Saving Psychotherapy From the Medication Takeover

The competition between psychotherapy and medication is pure David vs. Goliath. The drug industry is one if the most powerful and profitable, with billions to spend, able to push product aggressively with unscrupulous marketing.
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One of the best experiences of my career occurred in the 1980s when I was a member of the group that decided which psychotherapy studies would be funded by the National Institute of Mental Health.

It was hard work. Every three months, we would review about twenty-five studies, knowing that only three or four would be funded. Psychotherapy research was relatively new in those days and it was often difficult to decide which approaches and which people were most likely to make contributions that would count. But our efforts were rewarded. The studies we supported helped establish the effectiveness of Cognitive Behavior Therapy, Dialectic Behavior Therapy, Interpersonal Therapy, and other forms of brief therapy.

Psychotherapy research is inherently more difficult to do than drug research. The treatments are harder to standardize, there is no real equivalent to pill placebo, the time horizon is longer, outcome measures less clear, and the patients are more heterogeneous. Many interesting studies were never done because they had fatal flaws in one or more of these areas.

But we did learn a lot. Psychotherapy is as effective as medication for mild to moderate presentations of many different mental disorders. It takes longer to work, but its benefits last longer and there many fewer side effects and complications. Comparisons between different psychotherapies usually end in tie scores -- suggesting that the quality of the therapeutic relationship and other common factors may be more important than the specifics of technique.

NIMH funding for psychotherapy took a nosedive starting with its "Decade of the Brain" in 1990. NIMH has become almost exclusively a brain research institute. Its once well-rounded biopsychosocial approach has been replaced by a narrow bio-reductionism.

The neuroscience research has been fascinating, but so far has had zero impact on clinical practice and has not improved the life of a single patient. In contrast, the psychotherapy research it displaced has been helpful to millions of people.

I have asked Marvin Goldfried to discuss NIMH's hope-over-experience faith that there is a simple brain explanation for the ineluctable complexity of mental life. Dr. Goldfried is Distinguished Professor of Psychology at Stony Brook University and is an internationally recognized clinical psychologist long involved in psychotherapy teaching, supervision, research and practice.

Dr Goldfield writes:

The National Institute of Mental Health is currently looking for a new Director. The person selected will have enormous influence on the future of psychotherapy research and practice.

The first question to be asked about psychotherapy is whether it is effective? According to reports of therapists during the first half of the 20th century, the answer was a clear yes. However, by the 1950s, mental health professionals began to question whether or not the therapist's say-so was sufficient evidence of clinical effectiveness. It was around that time NIMH began funding important research showing how talk therapy was indeed effective in dealing with many different mental disorders and problems in living.

Unfortunately, psychotherapy research has been sadly reduced and is under threat of extinction. In the late 1980s, there was a sea change at the NIMH, moving away from a broad biopsychosocial to a reductionistic neuroscience model.

Things got even worse in 2001, under the leadership of Dr. Thomas Insel, the then new Director of NIMH. The biomedical model of understanding and treating psychological problems became even more explicit in grant funding decisions.

Under Insel's leadership, the NIMH took the stance that mental disorders and psychological problems could be understood as simple diseases of the brain. He redirected almost all NIMH funding to research aimed at discovering the fundamental biological indicators of mental disorder and new drug solutions.

Studying the brain would provide "exciting opportunities for drug discovery and development.

So far, these promises have turned out to be remarkably premature. The neuroscience discoveries are fascinating, but far removed from helping patients or aiding drug development.

It is questionable that medications will provide the cure-all even for severe mental diorders and, almost certainly, they will not be the primary treatment for individuals with milder problems and reactions to stressful life experiences.

It is limiting to treat individuals as if they were psychologically disembodied organisms, uninfluenced by the psychological and social aspects of their lives. For problems based in psychology and social context, talk therapy will likely remain the treatment of choice.
NIMH should be setting aside funds to support research studies to prove and improve the effectiveness of psychotherapy in treating various psychological problems. Basic research is wonderful, but shouldn't swallow its entire budget.

Unfortunately, NIMH funding -- our tax dollars -- are now earmarked for research directed only toward drug development at the expense of studies on psychotherapy. This will have an adverse effect on how we practice therapy, and on the countless patients who would stand to benefit from effective talk therapy.

What will be the future of psychotherapy research funding at the NIMH? It depends. As of this past September, Dr. Insel has stepped down as Director of the NIMH to take a position at Google. The Institute is currently searching for a replacement, and who is selected will be at the forefront of the essential question: What will the NIMH do to support research to improve the effectiveness of talk therapy?

Thanks, Dr Goldfried.

The death of psychotherapy research will eventually have a deadly effect on psychotherapy practice. Increasingly, treatments require proof of efficacy as a precondition for adequate insurance reimbursement. If we don't do research on psychotherapy, we can't prove its efficacy and psychotherapy will be further disadvantaged in its already rigged battle with medication for scarce treatment dollars.

The competition between psychotherapy and medication is pure David vs. Goliath. The drug industry is one if the most powerful and profitable, with billions to spend, able to push product aggressively with unscrupulous marketing. Psychotherapy is a smalltime, mom and pop operation with no budget to sell itself.

The only way people will discover the relative virtues of psychotherapy and the vices of meds is to have repeated head to head comparisons between the two. Drug companies never finance this type of study because they know they would often lose. And why risk a fair fight when you can go backdoor to MD's and patients with the misleading advertising message that all mental disorder is chemical imbalance and brain disease.

The role of the NIMH should be ensuring a fair playing field. Instead it has piled on the med side, expending its enormous research budget only on biological research. The lack of NIMH support for psychotherapy research guarantees that meds will continue to be way overused and psychotherapy will continue to be way underused. This is a great disservice to the millions of people who could benefit from psychotherapy and are harmed by needless meds.

For 30 years, the NIMH has been guided by leaders espousing the most narrow minded version of biological reductionism. It privileges the already privileged drug industry and slights the already slighted practice of psychotherapy. It celebrates the benefits and ignores the risks and limitations of drugs and acts as if psychotherapy does not exist.

NIMH has made grand and empty promises of future neuroscience breakthroughs, but has neglected its basic responsibility to fund research that will actually improve the mental health of people in the present. NIMH loves fancy basic science and couldn't care less about the clinical care received by our citizens. It is run by, and for, scientists with an indifference to the needs of the taxpayers who support its budget.

This will continue unless the search for a new Director asks deeper questions about the proper role of NIMH in our society and whether its research agenda shouldn't be brought back into proper balance between future opportunity and current need.


Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.

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