From the President

Barry Dauphin, Ph.D.  

I would like to extend (belated) New Year's greetings to MSPP members and readers of the MSPP News. I hope that the new year proves beneficial for you and for psychoanalysis. It is a new year which ushers in new challenges.

When I attended the most recent APA convention as MSPP representative to Section IV, it was clear that many Division 39 members were growing increasingly concerned about the potential ramifications of evidence based treatment or empirically supported treatment. Basically, evidence based treatment (EBT) involves a movement within the APA to mirror the approach taken by medicine to create a template of the most empirically supported treatments for each diagnosis. Within the field of psychotherapy this takes the form of trying to match various therapy techniques to diagnostic categories from the DSM-IV. Many within the APA support the idea that only treatments which have proven (?) to be effective for specific diagnostic entities based upon double blind trials should be considered appropriate for any particular diagnostic category. This obviously favors short-term cognitive behavioral forms of treatment aimed at rapid symptom reduction. Despite the fact that very few diagnoses have been studied in the way proposed and the fact that many treatment studies have stringent inclusion criteria, fail to represent “real” world practice, fail to study complicated cases and largely ignore process and long-term outcome, many academic researchers are pushing hard to exclude treatments which are difficult to study within the inappropriately rigid criteria set forth.

Such a movement has incredibly large consequences for the kinds of treatments which will be available to patients, the flexibility of treatment modality which will be reimbursed by insurance companies, and what is considered legal and ethical practice. Although psychoanalysis enjoys a long history of empirical research, many within the APA would like to set the criteria for what counts as empirically supported in a very narrow and inflexible manner and treat psychotherapy as if it were exactly like physics and as if the variables studied are as quantifiable and controllable as the volume of a liquid. Treatments which would count as empirically supported are those which lend themselves to manualization, meaning only those procedures replicable to the letter by inexperienced technicians working from treatment manuals in which every step of the “therapy” is spelled out in detail. It is important to remember that what would count as successful treatment (that which would be approved) is determined in a similar manner to that of a horse race. The important thing would be which horse crosses the finish line first. In many respects it wouldn't matter whether all the horses were dogs, one of them is gonna cross the wire in first place. And what counts as winning is determined in no small part by those who get to set the length, conditions, and handicaps of the race. Few outside of psychoanalysis and some humanistic forms of therapy seemed particularly interested in long-distance journeys, be they races or not. As I see it, the APA seems willing to gamble with the emotional lives of those with whom we're supposed to work (‘cause daddy needs a new pair of shoes?). Gone would be the patient's desires, goals, and interests in treatment. Instead the criteria would be determined by the outsider who pays for the treatment and the monitor who assures the “quality” (or closeness to manual) of the treatment.

Consider for a moment a procedure used by many insurers. They ask a therapist to provide a score representing the patient’s current level of functioning and highest level within the past year (i.e., GAF). Treatment length is determined by the time it takes for the patient to reach or approach their most recent high quite apart from any consideration of the person’s potential or goals and ambitions. I wonder what kind of trouble a therapist would get into if the patient utters, “gee, I've never felt better in my life.” At the same time, at the bottom of many forms is a disclaimer roughly saying that the insurance company assumes no liability for the treatment and treatment is the responsibility of the therapist. Consider it as a Don't even think about suing us clause. That's all they will pay for. Even if one were tempted to say “fair enough,” does the profession really wish to make a capitation formula the highest standard to which our field should aspire? That's the best we can do? Insurance companies won’t pay for more, so let’s pretend those standards are the best? I’d say something smells in the stables.

It was clear to me that my fellow psychoanalytic colleagues in Section IV as well as in Division 39 in general were growing increasingly alarmed about the potential harm to psychoanalysis and to those with whom we work. I sense that many of my colleagues were beginning to worry that we could be put out to pasture. Unfortunately, the destination many EBT devotees have for psychoanalysis is the glue factory and not out to stud. Although Division 39 has taken no official stand regarding mandatory continuing education (most of our colleagues within the Division seem to actually support it out of fear of the unidentified and fabled lazy clinician, AKA the other guy) or prescription privileges (Division 39 will not stand against official APA policy in this matter), I gathered that most were growing dismayed about the agenda of the parent organization and the zealousness of those in favor of EBT. In many respects almost everyone I spoke with from Division 39 seems to “get” this. Perhaps it will be Little Hans to the rescue. It is especially ironic for psychoanalysis to be in this position considering the amount of empirical research conducted on various forms of psychoanalysis as well as the tremendous amount of anecdotal data (especially, well documented case studies) which have been carefully recorded in clinics, theses and dissertations and in journals for decades. It is as if none of this would count—a horse not fitted with blinders but a blindfold. Regarding the purported inadequacies of case studies and the concerns about "suggestion," suffice it to say I contend that Adolph Grunbaum’s philosophical writings should be respected not worshipped.

It was also clear that many in the APA recognize that this is a hot issue. In fact one of the panels at the APA convention was supposed to be a debate on this very matter. Unfortunately, the psychoanalyst Nancy McWilliams, Ph. D., was unable to attend because of the crack-of-dawn scheduling of this panel. Next, the moderator of the panel went to a great deal of trouble to inform us sleepyheads in attendance that this was not going to be a debate. Instead the message was going to be one of the unity of psychology. Unity was the cherished brainchild of then APA president Sternberg. Although the position of “Why can't we all just get along” might have some appeal on Oprah, I would suggest that it is a dubious position for those interested in scholarship. Furthermore, not looking beneath the surface of these seemingly laudable sentiments carries a special risk for those who think psychoanalytically (i.e., the discipline of looking beneath the surface). I say this not to be mean-spirited or to be itching for a fight but to help us remember that the obstacles which we face are formidable and that there are many efforts behind the scenes to delegitimize psychoanalysis and other forms of therapy. Although the arguments in favor of evidence based treatment are usually made with high minded language, it is important to note that this effort will limit patient choice and markedly enhance the economic position of the very segment of the psychotherapy community which is making this case. Perhaps that is just a coincidence. But do we want to bet the farm on that? And while some may try to make the same quarrel with psychoanalysis (that we're just in it for the money), I know of no psychoanalysts who are actually in favor of prohibiting cognitive behavior therapy, behavior therapy, and other widely recognized forms of therapy.

I encourage us not to be accomplices of putting psychoanalysis to sleep. Now more than ever, we need vibrant dialogue, active participation, and playful risk taking. The intimacy of the psychoanalytic enterprise can be daunting for those who cherish psychoanalytic psychology as well as for those who don’t. There is no doubt great value in the double blind study, but there is also a hiding place to that method. The double blind research design for many therapeutic procedures focuses on a technique devoid of the person applying the technique. The therapist or researcher can hide amongst the variables, the statistical formulas, the procedures and the herd. Technique can be discussed impersonally. The researcher can address the audience from a secure position, safely depersonalized. On the other hand, to any who have presented process or case material to a psychoanalytic audience, it could feel as if there is no place to hide. It seems all out there. Scary but invaluable. The detailed presentation of the individual by an individual teaches us all things no amount of anonymity, randomization, detachment, and group statistics could ever propose to. MSPP will continue to strive to enable this intimate way of working with others and fertile educational forum to exist and to thrive. Please join in.