The dire state of psychotherapy.

A year after Australia took the very bold step of approving psychotomimetic drugs (drugs that mimic psychosis, known in polite circles as ‘psychedelics’) to assist in psychotherapy, an advisory panel for the US Food and Drug Administration (FDA) did not approve the use of MDMA (methyl​enedioxy​methamphetamine) in PTSD. The science is just not there, they said, which is exactly what the advisory panel in Australia said (and I said, Substack July 11^th 2023). However, they were over-ruled by a write-in campaign organised by a private lobby called Mind Medicine Australia, MMA (which is registered as a charity and pays its organisers very well). Their website says:

Mind Medicine Australia is not seeking in any way to encourage consumers to seek to obtain MDMA or psilocybin as a Schedule 8 medicine, seek a prescription for that medicine or seek to participate in MDMA or psilocybin assisted therapy. We are simply seeking to provide Australians with comprehensive educational content …

Immediately beneath that high-sounding disclaimer, it says:

Why psychedelic-assisted therapies are needed now: Current treatments for mental illness don’t work for a large number of people and can cause nasty side effects. There is no clinical justification for the number of medications and treatments some patients receive.

I agree with their reasons but not their solution (although when I say things like that in public, I’m promptly savaged by the guardians of right thinking in psychiatry). However, what MMA don’t explain is why adding drugs to the lists is the correct solution to the problem. Just remind me, what’s the problem?

Here we run out of road. For them, and for the mainstream, the problem is: “What are the correct drugs to rectify mental disorder?” But that begs a critically important question, meaning it assumes the truth of the prior proposition that has not yet been proven, namely: “Is mental disorder the sort of thing that can always and only be corrected by drugs?” This leads us straight into the black hole that reigns where psychiatry’s intellectual justification should be.

In more general terms, the question is: What is the nature of mental disorder? To answer that properly, we need to be able to answer: What is the nature of mind? It doesn’t matter how clever psychiatrists are or how they use scientific jargon to distract us, these questions are always lurking in the background. So it was interesting to read another commentary on the use of psychotomimetic drugs [1] which raised the same question: Assuming these treatments work, is it the therapy, or is it the drug? That’s not trivial, although the authors of that article are convinced it is the drug doing all the work, and the therapy is simply a nice add-on.

The lead author is Prof. Guy Goodwin, recently retired from Oxford University to start a private company called Compass Pathways which pushes psychomimetic drugs, among many others, and another is the ubiquitous Charles Nemeroff, whom we met on August 6^th. Like Nemeroff, Goodwin had a PhD in neurophysiology before he started medical school, so we can be fairly sure of his orientation re mental disorder. Sure enough, they don’t disappoint: the antidepressant effect of these drugs, they say, is due to their action as serotonergic mimics (agonists), even though the “serotonin hypothesis” of depression has been debunked. They feel we should stop calling it “psychedelic-assisted psychotherapy” (PAT) because this isn’t proven. We don’t know anything about the form of the psychotherapy (which is true), whether it’s the therapy itself that works or just having somebody nice and supportive around while the patient goes for a trip, or whether it’s a pure drug effect that will also work without therapy.  

The important point is that one side sees mental disorder as some sort of primary mental tangle caused by life experiences, while the Goodwin-Nemeroff side predictably see it as wholly biological. This “debate” will never be resolved because the two sides aren’t even talking the same language. When one side says “depressed,” they mean “reaction to loss of some sort that can be resolved by mental changes,” while the other says “genetically-determined disturbance of brain chemistry that can no more be resolved by talking than talking can change the colour of your eyes.” This is similar to how religion played out in medieval Europe. What one side saw as “reasonable questions on theological doctrine to be resolved by discussion” the others saw as “monstrous Satanic ideas that can only be resolved by burning the offenders.”

This isn’t a far-fetched analogy because in each case, the arguments are ideological, not scientific. If you’re going to practice “PAT,” then you need a formal theory of psychotherapy as a guide, otherwise it could easily go wrong, as Goodwin et al warn: “… it is obviously made more complicated by the change in consciousness and the potential for abuse of the patient in an altered state” (p21, emphasis added). The two positions are becoming clearer: the standard psychiatric model, in which the drug does all the work while the nursing and other staff simply hang around being nice (like ECT), or the psychotherapy approach, where the psychiatrist writes a prescription and hands the patient over to the psychologists, nurses, social workers etc who will do the actual work of psychotherapy.

Why shouldn’t the psychiatrists do the psychotherapy themselves? Well, here we run into another problem: most of them can’t. They’ve had very little training and often little or no experience. Now I know that “competence in psychotherapy” is part of the core curriculum for psychiatrists in training but, following the American example, psychotherapy has withered. The US is different in that private psychiatry is dominated by what the insurance companies will pay for. What they won’t pay for is open-ended, unsupervised talkathons conducted according to long-discredited models of mind such as Freudian psychoanalysis. Overwhelmingly, they will only pay for quick (10 mins) “med checks” of patients by psychiatrists: “Are you taking your tablets? Any problems? OK, see the social worker on your way out. Here’s your script, come back in a month.” This is not an exaggeration, I’ve seen it in action.

A report in the American Journal of Psychiatry [2] showed that from 1996-2016, the number of psychiatrists offering psychotherapy dropped to about half, while the number of visits that actually involved psychotherapy was about 20% (summary here). Since then, the authors believed, these figures have continued to decline. It means psychiatrists are being deskilled, insofar as they were ever “skilled” in the first place. Meanwhile, public psychiatry there, and here, and pretty well everywhere in the world, is and always has been biological. Large numbers of patients are herded through brief, check-list “assessments” by junior staff who probably won’t see the patient again, then they’re drugged, shocked and shoved out again. What it means is that anybody wanting psychotherapy will have to choose the psychiatrist carefully and pay for it, which restricts it to wealthy, educated, urban, older white people. Anybody else takes their chances in the scrum. The unseen effect is that any professional interested in managing mental disorder from the humanist point of view won’t last long in the public system. Complying with the mental health act becomes more important than seeing to the patient’s needs.

Can this be rectified? I doubt it. Psychiatry has locked itself into the “mental disease is brain disease” mode and there is no indication that any of the “key opinion leaders” are willing or able to rethink their position. A psychiatrist who has spend 40 years prescribing drugs and administering ECT to swarms of essentially anonymous people with “chemical imbalances” is not going to stop suddenly and ask “I wonder whether any of this stuff is right?” That doesn’t happen. But even if it did, even if the psychiatrist decided to train in psychotherapy, who’s going to teach it, and what are they going to teach? Classic Freudian psychoanalysis has more or less died out but there are so many problems with it [3, 4] that it could never be resurrected. There is the modified form known as psychodynamic psychotherapy but this is not much better than people picking from Freud the bits they like and rejecting the rest, so there is no guarantee that any two such therapists are working from the same textbook. Yes, there are core elements like ego defences and the unconscious but the problem with this sort of show doesn’t lie at the core, it’s the fringes we have to worry about. Fringe therapists are where the danger lies.

There is a further problem here in that there aren’t enough teachers. Even the very basic training given to trainees (residents) takes several years; many of the (relatively few) psychiatrists who would feel comfortable running a training program are approaching the ends of their careers and may not want to start the whole business again. If you’re 75 or more, then writing lectures, compiling reading lists, clinical supervision, supervising and marking exams and so on may not be such an appealing prospect, especially as you’d be dealing with people who, for decades, have had no hesitation telling you where you were wrong and were often somewhat less than polite about it.

What about psychologists? Surely they could manage the teaching? Yeah, right. Psychiatrists are going to crawl to psychologists and say “Well, chaps, looks as though you were right all along. No hard feelings, so what about you teach us how to do it?” I don’t know many professors of psychiatry or bigwigs in the various colleges but I can’t see that happening. They’ve spent their lives building their empires; giving it all up, closing their various institutes of the brain and token mind or their department of the black cloud is not an option. Their empires are their memorials, not the numbers of patients they’ve helped. But even if they did, what could the psychologists teach? They’ve spent the last century painting themselves into an anti-mentalist corner of reflexes and reinforcement schedules, so they can hardly say: “That’s fine, let’s start with the unconscious.”

Finally, there are those who say the psychotherapy will look after itself, what counts is the trip. Depressed people gain insight and meaning and empathy from the experience, the staff are only there to make sure nothing goes wrong. That’s all very good, assuming we can define insight and meaning (one person’s insight is another person’s delusion), but it’s also important to recall that, with psychotomimetics, things often do go wrong. It is not at all uncommon for people to develop severe and intractable anxiety states after a bad trip, and drug-induced psychosis is very real. Granted, these people are often doing it wrong, such as taking too much of the drug, mixing them or doing it alone but the risks are real and insight is definitely not guaranteed. Anyway, why are people who have spent their careers chasing chemical imbalances suddenly concerned about insight?

My final concern is that these chemicals have been used for centuries to induce ecstatic religious and mystical experiences (after all, the common name for MDMA is ecstasy). Nobody can say where the therapeutic insight stops and outright mysticism starts. While it’s the case that where we need a solid wall between psychiatry and mysticism, these drugs breach that wall, especially in the hands of fringe therapists. Psychiatry has enough trouble as it is controlling its drift to mysticism, that’s what drives the search for a biological cause for mental disorder. Since even the biological experts have no clues how these drugs work, and since the psychotherapists haven’t got a theory of mind or a model of mental disorder that will stop them becoming an exotic cult, I’d say the US FDA did the right thing in rejecting them. But since there’s so much money to be made from prescribing them, I don’t think they’re going to go away in a hurry.

****

After what seems like years of work, my account of all theories used in psychiatry should be (may be) published this week. Unable to come up with a titillating title, we stuck with Theories in Psychiatry: Toward a post-positivist psychiatry. This says that the positivist goal of writing a non-mentalist theory of mind has run out of rope and the sooner we dump it, the better for all. That is, that same drive to find a biological cause for mental disorder is going nowhere, at vast expense. The systematic medicalisation of social problems and drugging of the population, especially children and adolescents, can no longer be justified. The longer we keep it up, the deeper the hole we’re digging.

This book sets the scene for the biocognitive model of mind for psychiatry. All that remains now is to convince mainstream psychiatry that they have a real intellectual problem.

References:

1.      Goodwin G, Malievskaia E, Fonzo G, Nemeroff C (2024). Must psilocybin always “assist” psychotherapy? Amer J Psychiatry; 181:20–25; doi: 10.1176/appi.ajp.20221043.

2.      Tadmon D, Olfson M (2022). Trends in Out-Patient psychotherapy by US psychiatrists 1996-2016. Amer. J. Psychiat,  doi.org/10.1176/appi.ajp.2021.21040338

3.      Masson JM (1990). Final Analysis: the making and unmaking of a psychanalyst. New York: Addison Wesley.

4.      Masson JM (1984). The Assault on Truth: Freud’s suppression of the seduction theory. New York: Simon and Schuster.

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