The Evolution of Psychotherapy conference is the largest conference in the world dedicated to psychological therapies and treatments. There are over 8000 therapists here from 52 countries. It’s held every 4 years and this year is in Anaheim California, just opposite the Disneyland campus.
Perhaps this year’s proximity to Disneyland creates a somewhat unfortunate metaphor, depending on how seriously you take the accusation that therapy and therapists can be disconnected from reality. Of course, for the pragmatists, this convention centre is one of the few in the world big enough for an event of this size.
The conference is dedicated to the past, present and future of psychological therapies. We see speakers representing an almost direct link back to the early days of Freudian thinking, right through to those presenting ideas that are only just starting to emerge as we talk. That sounds dynamic and wonderful until you think about one inconvenient fact – outcomes in psychotherapy have not improved in the last 50 years. In the 1960s, specific directive targeted strategies replaced non-directive analytic techniques, and substantial improvement in therapy outcomes were seen. But we haven’t seen much more since then.
So the obvious question is “If it’s not about improving client outcomes what is psychotherapy evolving towards?”
This question is one to which the Evolution conference gives me a frightening answer. It seems to be evolving into narcissistic empire building at best and snake oil selling at worst.
There are speakers here that were involved in the development of thoughts that changed the way we view the human condition (Yalom, Kernberg, Minuchin and others). These comments do not apply to them. There are other speakers who meticulously research their field and deliver extraordinary insights into treatment (Barlow, The Gottmans, William Miller). These comments do not apply to them. Finally, there is a small group represented here on the cutting edge of trying to figure out, through rigorous application of science, how to optimise the treatments we do have (perhaps best represented by Scott Miller). These comments do not apply to them. Perhaps I have missed some others to whom these comments do not apply.
However, these truly great thinkers serve as thin veneer for the rest. Time after time I have walked into presentations to see someone spruiking with passion (or practice) their revolutionary new idea. The “idea” could be a repackaging of some banal folk wisdom, with no evidence base around it. However, that doesn’t stop the 10 books, half a dozen training DVDs, and $5000 accreditation program to learn how to implement “the idea”. The sales pitch follows a generic formula: step 1 -Personal Narrative; step 2 – anecdotal evidence; step 3 – superficial explanation of only the most obvious parts of “the idea”; step 4 – dire warning that everyone else at the conference is in the business of harming their clients because they don’t understand “the idea”; and step 5 – the “science” is trotted out. The science tends to be a piece of therapy research of vague relevance authored by someone else that hints in a footnote that the “idea” is legitimate. Even better, it could be some prominent piece of hard science, preferably in epi-genetics, brain imaging, neuroplasticity, or my personal favorite, quantum mechanics, whipped into service of the “idea” like a top racehorse used to transport a pet hamster round the garden.
Uninhibited by scientific caution, or a shred of self doubt, these guys (and they are mostly guys) wax lyrical, hype up the audience, play to the crowd and then sell the product.
Thankfully, most of the products are largely innocuous: “talk a bit about which parts of the brain are associated with your memories of trauma and that helps clients to defuse from those memories”; “get a bit of exercise and people are often happier”; or “try and avoid being nasty to each other and your relationship will improve”. These ideas are not harmful on their own. Frankly, the clients of the therapist who is impressed enough to buy a training package in one of these techniques, is almost certainly much better off with these panaceas than anything the therapist might create on their own.
However, some of the ideas are downright dangerous. A good example of this for me was a devout gentleman who spoke rapturously of his mission from god to transform the way we approach mental health. All the steps were there: emotional anecdotes; brain imaging research; the dangers of not doing it his way. Yet a whole new level of steroidal energy was in this talk. I actually had to move further away from the crackle of the audio speakers as with nearly every sentence he peaked out their capacity to contain his fervor. The idea that he was so passionate about was that, prior to medication or psychological therapy, EVERY client should receive a structural and functional brain scan.
The evidence he presented included some great case examples: a football player with multiple minor traumatic brain injuries had developed anger and impulsivity problems; a young girl was bitten by a leech and developed lyme’s disease and symptoms looking like depression; a boy (the speakers godson) developed a temporal lobe cyst and became violent at school. Of course, the psychiatric symptoms in each of these cases truly are better explained by the brain pathology. These are the examples used to support the approach that this should be a treatment for everyone. His institute has now scanned over 80,000 brain images all using SPECT (single positron emission computer tomography). They charge around 3500 USD for the scans and the scan requires an injection of a radioactive tracer dye. The piece of data he didn’t present was “how often do you find something important?”
When I worked at the Royal Brisbane and Women’s hospital, we decided to include a syphilis test as part of the routine blood work. We found around 1 in 700 admissions actually had syphilis. Given that the “madness” caused by syphilis can be cleared up with a shot of antibiotics, that the test cost us 9c, and that blood was being taken anyway, this seemed like a great investment at low risk even for a long shot.
I am not a wowser who believes that all nuclear medicine is inherently dangerous, but any invasive medical procedure carries risks. These risks are usually low frequency, but when you start getting 80,000 radioactive injections under your belt, your odds of complications start to shorten. So for each of those complications, how many people are saved by the new information gained? I would have found this information relevant.
It is entirely possible that this “image first” approach will improve outcomes in psychiatry. However, the way we work is “do the science first, set up the company and the clinic later”. I am, of course, doubtful the “image first” approach will lead to anything. With 80,000 functional brain images alongside clinical interview data and outcomes data, any meaningful results would have been published in New England Journal of Medicine, and the researcher could expect to be on the cover of Time magazine.
Perhaps in the bright new world of charismatic therapies, you can circumvent science and peer review, as long as you have emotive actors and a handful of self help books to your name. Start an institute, film some DVDs, get on the couch with Oprah and you are set. Picture yourself at Disneyland.
When I went to Disney, my colleagues and I played a game called “spot the vegetable”. In amongst the heady mix of every possible combination of fat, sugar and salt, real food was hard to find. Then imagine our excitement when right there next to one of the rides, we found a small stall that was serving kebabs on a skewer, and right there on each and every kebab were mushrooms, capsicum and pineapple – Real Foods shining like a beacon from a forgotten time when foods had nutrients in them. Over the road at Evolution of psychotherapy, I have begun playing “spot the data”. If you look hard enough amongst all of the (un)intellectual sugar, there are some people working ethically and tirelessly to gather evidence of what they are doing. They are both as rare and as great a pleasure to find as any vegetable at Disneyland.