They are so bold, in fact, that in a recent commercial, they 'told' on themselves and used their own admission to try to sell more of their own product.

Where is the APA? Are they conducting research to show the value of psychologists and psychotherapy? Apparently not. Are they conducting research about what is most beneficial to patients? Nope. Are they conducting research on brain structures and "chemical imbalances." Why, yes! Has it produced any meaningful, usable understanding of mental illness, its origins, and how to cure it? No.

In sum, the APA is an utter failure at representing the true nature and interest of its members. It parades itself as an collective, scientific organization that can speak for all of us and give expert advice on a variety of psychological issues. However, it does not speak for me and I suspect there are many like me who agree. I think it would be difficult to defend that the APA produces scientifically rigorous research on which their opinions are based - especially since all of their scientific 'eggs' are in one basket - a basket that has produced no useful outcomes yet, but more time, money, and energy are being pumped into it.

Great "science."

Prescribing Psychologists: The Wrong Strategy

One of the interesting mental health topics of the day is the fast and furious move to get psychologists prescribing rights. Historically, only physicians (and a few other medical specialities) were entitled to prescribe medications. As times and needs have changed, there has been some suggestion that psychologists ought to have some ability to hand out medications as well. Beyond mere suggestion, there have been some states to approve this move. There is also a powerful movement of psychologists who are pushing to make this happen nationwide.

There are certainly pros and cons to making this change. One very strong argument for it is that in rural areas where there are few practitioners, having a mental health provider who can provide all services under one roof may be of great benefit. At a minimum, it would be convenient for those who need such services since it is often the case that a person may need to travel a great distance to find mental health care. The other argument for giving psychologists prescription rights is that they are more clinically minded than physicians, implying that they would use medication more sparingly and appropriately, especially since they are working with those patients in therapy already.

I would argue, however, that there are far more cons than pros to taking on this burden. First and foremost, as I have discussed previously, psychologists are trained as clinicians, theorists, and to apply analytical techniques to help identify, understand, and ultimately help patients change behaviors, thoughts, and feelings. Even though our training is being abused and diluted these days, we are still strongly analytical thinkers (between pharmaceutical companies, the APA, and "evidenced based" treatments, this skill will eventually become a thing of the past, unfortunately).

The mindset associated with using medication is very different. The medication mindset is inevitably about looking for target symptoms and doing what is necessary to reduce or eliminate them. Not so ironically, this is a very similar approach as the evidenced based practices. As I've said previously, I don't think these approaches are inherently bad; they have a place for some patients in some situations. Thus, the problem I foresee is not simply about the reduction in symptoms.

The problem is more about psychologists losing their professional identity and those traits that make them unique and important in mental health care. Making such a dramatic shift in mindset and day-to-day functioning (e.g. going from providing psychotherapy to providing medication checks) is going to influence the psychologist's thinking and overall practice strategy. I look at this like someone who spends a few years working in a pain clinic and then changes jobs to a state hospital. By necessity, the mentality and focus will shift away from one thing and onto others demanded by the new role. Again, this is not inherently bad. However, it is fundamentally bad for psychologists.

Advocates for giving psychologists prescription rights point to the aforementioned issue that we are in a better position than our peers to give and monitor medication since we are already working so closely (in psychotherapy) with our patients. This is absolutely true! All things being equal, having the same provider give medication and therapy is preferable to the alternative of having two (or more) providers offering those same services. While this is a good scenario, all things are not equal. This scenario is idealistic, not realistic. Not so long ago, psychiatrists were in precisely the same role in that they were providing both talk therapy and medications. As time continued, demands changed, and insurance money corrupted (as it always does), psychiatrists spent less time in therapy and more time giving medicines.

Bottom line: The same will happen to psychologists.

The in the beginning, there will be a time when we do both and do them well. In time, the current wave of the culture (i.e. quick fixes, symptom mitigation, pills for everything) will continue to grow larger. More medication will be manufactured and marketed as a miracle cure. Consumers will demand to have these medications. As demand increases, more suppliers will be necessary. We just so happen to have this whole new batch of prescribe rs who can offer you psychotropic medicines. Referrals will start to be for medication only, which will demand more time from the psychologist to schedule follow up for medication checks. In time, their schedules will be dominated by medication checks.

Just as has happened in the past, the next tier of clinicians - a trend we have already seen with more Master's level clinicians doing psychotherapy - will grow and psychologists will become the new psychiatrists. Psychiatrists will have to compete or lurk into the background. Ultimately, psychologist's will have lost the very traits that made them clinical, unique, and helpful to their patients. Psychologists will not save the day and bring common sense back to mental health. In time, they will become just as corrupted, even though the movement started with pure intentions.

Besides that medication is already overused, it will become worse. Make no mistake, psychologists will get prescribing rights. Pharmaceutical companies will make sure it happens. It is the wrong move for psychologists because it will corrupt our already fragile professional image. Our professional demise is growing stronger and, sadly, both our professional organization and so many of its own members are fueling the plummet. This, my friends, is the unavoidable, inevitable outcome of compromising your integrity and values.

Just kill the pain - Please!

It seems like a wicked combination of factors is at work in America today. We are certainly not taking better care of ourselves, nor are we seeking out working efforts to make ourselves better. We prefer to find some quick fix to whatever problem arises, from weight loss to poor sleep. So, as we grow more stressed, pulled in more directions, and busier, we are finding fewer and fewer healthy ways to treat a growing number of problems. I honestly do not believe it is fair to hold the average person accountable to see, much less do something about this catastrophic problem. No, on the other hand, I think it is the job of the health care professionals to notice it and then to take action. Naturally we cannot force people to take good care of themselves, but we can offer them good options.

How does this relate to mental health, Dr. Rod? Good question. It relates because of - seemingly- a philosophy that permeates the field today. The philosophy is that, given the limitations we face (e.g stigma, insurance coverage, time restraints) some treatment is better than no treatment. In other words, if someone does not have or want to take the time to work on the problems they have, at least we can give them medication. Taking medicine is better than offering them nothing, or, if they intend to not attend therapy, for example having medicine is better than sending them out with nothing. I can imagine there are a variety of professionals who would say, "Sure; it's better than nothing." If you know me at all, you will know what my response to this is: I disagree.

I love to use metaphors to illustrate points, so get ready. Imagine you are busily living your life, raising your kids, and working. During the course of a typically busy day, you have the misfortune of breaking your arm. The obvious (and only healthy) solution to this problem is that you do what you need to do to get treatment. The doctor will set the bone (ow!), cast it, probably give you some pain medication, and then send you home with some instructions on how to best care for yourself. If we follow the logic laid out above, the same person might say, "I'm too busy to take the time to go through all of that. Instead, I'd prefer to just take the pain medication, please."

First, no care provider would recommend this, nor can I imagine anyone would even agree to it. They would insist upon the proper treatment, outlining the myriad of inevitable complications associated with not receiving this treatment. Secondly, if the patient actually went through with their plan, imagine the outcome of their situation. The pain medication would certainly work to some extent, for some period of time, but it would wear off and the mounting problems from failing to treat the actual problem (the broken bone) would become too many to name. The problems would begin to infect and affect surrounding areas of the body; functionality would become more difficult; relationships would be affected; and death or serious injury would certainly occur in time if the problem were left to its own devices.

Back to the point: aren't emotional problems just the same or at least amazingly similar? If we go back to the above scenario and change the ailment to depression, anxiety, or sleeping problems, doesn't most (if not all) of the associated complications remain equally true? I find this to be the most fundamental, simplest of truths. The only difference is that there are plenty of care providers who would not only happily provide the 'painkiller' in the above scenario, but would recommend it as the best, or even the only choice available. Most would be incredibly unlikely to offer any alternative or inform patients of the need to address the deeper issue.

Even if you believe in the efficacy of medication, you must also agree that it does not treat the actual problem. Using the metaphor, even though pain does result from the broken bone and there is no inherent harm in lessening the pain, any reasonable care provider must agree that the pain is not the problem and not the target of our treatment. It is a symptom that is a direct result of the problem, which is the target of our treatment. Choosing to treat only the symptom is not better than no treatment at all, because we have misled the patient into believing the symptom is the problem. As a result, they continue to cover up the actual problem, while it runs its course infecting and affecting the surrounding areas, relationships, life, work, etc.

Daily I am amazed at how simple this is, yet completely unapplied. We used to understand this and use it everyday. What are we doing now? How do we justify it?

The Missing Team Members, Part II

Building upon this idea, even if the APAs are failing to uphold the old traditions of their members, there are other professional organizations that are barely a shadow to most of us. In doing some research for a class I teach, I accidentally stumbled upon an organization that has many of the same ideas I have been talking about here. As it turns out, they are doing research, writing books, and seemingly trying to get the word out in much the same I naively hope to do. I was thrilled to see that the organization was not a group of hacks who had lost their professional licenses or a group of citizens with half-baked ideas. No, they are physicians, psychologists, and professors at large and well respected universities. After making contact with this organization, I learned of others as well. After having spent a few years studying and working in this field, it was nice to learn that my ideas were not completely out of left field; that there are other highly trained professionals around the world who agree. As a graduate student, employee, and even as a private citizen, the message I have most often gotten is, "This is proven fact; it's the standard of care. Don't question it."

Does this mean we intend to overthrow the mental health 'government' and force everyone to believe what we believe? Of course not. What is does mean is that we should seek to maintain the free exchange of ideas, have debate, give patients a full range of information, and not make the same massive mistake we have made throughout the entire history of mental health: thinking we have found THE answer. Every time a new idea has emerged on the scene (e.g. Insulin, lobotomy, Thorazine), the mental health community held it up as the quick, easy, and unquestionable answer to all the problems up to that point. Not only is that reasoning ridiculous, but each and every time it has turned out to be, 1) not the answer, and 2) unethical or even harmful. We now look back on these times as being barbaric. We scoff at our idiot ancestors who ever thought that removing part of the brain was good treatment. There is no doubt in my mind that several years down the road we will look back on this time as equally barbaric, unethical, and we will laugh at the reasoning we used to use drugs to suppress human experiences. That's a bigger discussion for a different time.

I guess the big point is this: we don't know what causes mental illness; let's stop pretending that we do. Every ad on television, every insert in a psychotropic medication, and every mental health professional who knows anything about anything will agree that we do not know squat about causation. We all have our views, hypotheses, and theories; chemicals and genetics is one of those ideas; it is not THE idea. Even if we argue that "most" professionals accept this right now, we ought to be scared of using this sort of reasoning. After all, "most" of the great thinkers of the day agreed with locking patients in basements and exterminating entire races of people. The hope here would be to give patients all the information - not just the information that the multi-billion dollar pharmaceutical industry can afford to promote - and let them decide what they want. As professionals we are supposed to know more than our patients so we can educate them about their options. We are utterly, unabashedly failing to do this in lieu of mindless writing prescriptions and sending them on their way.

So we have some ideas and we make good guesses about how to proceed. Up to this point in mental health history, few could reasonably disagree that the best treatment option we have - most successful outcomes, most heralded by patients, fewest side effects, shortest term, likely the cheapest in the long run, and probably other benefits I'm forgetting - is talk therapy. If we are going to make guesses about what is going on, what works, and we intend to actually follow the evidence, how is it that we miss the most logical, least harmful, and least invasive conclusion? I argue that it is because we are not interested in doing what works, following the evidence, or ultimately doing what is best for the patient. We are interested in making money - a lot and quickly - and not disagreeing with what is commonly accepted. Psychotherapy is hard work both for the patient and the professional. When did we stop working hard for good outcomes? Sad for a group of so-called professionals.

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The Missing Team Members

Perhaps the most troubling implication behind all of the thoughts up to this point is that patients - those in need of mental health services, to whatever extent - do not know what is going on with them or what they should do about it. I am certainly an advocate for free market principles and believe that advertising should be allowed. Other than being intentionally misleading, pharmaceutical companies are not wrong to promote and attempt to sell their product. The big missing element here is from the "competition."

Unless you've crawled out from a dark cave somewhere, you have been inundated with the message that chemicals, genetics, and other neurophysiological agents are (thought to be) to blame for mental health issues like depression. Advertising and marketing has done a lot to promote this message. What you have not heard is that these claims are unproven. They are hypotheses at best. Most concerning, though, is that you have not heard that there are other treatment options available to you. In most cases, the treatment options that you have not heard of are MORE effective than the pills you been told about. This is not the fault of pharmaceutical companies, it is the fault of psychological and psychiatric professional organizations. Not only have they utterly failed to promote the professions that keep them alive, but they have abandoned their members. They have done this by adopting an unproven hypothesis as fact and put all their eggs in one basket, so to speak.

It doesn't even matter if chemicals, genetics, or biology are "to blame." What matters is that there are options and we are not providing them to patients. We are blindly allowing pill manufacturers to dominate the thinking of average citizens and we have allowed insurance companies to push our practice - one that stands alone better than pills - into the periphery. People think psychotherapy is a thing of past; an antiquated practice that we foolishly attempted years ago, perhaps in the same category as leeches or insulin shock therapy. People are being told that talking does nothing since their problem is just simple chemical malfunctions - a fact that has been well established. Of course, this is far from factual, but how would the public know this?

When a controversial political issue comes into the mainstream, they sprint to the APAs to make an expert statement for the record. When it comes to the treatment of mental illness, what is available, and what works, they are silent. Professional organizations that do not promote the well being of the professionals they purport to represent? What sense does this make?

Substance Abuse, Diagnosis, and Medication

The same ideas I have discussed in former posts applies here as well. Many of the patients I see on a daily basis share the common thread of substance abuse in their past or, all too often, in their present. As most know, substance abuse is a monstrous - and growing - problem in America today. We unquestionably need more substance abuse treatment and qualified professionals to address these issues, but that is a discussion for a different post, different day.

The problem for today is the equally problematic issue of missing or ignoring the problem of substance abuse. The majority of patients I see come to me with varying diagnoses, which have rarely been explained to them with any accuracy. More often than not, most or all of their "symptoms" have occurred during the course of active addiction, withdrawal, or some minuscule window of sobriety in which no hope of a baseline has been established. Given their history of diagnoses and medications, I find myself asking daily, "How did your doctor justify this diagnosis when you were abusing heroin at that time?" Naturally, the patients never have an answer to this and I doubt the doctors would either. If you don't believe me, that's okay. The DSM makes it very clear that all of the major mental illness diagnoses cannot be better accounted for by another diagnosis, cannot occur during the course of a medical condition, and cannot occur during the course of drug intoxication or withdrawal. In other words, if you were abusing heroin everyday for 5 years and that's when you experiences your "highs and lows," poor sleep, depression, and angry outbursts, you don't meet the criteria for Bipolar Disorder.

This may seem like an exaggerated case, but it's not. I have this discussion with at least one - and more often 5 - patients per day. Granted, I work in a setting with very poor, very ill people, but the point remains: we are overdiagnosing, providing poor assessment, and assigning inappropriate treatments based on the overdiagnosis and poor assessment. This is a recipe for disaster at best. What's truly scary is that not only are we doing this routinely, but we are defending it as good treatment and calling it the standard of care.

As if this wasn't a big enough scare, I am struck by an amazing irony. When a patient has a substance abuse issue - using drugs to achieve a feeling or state they can't otherwise or to medicate unpleasant feelings away - one of our first bits of advice to them is to take medication - a drug designed to help them achieve a feeling or state they can't otherwise or to take away unpleasant feelings. Our response to a person who abuses drugs is to give them drugs? This is not a helpful intervention; in fact, I would argue it's harmful to patients. We are in violation of the first two principle of ethics: 1) Do no harm, and 2) do good.

We have stopped caring about truly good outcomes for our patients and have settled for mitigating symptoms. If we were doing this for our own selfish gain, I could almost forgive us, but we're not. We're telling patients that this is good, healthy, and proven effective. None of the above are true. We need to get back to actually trying to understand why people are how they are and do what they do. We need to get back to dealing with those underlying reasons why people abuse drugs and alcohol, help them deal with those unpleasant feelings, and stop labeling normal experiences - even bad normal ones - as mental illnesses.

Evidence Based Practices

No one would argue that doing something supported by evidence is a bad idea. I agree with that, but it's also important to consider what evidence exists. If someone bought a new car because they said the old one did not work, but as it turns out they never tried to turn it on, the evidence - while technically accurate - is not very useful, even though the conclusion is true. The very same phenomenon is at work with evidence based psychotherapy practices.

The problem begins with how research is conducted. We all know that research has its limitations and we're all comfortable knowing that nothing is perfect and we study and talk about averages, etc. This is not the issue. The issue is that some things are easily researched and others are not. We can talk about how the "therapeutic relationship" is a very curative factor in therapy, but it's very difficult to quantify and study the therapeutic relationship. Even attempts to break down into pieces and study do not fully do it justice. We'd all agree that the relationship is key and most would agree that it is far more complex (and important) than even research can explain. The same problem is true of other aspects of psychotherapy. I figure this is the explanation for the rise of CBT and like therapies. It is not difficult to take a manualized therapy like CBT, take a piece or two out of it, and then study those pieces. In and of itself, this is not troubling because it will show what techniques or styles are workable or effective for certain conditions.

The bigger part of the problem is how we define both "effective" and "condition." Because human change, particularly personality or "internal" changes, is difficult to measure, it's far easier (for the sake of research) to study behaviors and/or symptoms. This is the nature of the term "effective." We define effectiveness as a change in behavior or a reduction in symptoms. Sadly, as any true psychologically minded person would agree, behavioral or symptomatic change is not necessarily indicative of progress. If a person steps on a nail, sees a doctor, and receives pain medication, the reduction in pain is not proof of healing. In fact, the process is much more difficult than that. Pain medication may or may not be part of that process, but it is certainly not the only part. The very same misinformation is used in pharmaceutical research. They claim "effectiveness" of drugs based upon a reduction in symptoms, or, even worse, as being better than no treatment at all.

The very same dilemma is with the definition of the term "condition." Recent research suggests that 1/5 of Americans have a mental disorder and at any given point in the future, 50% of Americans will meet the criteria for a psychological disorder. Yikes. The very idea that this overwhelming percentage of people are disturbed enough by psychological symptoms that they their functioning is significantly impaired (remember, that it is the DSM standard: clinically significant distress) is laughable. We are defining "conditions" seemingly as any distress a person experiences that they do not like.

"Effective" + "Condition" does not = good research. Yet we say that it is . CBT is heads and tails above other treatment modalities by these standards and we hold it up as God's answer to our psychological prayers. Any non-CBT practitioner will tell you that how they practice therapy is very effective and their patients get better, but this is not reflected in the research, since is less quantifiable. Therefore, it has not earned the coveted "empirically validated" title, thus, it is irrelevant.