Its worst effect is that those professionals who have the most impressive qualifications and titles can turn out to be be the least skilled treatment providers, which makes it very difficult for patients who are serious about recovery to find a competent therapist.
…the dominant paradigm in psychiatry…assumes that mental illnesses are genetically influenced brain diseases…
I have never come across a psychiatrist who thinks that. Most would probably say that genetic influence is a possibility in some cases, and that brain disease is a possibility in some cases. But the professor would like to win the argument, so to do that he argues against something almost no one believes. OK, professor, you win the argument!
This is not a book review, however.
The professor doesn’t only write books, you see. He also treats patients. You can tell a lot about how he treats patients from an anecdote he tells about a taxi driver (p. 164). First, we discover what interests the professor:
I expected that I would soon have to correct some widely held prejudices about the mentally ill, but my interest was piqued.
A little later, we discover what doesn’t interest the professor, when the taxi driver says:
‘I was mentally ill once.’
Here comes the convoluted life story, I thought.
The professor is interested when he thinks he can show off his superior knowledge, but he becomes bored when he thinks he might have to hear about another person’s life. The professor is no psychotherapist.
Being no psychotherapist doesn’t stop him trying his hand at a little amateur psychotherapy, though. No prizes for guessing what kind of psychotherapy he decides to try — CBT, of course! (And when he can’t get that to work, he tries mindfulness next, obviously.)
The hapless patient is Peter, whom the professor sees for more than a year without any lasting success. The professor is usually late for their sessions (p. 3):
Checking his watch as I rush through the door…Peter looks at me scornfully, then cracks a smile…
Skills, lack of
Although the professor claims to be attempting CBT, even the most elementary skills of therapeutic alliance and formulation appear to be completely beyond him. He sees CBT as merely a protocol, a set of techniques that he can apply mechanically and impersonally (p. 4):
In our first few months together I followed the usual protocol for this kind of treatment, asking him to keep records…
Because he has no significant human relationship with Peter, he is unable to get close enough to him to understand how Peter feels. Because he doesn’t understand how Peter feels, he is unable to formulate an understanding of Peter’s difficulties. Because he has no formulation, he cannot make an appropriate treatment plan. Because he has no treatment plan, he just stabs in the dark at what to treat…and misses.
…I did my best to challenge [Peter’s] belief that [the voices he heard] were omniscient and omnipotent, and I did my best to challenge his belief that they were irresistibly powerful.
Those are beliefs about the voices, so Peter must have come to believe those things after he started hearing the voices. Therefore those beliefs cannot possibly have been the cause of his hearing voices, and so challenging those beliefs will definitely not make the voices go away.
The professor concludes, hitting the nail on the head (p. 6):
Sometimes I feel as if I am only pretending to be useful.
The thing is, the basics of how to form a close therapeutic alliance have been known since before the professor was born. He just didn’t bother to learn the skills.
Also, the basis of CBT formulation has been around for at least half a century. Psychiatrists were having success using similar ways of thinking about mental illness well before CBT emerged as a distinct therapy. The professor didn’t bother to learn that skill either.
The professor’s problem is caused by the narrowness of his thinking. His paradigm is that the only useful kind of learning is book-learning. Learning how to get to know and understand people doesn’t count for anything in his world. Learning how to make sense of seemingly mysterious symptoms doesn’t count for anything in his world. It’s the professor’s book-learning paradigm that let Peter down.
The book-learning paradigm is rife in the NHS (and in the remarkably similar US healthcare industry, too). If you are looking for a psychotherapist, it is vital to realize that an academic approach is very unlikely to work. Sign up with an academic psychologist, and you can easily waste years of your life filling in forms and trying to adhere to protocols, while your illness becomes ingrained and harder to treat.
Looking for evidence
Successful psychotherapy is a collection of practical skills, not an academic exercise. Any patient who is serious about recovery would be well advised to look for evidence of those practical skills in their potential therapists.
In all forms of psychotherapy, a close trusting relationship from the very first session is vital for success. This means you experience strong feelings, and you talk about how you feel. If your therapist merely gathers facts and discusses diagnosis, then your therapist is barking up the wrong paradigm.
In CBT, in particular, a strong focus on understanding the causes of your difficulties is equally vital. This means you spend a lot of time getting into the details of your most difficult thoughts and feelings. If your therapist merely hands out techniques and tries to suppress symptoms, then your therapist is lost in the library.
If you want to get well, start by getting the right therapist.
Hat-tip to Katie at Under The Stars, whose post about this book, *Insert label here*, ends:
You are not a broken brain to be fixed, you are a person and you deserve to be treated as such.