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Jonathan Shedler Ph.D.
Therapy
It’s Time for Psychology to Lead, Not Follow
Psychotherapy is not a medical treatment.
Posted Oct 27, 2019
One of the most powerful constructs I know is called supervenience. It helps us understand why knowledge at one level of analysis can be irrelevant at another.
For example: When you watch a movie on a screen, you are seeing arrangements of pixels. The movie is 100 percent dependent on pixels and cannot exist apart from them. But knowledge of pixels is irrelevant to understanding the movie. We could know everything there is to know about pixeIs and have no concept of Luke Skywalker, Darth Vader, or the battle for the empire.
Movie supervenes on pixels.
Likewise, mind supervenes on brain. Mind depends on brain and cannot exist apart from it. But knowledge of brain is not knowledge of mental life. They are different levels of analysis requiring different concepts and methods.
The National Institute of Mental Health (NIMH), under the direction of Tom Insel, made the assumption that mental health problems are “brain disease” and neurobiology would unlock the cure for all manner of mental and emotional suffering. NIMH bet the farm and failed spectacularly.
Now Insel says, “I spent 13 years at NIMH really pushing on neuroscience… and when I look back on that I realize that while I think I succeeded in getting lots of cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness. I hold myself accountable for that.”
No, they did not move the needle. That $20 billion gamble with taxpayer money did not improve the mental health of one single person. Not one. Despite endless promises, there is no biological test for any mental health condition. There are no new or better treatments. But, hey, what’s $20 billion among friends?
Neurobiology is one level of analysis, mental life is another. Thoughts and feelings must be studied at their own level of analysis. The brain is the subject matter of neurobiology and mental life is the subject matter of psychology. There are, of course, areas of intersection and overlap, but neither can supplant the other.
NIMH bet the farm on naive biological reductionism—assuming neurobiology would answer the important questions at the biological and psychological levels both. The assumption did not follow from scientific findings. It was a premise, reflecting the worldview of a researcher who built his career dissecting rodent brains. It was the equivalent of abolishing movies because engineers are working on cool video screens.
Twenty billion reasons say they bet wrong.
The lesson is that psychology must blaze the trail for psychological treatments using psychological concepts and methods. It must not play handmaiden to medicine or ape its concepts and methods.
It is an intellectual, scientific, and clinical dead-end when psychology seeks to be “like” medicine or like any other discipline. Psychology should not be more like medicine. Psychology should be like psychology. Psychologists contribute most to understanding and treating mental suffering by being first-rate psychologists, not aspiring to be second-rate medical doctors.
This is one reason why the new clinical practice guidelines issued by the American Psychological Association, which evaluate and recommend psychotherapies based on Institute of Medicine (IOM) criteria, are a tragic mistake. The criteria were designed to evaluate biological interventions like medication. Psychotherapy is nothing like medication.
Aping the methods of pharmaceutical research does not elevate psychology. We should not mislead the public to think emotional suffering is like medical disease, or different kinds of psychotherapy are like different medications. These assumptions are false at every level. Psychotherapy is not like medication, psychotherapy is like psychotherapy. And we should help the public, policymakers, and fellow healthcare professionals understand what good therapy is—because they do not know.
We should study the outcomes of psychotherapy using our own psychological concepts and methods. We should study how people change and how lives change, not diagnostic categories from the Diagnostic and Statistical Manual of Mental Disorders (DSM). We should study the outcomes that matter to patients and the therapists who treat them. Real psychotherapy is not about DSM diagnoses and never was. Real psychotherapy outcomes cannot be reduced to DSM symptom lists. There is no excuse for debasing psychotherapy by forcing it into a medical Procrustean bed.
Psychology has its own concepts and methods. Wilhelm Wundt established the first experimental psychology laboratory in 1879, studying mental life scientifically at a time when bloodletting was still common medical practice.
Just once, can psychology lead, not follow? Just once, can our professional organizations stop positioning psychology as handmaid to medicine and second-class citizen of healthcare? Just once, can our professional organizations stop stooping and groveling and debasing psychology by trying to shove the round peg of psychology into the square hole of a broken healthcare system?
Can psychology define for itself what we treat and how we treat it, instead of forcing ourselves into misshapen slots defined for us by medical researchers, healthcare systems, and health insurance companies?
Can we contribute to the world as psychologists using psychological concepts and methods? Can we be proud to be psychologists again?
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Wonderful
Wonderful article as always by Dr Shedler.
Article
You took the words--right out of my mouth! Bravo Dr. Shedler, Bravo!
~Dr. J.
We still need neuroscience though, long-term
I really agree with the spirit of this - The RDoC, and neuroscience in general, haven't had much of an impact on mental illness (or, is there a different word I should be using?)
At the same time, pure psychology hasn't identified very effective means for promoting mental health either.
Neuroscience hasn't been very useful so far, but if we're ever going to overcome the limitations of self-report and the ambiguity of behavior, we'll almost certainly have to integrate neuroscience.
Psychology is an art and a science
I had to title this somehow.
Saying twenty billion "reasons" is misleading. Attacking another part of the equation of human research, albeit on mice, with an imperfect statement, doesn't help.
Some of the worst and most abusive research into human issues is done on animals by psychology; see anorexia studies involving baby nursing chimps/monkeys taken from mothers too early: seeing mothers but not allowed to reach them, mothers suddenly not allowed to reach babies either.
It is twenty billion dollars, period; not reasons.
Psychology is also an imperfect science, and only if done well, is a true art. It is abusive and a failing science if it displays a lack of empathy, a lack of conscience, a lack of integrity, arrogance.
For example:
Psychologists are not equipped to see inside brains of domestic violence victims. What impact does domestic violence, including psychological and financial abuse, have on a developing brain? On any brain? Types of domestic violence and their impact on brain formation or maintenance of good brain health, good second brain (stomach) to brain health? Impact of sexual abuse within domestic violence? Child abuse within domestic violence and impact on brain development and health of children? Impact of these stressors on innocent parents' brains? On the abuser's brain over time? Brain pathways?
But how many psychologists truly understand domestic violence? How many understand the nuances, complexities, needs, damage done, how to assist? How to make things better? Do you understand the impacts on children, both long term and short term? Do you understand how the impact on the parent impacts the child's life long health and lifetime living and opportunities based on impacts to both parents and children? Do you address it correctly? Do you understand the more deep dynamics of what, how and why?
How much does psychology label, rather than address behaviours and outcomes? But are labels correct to address personality disorders, or only neuroses? Are these dynamics properly understood?
How much of psychology causes more damage by getting the psychology wrong, by being arrogant and power-wielding, rather than humbly learning, enquiring, assisting and being a healing art form?
I agree, l. Scott
“Mind depends on brain and cannot exist apart from it.” Is there proof of this statement? Not to my knowledge. At least that’s not what those who’ve had near death experiences contend. What if there’s a soul, and that’s where the mind/consciousness exists? The reality is we don’t know, and making incorrect assumptions is part of why the “mental health” field is facing disrepute today.
Nonetheless, I agree DSM “bible” believing psychologists are worthless human beings, who do more harm than good. Personally, I believe that the Jungian psychologists’ theories are likely much closer to the truth. So I do hope the psychologists do stop “conspiring” with the scientific fraud based psychiatrists. But since covering up child abuse and rape is the primary actual societal function, both historically and today, of both the psychologists and psychiatrists.
Please go to my similar comment on the Mad In America website, about this article to see my URLs, since URLs are not allowed on this site's comments.
I can guarantee the psychologists that they will never “help” any child abuse or rape survivor by denying reality, and trying to force someone to accept injustice, or merely “change your thinking.” And the psychiatric drugs don’t cure concerns of abuse either. Starting to actually arrest and convict criminals, the men (and women) who harm women and children, is the solution. Justice is the solution. A return to the rule of law is the solution. Communism doesn’t work, never has, and never will. Just google “communist manifesto” to see the psychiatrists, psychologists, and social workers role in the communist take over of America.
“Can we be proud to be psychologists again?” Based upon personal experience, I know the psychological profession has never confessed, nor made proper amends, nor changed their evil way. In regards to their historic, and continuing, child abuse and rape covering up sins, which are illegal. So I don’t think you should be proud of your profession. I think all of the child abuse and rape covering up “mental health” workers should be ashamed of themselves. And given the huge percentages of their clients who are child abuse survivors, it’s likely most of the "mental health" workers actually belong behind bars. For systemically aiding, abetting, and empowering the pedophiles and child sex traffickers on a massive societal scale. Which has led to a very dark time in our countries’ history.
Please go to my similar comment on the Mad In America website, about this article to see my URLs, since URLs are not allowed on this site's comments.
Take the red pill, and wake up instead. Your industry’s systemic crimes, do have real life systemic consequences. The psychologists and psychiatrists, and all their “mental health” minions’, systemic child abuse and rape covering up crimes are destroying our country. And it’s all by DSM design, even according to an article published by Psychology Today.
Please go to my similar comment on the Mad In America website, about this article to see my URLs, since URLs are not allowed on this site's comments, even Psychology Today's URLs, oddly.
Both the psychologists and psychiatrists, and all their “mental health” minion, actually need to get out of the child abuse and rape covering up business.
love leadership
A few weeks ago I wrote a poem in my biomedical ethics class asking for people with PH.D's to lead and not follow.
This article gives me hope for the future and I think your courage is similar to mine, and I love you for it.
Great job!
Agreed-It's Time for a Psychologist General of the U.S.
Dr. Shedler,
This is an excellent and long needed comment on the unduly subordinate role that psychology has played in our society for far too long, as you point out. It is indeed time--and I think the public is ready for--a particularly holistic-integrative--psychology, to step out into its authority as a leading influence in our individual and collective well being. The "writing on the wall" at both individual and collective levels could not be plainer: short-term, medicalized approaches to mental health can be critical for some people at some stages of their struggles, but as an overarching philosophy for our society take us only so far, and sometimes feed the "quick fix/instant result" mentality that gets us into trouble in the first place. The present mental health crisis, both individual and collective calls fo a much broader and deeper approach. This approach needs to address several areas in particular that medicalized approaches tend to broach at the level of biology or behavior but not with regard to people's core inner lives. These are 1) the profound relational deficits (e.g., traumas, emotional and physical abuses, socio-economic degradations) of many in our society; and 2) the deficits of meaning and purpose, love for life, and existential awe. This was my main impetus for an article just published in the November issue of Scientific American Magazine calling for the creation of a "psychologist general" of the U.S. to focus on discernibly psychological approaches to our mental health crises. Thank you for helping to articulate that need and that urgent concern.
Content Marketing, and No Ethics!
As rates of mental illness stress, suicide and drug addiction climb, psychologists are still pretending that marketing and corporate funding of research are benign. Plenty of psychologists, made a of money misleading the public about "Neuroscience" just like they use their credential to mislead and gas light the public about everything else.
Of course no questions or dissent was allowed, and in academia any student that questioned any of this, would not get corporate funding. Now that we live in a nation of alternate facts, beliefs, nonsense and denial, a few are separating themselves from the criminals, who made lots of money.
The corporate funded psychologists have done generational damage, as they spread lies and alternate facts. They justified racism, intentional trauma and even torture, because it was profitable.
Patients are Our First priority, not "Agendas"
Thank you for this article, it gives me hope as a psychologist that our field has not been hijacked completely by those looking to advance their own agendas. Our first priority should be the welfare of our patients, not getting "lots of cool papers published by cool scientists at fairly large costs—I think $20 billion.." Those using our field to advance agendas like "social justice" or other programs are not looking out for patients, they are looking out for themselves and their livelihoods. It's no wonder that the mental health in this country is getting worse, not better.
You're too late
Psychology has been leading the sheep since Woodrow Wilson enlisted Edward Bernays to manipulate the thinking of a pacifist America into allowing him to join the war against Germany in Europe.
Bernays then created both media advertising and public relations (professional lying) to deliver the flock to consumerists for shearing. A century later, and it's only gotten worse for mere mortal humans. Few can survive in the world without a horde of corporations vying for attention and custom taking most of what they have in return for very little.
3pm
Neo, while some might consider your response negative, I get it. Too late indeed are many. The environment, we still have plastic bags, corporations, hello the ceos make significantly more money but still eat at fast food chains, aren’t they too smart to eat fast food? You’d think they would know the calorie count and that processed foods can lead to real diseases like diabetes and many others. So here’s the solution to your title of “you’re too late” with the most respect dear Neo, while people are being born, while life exists, we are never too late. Psychology isn’t the only area that decided they’d specialize in: breaking bad. It is too late for some but until the end of civilization it cannot be too late for others.
Time to bootstrap psychology and learn that your able to exist without the other parts you’ve been claiming for too long are your added benefits.
Best of random chance.
Let’s take it one step further
Great piece! It is refreshing to hear comments like these and to advocate for psychotherapy as something far different than medical forms of treatment. But I encourage you to go even further. Take another humanistic step to understand emotional distress as a natural reaction to living, not a form of pathology. That is the reason why trying to force the psychology peg into the medical model hole is futile. The key is to understand that distress is a natural and meaningful human response, not pathology that needs corrected. Relief comes by “listening” to the distress, sharing it, and developing faith in the process of life, one individual at a time. They aren’t “patients“ with “disorders” and we aren’t “doctors” who “treat“ them with “therapy”.
Step by step
Dr. Ruby let those last words be a continued chant in all offices. That needs to be framed and in the reception area of all psychological offices
So when you come in you know you’re not being told or diagnoses as not normal with a “disorder” I’m sure business will still bloom. Since people hardly listen and are almost always on their phones, people need someone to talk to. Therapists won’t lose their jobs for doing the right thing and leading rather than referring them to some medication or other doctor for more of a playground. That’s such a sociopathic move. We’re human. It’s time for psychologists to get off of the high horse as well, especially when they’ve been making money for others so long. They were used if as much if not more than the terrible things they did to people. Medical companies. So maybe the way psychology is now is kind of reaping what you sow. It’s sad but what goes around come around. Get it together psychology. Here’s a quote from my poem
“Without our mind
Our boss, our brain
This is the moment we are at risk to become insane”
Unfortunately, here in
Unfortunately, here in America we live in a very psychological society where well intentioned/well meaning 'experts/professionals' have unwittingly/inadvertently turned what was once 'normal' into 'abnormal' and are profiting handsomely from it. When are people going to stop succumbing to the pseudoscience of psychology and psychiatry?
Shedler article
This is a terrific article with an important message. The billions of dollars that are being spent on studying the brain are not going to help human beings much in the foreseeable future. We need to be studying the mind. The mind is the faculty we use to live our lives. We can study the mind through phenomenology, studying people's experience in using their minds, emotions, intentions and perceptions.
Intervening at the level of the brain to help people who are suffering with mental illnesses is very risky and not of much benefit. Intervening at the level of the mind with psychotherapy writ large is very beneficial and not very risky.
The NIMH is wasting billions of dollars, a criminal waste of money..
It should be studying psychotherapy.
Vital information
Thank you Dr. Shedler for stating this so well. Psychiatry has NO clue how to help anyone, nor does it have any real desire to do so. Instead psychiatry has proven their ultimate objective is maintaining power, status and control. Psychiatry and their DSM bible of made-up, damaging labels has severely harmed many people and destroyed many lives. So yes it begs the question why on earth does psychology grovel and kowtow to psychiatry? Why is there even a DSM in any psychologist's office? Psychiatry has driven mental heath care into a ditch long ago. It is crucial that psychology get out of the back seat and take over the wheel.
Training
Before psychology can lead, it must reevaluate the way psychologists are trained. The confusion you experienced with a trainee after asking how they understood a patient's anxiety was far from an isolated incident. Psychologists are not learning how to think psychologically anymore, to the point that the concept itself leads to stupor... think psychologically? Huh?
Clarification
Actually the trainee I described in a previous blog post was a psychiatrist, not psychologist.
Peer Support
I work as a peer support worker in Community Mental Health Services. I notice a slow but steady move towards professionals being open to learning from people with 'lived experience' of challenges to Mental Health.
Initially I was shocked that there was so much stigma within the organisation, with concerns about vulnerability overshadowing capabilities. However, as services are noticing the powerful impact of peers working alongside people as they explore what recovery looks like for them, I am hopeful that the tide is turning....
A lot less hubris
A lot less hubris and lot more intelligence would go a long way towards making psychologists good at helping people with mental health problems.
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