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Those of us who are nearing retirement from work as a psychotherapist have been privileged to witness extraordinary changes over the course of our careers.
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There were a lot of people coming home from the war who were compromised and needed help functioning at a higher level. Neither psychiatry nor the psychoanalytic movement was equipped to handle the great demand of the returning GIs. The VA hospitals were very proactive, and they started bringing in PhD psychologists and social workers to do psychotherapy and counseling. Clearly, it is possible to achieve results in psychotherapy — not perfect results, but results — in four to six months, and here the analysts were talking about five years, five times a week.

It was absurd.

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If you are practicing medicine that is so at odds with prescribed treatment protocols, at some point you set yourself up to be liable for malpractice. In recent years, psychoanalysts have become more receptive to medication, but many are still quite anti-drug. Most psychiatrists today would actually like to do some psychotherapy.

Many of them have trained in psychotherapeutic techniques. But they can earn substantially more by practicing psychopharmacology rather than psychotherapy.

In fact, the government is hiring independent-minded, independently trained physicians who are using drugs to the best of their ability to heal people. Empathy and intelligence, combined with a certain formality. There needs to be a formal structure to guarantee confidentiality and safety, so that you can speak candidly in a way that one often does not speak with friends or family.

Beyond that, philosophical orientations and orthodoxies it do not seem much to matter. I will say, however, that cognitive-behavioral therapists do better with many anxiety disorders. Some people are inclined to think rigorously in a situation, while other people allow their emotions to take control. But you can learn to modulate some of the anxiety and franticness if you are so taught, and cognitive-behavioral therapists more consciously teach. Barack Obama, for example, clearly has enormous mastery over his emotions.

Psychotherapy did start out as heavily Jewish, but that is much less true today. The detached scientist-therapist had to become a warm and caring friend. Toward this end, clinical psychologists created non-university-based psychology degree programs, the first being the California School of Professional Psychology, which opened its doors in Within three decades these programs were graduating twice as many clinical psychologists as traditional Ph. Much as they had engaged in a broader philosophical struggle with psychiatry during the s, therapists in the s sought to counter the increasingly predominant view within primary care that unhappiness was biochemical in nature, and the best treatment for it pharmaceutical.

Clinical psychologists, counselors, and social workers who performed therapy worked together to promote a rival view, changing their image to that of the caring professional.

Why is it so hard to get good therapy?

Leaving behind Freudian psychology was a key part of this shift. By drawing on non-Freudian traditions, clinical psychologists built a simpler vocabulary to connect with average people. The rapid appearance of these words in the public lexicon in the s is as significant as the earlier rise of Freudian terminology. But for the public to make buzzwords out of these terms meant that the problems they named had stopped being part of the normal backdrop of life and become serious cultural, even political, issues.

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James L. Nolan, in The Therapeutic State , notes that self-esteem would soon become a commonplace subject in regulations issued by the Department of Health and Human Services, the Department of Education, and other federal agencies. By leaving the bounds of psychotherapy and entering the popular realm, these words became part of an emerging worldview.

In the new Age of Depression, people came to believe that the good life consisted of high self-esteem and a stress-free existence. Although clinical psychologists helped to build the new vocabulary, that vocabulary was not consciously contrived. The first article on emotional stress as a cause of sudden death appeared in The popularization of self-esteem, stress, and related ideas was not simply the work of the clinical psychologists who employed the terms professionally.

It represented an ideological shift in American society. Whether the words an ideology uses are esoteric or common, the content must express the interests and aspirations of the people to which it is directed. Many Americans in the s had depressive symptoms or suffered from the psychological toils of everyday life, but for various reasons lacked anyone in whom to confide their troubles.

Talk of stress and self-esteem helped convince people that therapists understood their concerns and wanted to help them. Starting in the s, the public conception of clinical psychologists, counselors, and social workers began to coalesce into a single character type: the caring professional. Social workers and counselors who worked in mental health began to align themselves more closely with clinical psychologists, thereby laying the groundwork for the emerging caring industry.

The term signified a new consciousness among these professionals that they were somehow different from general social workers, and more like clinical psychologists. A similar trend occurred in counseling. As clinical social workers and counselors began integrating themselves into the caring industry, organized psychiatry began its long decline.


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The role of psychiatrists in dispensing psychoactive drugs was increasingly being ceded to primary-care doctors, and they had long since relinquished psychotherapy, the basis of the emerging caring industry. Instead, many psychiatrists were destined for relatively minor roles under the emerging realities of managed care , a system in which health care costs are reduced by bringing together panels or networks of health care providers. Not surprisingly, the number of psychiatrists increased only modestly over the next few decades, in contrast with the explosive growth among clinical psychologists, clinical social workers, and counselors.

Academic psychologists, too, felt sidelined by the rise of the caring ethos. The non-university-based psychology degree programs infuriated them. They spent the next four decades ridiculing clinical psychology, trying to return the discipline to its scientific roots.

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Yet academic psychologists err in assuming that clinical psychology is still a branch of psychology, and therefore of science. It is not. Professional psychology and the caring ethos are part of a larger social movement whose purpose is to help unhappy people feel better in a lonely world. Many histories of psychotherapy dwell on the bizarre, sometimes outrageous, therapeutic fads of the s. But focusing on these fads distracts from the broader history of psychotherapy — not because these fads faded quickly, but because doing so obscures the rise of the caring ethos that was occurring at the same time.

By , although some Americans were still screaming their aggressions away, or engaging in orgies to find their true selves — and thereby grabbing the headlines — the less exciting but more enduring fact had been realized: most mental health therapy in the United States had become short-term psychotherapy. Just who was dispensing this psychotherapy grew increasingly irrelevant, as the basic structure of a short-term therapy session was the same regardless of whether the therapist was a psychologist, a social worker, or a counselor.

By , more clinical social workers were performing therapy than were psychiatrists or psychologists. Helping people solve their everyday problems characterized much of this therapy. Increasingly scarce were the metaphysical doctrines, laid down with certitude by solemn psychotherapists with European names. Gone, too, were the sectarian differences, the innumerable delicate distinctions between schools that therapists once drew with an ideological fervor.

T he rise of managed care helped to turn an established trend in American culture — the rise of loneliness, depression, and other mental health ills, along with short-term psychotherapy as the preferred remedy — into a new industry. Managed care grew rapidly in the s and s to contain runaway medical costs. As researchers noted in the journal Health Affairs , total enrollment in managed-care mental health programs in the year was million — higher, in fact, than enrollment in the non-mental-health sector of managed care.

The rise of managed care did not really change the degree of access to mental health care; rather, it changed the nature of that care. A article in The American Journal of Psychiatry shows that managed care accelerated the trend toward fewer psychotherapy sessions, with patients receiving six sessions on average, and one third of patients receiving only one or two sessions.

It also reduced the time for an individual session.

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In , the average therapy session lasted 55 minutes; in , under managed care, the average was only 34 minutes. Ever attuned to public opinion, managed-care executives realized that the therapist in American life had become a substitute friend for unhappy people. They realized this even before many psychologists did. Psychology Today did not run its first piece on short-term psychotherapy until , although short-term psychotherapy had already been dominant for years.

Though providing a caring professional to people with mental health ills seemed intuitively reasonable from a social perspective, from a scientific perspective it was a leap of faith. There was no real proof of the efficacy of short-term therapy by the time the managed-care revolution was underway in the s and s; most of the studies conducted up to that time were flawed.

Indeed, as of , as an analysis in the journal Family Process notes, only a few studies meeting strict methodological criteria had rigorously scrutinized short-term therapy — despite the fact that it had become and is now the dominant form of therapy. Managed-care executives bet on the method because it saved money and because customers wanted it, not because it was known to be effective.

They grasped the shared sentiments of the American people, and the essence of what psychotherapy had become. This is one origin of what became the new mental health emphasis on how people feel: a managed care customer goes to a caring professional feeling bad, and leaves feeling good. Since feelings were much easier to measure in a client than abstract psychological criteria determined by the therapist, starting in the s, improvement in feeling became the standard against which all therapeutic methods were judged.

It was only natural that they should see in the innumerable obscure distinctions of psychoanalysis a manifestation of the inherent falsehood of Freudian doctrine. Managed care executives wanted to turn mental health into a commodious institution, a kind of happy home where people might enjoy artificial friendship — and over-intellectual egotists who think dark thoughts in a language that average people cannot understand do not make for a happy home.

Census Bureau numbers. Another 2. This represents an increase from Socioeconomic status, in turn, is linked to mental health: People who are impoverished, homeless, incarcerated or have substance abuse problems are at higher risk for poor mental health. Negative stereotypes and attitudes of rejection have decreased, but continue to occur with measurable, adverse consequences. Generally speaking, the participants in this study were not very open to acknowledging psychological problems, but they were somewhat open to seek mental health services. Cohort effects, exposure to mental illness, and increased knowledge of mental illness are factors which could potentially change beliefs about symptoms of mental illness.

Participants appeared apprehensive about seeking professional help for mental health issues, which is consistent with previous research.


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However, participants were willing to seek out some form of help. People of color account for 60 percent of the prison population. Furthermore, many believe that discussions about mental illness would not be appropriate even among family.