This is the continuation of a transcript for this podcast. Part 1 can be found here.
Jonathan Engel: So one of the interesting things that came out of Freakonomics -- and they've done all sorts of statistical studies -- is actually how little effect, how little influence parents actually have on their children. That, in fact, it turns out that if you do fairly rigorous econometric studies, children's peer groups wind up having a far, far greater long-term effect on the development of their own persona than the parents do.
Now the parents have some influence in sort of biasing those peer groups, that is if you see your kid getting into trouble and you're a very proactive parent, you can kind of maybe transfer him to a different school system or get them out of town or put them in a boarding school or maybe relocate the family; in other words, there are ways of trying to subtly shift that peer group. But it's the peer group more than the parent which seems to really have a very, very formative effect.
Well, this would be a shock to about 90% of Americans; I think most Americans who have children assume that they are the single greatest influence on their child, on the person that child will be. Well, they're a very, very great influence because of the gene pool that they bestowing upon the child, but in terms of the psyche of that kid, they're less of an influence than they'd like to believe.
And yet I think as a nation, we still cleave to that very, very Freudian idea that parents, by their actions, by their words, by their interactions, by the love that they either withhold or bestow, have an enormous ability to influence the shape of that child's adult psyche, the person that kid will become, whether it's a loving person, an honest person, an insecure person, a trusting person; that that's really all within the power of the parent to determine. It's a very Freudian idea, that things that a parent does to a child at age three will determine how that person feels at age 33. And yet an awful lot of the data seems to suggest that's really not so true, that so long as you're not actively abusing the child, so long as you're not actively injuring the child, you're more of a benign and, perhaps, absent influence than you'd like to believe.
David: Yeah, that makes sense to me as a parent of four kids.
Jonathan Engel: And one of the things that happens is you watch how different your kids are, right? And you sort of think, I'm the same parent -- then people talk about birth order, well, I'm not so sure. In fact, it really does seem to suggest that parents have less influence. I think you said -- and I know we're getting off the subject -- you're a model, you're the single adult that these kids know best in their whole life, because they lived in your house. So if they liked what they saw, it's a template for how to live their life. But that's a very conscious decision they make; I mean, if they watched how you handled money, or they watched how you constructed your career, or how you dealt with other adults, or how you entertained people, that's a very, very present model in their mind. But that's different from saying that you're an influence on their inner psyche, on their feelings and their psychological processes. And yet Freud would dictate -- and I think an awful lot of Americans believe -- that as a parent you really have the ability to create that psychological health inside that person.
David: Well, he lived in a much different world than we do now; and I'll tell you, right now I'm persuaded that peer culture, of course, is very important, but then we also have media culture which has an incredible influence. But that's kind of a rat hole that's taking us a different way. Mark, were you trying to get a word in there?
Mark: Well, yes.
David: Go ahead.
Mark: If we do step back and look at kind of the thrusts, if you will, or the major themes of the different schools of psychotherapy in this case, Freud really started with a focus on the individual; and as that developed -- of course, the orthodox analysts didn't really make that development -- it became more relational, more social in nature, and thus you have people like Sullivan who emerged. I guess part of what I see happening today is that you have different notes or themes that each of these sort of schools of psychotherapy have contributed. For instance, the focus on rapport and relationship comes out of this sort of humanistic angle or theme which is something that the psychodynamic psychotherapists also, as those ideas evolved, grew towards. You have a very technical approach, you know, various different kinds of techniques that have focused, for instance, on thoughts or behaviors or things of that nature. And all these things have been in isolation and what we're starting to see now is a lot of cross-pollination between these different theories.
Jonathan Engel: I was just going to ask you, do you as a practitioner, do you see a convergence of these different schools? That is, that they're coming closer together as opposed to moving farther apart?
Mark: I think absolutely that they're responding to their own social environment, and they're responding to each other. So the forms of psychodynamic psychotherapy that are still around and thriving, if you will, are things like, David, we did the interview with Myrna Weissman or the interview on transference focus psychotherapy, where a lot of these relational ideas -- and it's more the relational aspect of dynamic psychotherapy that's surviving and thriving even. And that's becoming more subject to empirical testing, if that helps.
Jonathan Engel: Yeah, one of the things that was interesting is some of the people that I wrote about I knew about, and some of them I obviously didn't, and one of the people that was new to me was Lightner Witmer who I wrote about essentially founded the child guidance movement in Philadelphia at the turn of the last century, so right around 1900. And he was trained as a sociologist; he was not trained as a therapist, so he sort of created this field out of whole cloth. He knew nothing about Freud. And he came at this from, essentially, juvenile delinquency.
He was hired by, I think, the Philadelphia school system to try to figure out why some of these immigrants were doing so terribly, these child immigrants; why some of them were truants or delinquents. And he sat down and talked to them as a safe adult and a good listener. I suppose that was very humanistic of him; he just sort of wanted to hear what these kids had to say without really trying to apply therapy.
And one of the things that he found out, repeatedly, was that often he had to place these kids exactly where you were just saying, Mark, in a social context. That it was pointless to try to make sense out of these kids' behavior if you didn't understand that the father was an alcoholic and beating the kids up, or that the kids were living in abject poverty and not getting enough food for breakfast, or that the kids were Jewish living in an Irish neighborhood and they were terrified to walk down the street because they might get beaten up by a gang or something like this.
And there was one famous case where a kid seemed to be having difficulty reading and they thought he was dyslexic and there were learning disabilities, and this guy realized the kid needed glasses. It was as simple as that; that the family was utterly broke and they couldn't go to an optician; and he got the kid some glasses and stuck him in the front row and the kid started doing fine. I mean that's obviously almost apocryphal, but it happens to be a true story. But his willingness to try to see these kids on their own turf and their own milieu, and to try to make sense of their life given the life they were living. And he did this utterly on his own.
Now today I think any psychotherapist worth his or her salt would, of course, take into account the context in which you're living. Are there financial pressures, are there marital pressures, are there issues going on in the family, are there issues going on at work? And of course you would ask these questions, but 105 years ago this seemed like a relatively new idea, to ask someone do you need glasses, or to ask someone are you worried about getting beaten up on your way home. All by way of saying that I think that there have been people who have been insightful along the way, and little by little -- I don't want to sound too trite -- but a lot of these different ideas, I think, are getting absorbed into the psychological zeitgeist, and I think probably therapists are being trained better and better because they're being taught to look at a lot of different clues, a lot of different approaches.
David: Yes, and one of the themes that runs through your book that I think that story is illustrative of, is the theme of American pragmatism. And I think many therapists today, if you ask them what's your approach, they'll say I'm eclectic.
Jonathan Engel: I do what works.
David: Yeah, exactly, that's a lot of what it comes down to, I think.
Jonathan Engel: And, you know, that's what I came away thinking as well, and the other word that comes out again and again besides the word pragmatic is the word empathy. It just seems to come up again and again that no therapist who is fundamentally unempathetic can be successful or bad; so that goes right back to the humanism, Mark and David, you were talking about, that the person has to feel heard.
But the other word that seemed to come up an awful lot in my research was the patient has to feel safe, the patient has to trust the therapist. And what does that mean to feel safe? Obviously the therapist is not going to physically attack you, but it's very possible for a patient to be sitting in a room with a therapist and to somehow not trust that person will hear them, whether you might tell them something very frightening and very sensitive and that they will do the wrong thing with it; they will turn it around; they'll misinterpret it. And the patient has to feel that if they tell the therapist something really deeply frightening and sensitive, that somehow the therapist will take it in the spirit that it was given and will somehow have the insight to see what those words mean. And until that trust is there, nothing constructive can seem to happen.
But the interesting thing is that someone who is able to establish that trust can be successful with a wide variety of patients; that's what came across again and again. I think, Mark, you brought this up, or maybe it was David, that some of these studies recently have suggested that therapists who are good are really good; they seem to have a very high success rate; whereas therapists who are bad, really seem to be bad generally. It's not just a question of finding the right fit of the right therapist to the right patient; there really are better and worse therapists out there, and all of the good therapists, virtually, are very empathetic people.
David: Yes, and you know what? As I was thinking about the questions and I was going through your book, there was one book, set of authors, that kept eluding me and it's finally come back to me: it's Truax and Karkov and I don't see a citation to them in your book, but they were Rogerians. They were trained by Rogers but they were part of the cadre of people that Rogers trained to go off and become therapists. And so they did a lot of therapy research and, of course, you might call into question their conclusions all confirmed Rogers' theories; they all strongly supported ideas of warmth, empathy -- I'm trying to remember the other factors -- rapport, you know, that whole sort of cluster.
Jonathan Engel: That whole range. You know, I'll tell you just a slight tangent. My mother is a practicing attorney, she has a fairly successful private practice in Washington, D.C., and she's a divorce lawyer. And she will tell you that she feels like she spends more time as a social worker than as a lawyer, that the patients come in -- not the patients, the clients come in and they think they have a legal problem, but what they really have is a psychological problem. And that she spends as much time counseling them on their psychic needs and on the psychic needs of their family and their children than she does on their legal needs.
And I quoted, there's a famous study that was done, I think, in the '70s when they asked people, do you feel better talking to a therapist, do you feel better talking to your physician, do you feel better talking to your priest or your rabbi, do you feel better talking to your lawyer? And as many people claimed that they had found their lawyer psychically helpful as that they'd found their therapist psychically helpful.
I think all that really means -- it's not to suggest that you can use a lawyer instead of a psychotherapist -- but it is to suggest that people who are feeling very frightened and where there's a sense of inner [unclear], are looking for safety, they're looking for psychic safety. And sometimes a lawyer can provide that sense of safety. To be with someone who really understands in detail the depth of your challenges and who can chart a way out suddenly feels very, very safe; and a lawyer can impart that sense of safety.
I suspect that the very best military commanders also impart that sense of safety. You're in the middle of chaos and anarchy in the middle of a war zone, and a terrific sergeant or platoon leader can sort of say, stick with me, do what I say and we will all get through this alive. And it's what you desperately want to hear. If I trust you, you will lead me to safety. And I think the best therapists are somehow able to get that message across to their patients: trust me, this will be scary, it may be long, it may be uncomfortable, but if you trust me and follow me, I will get you to safety.
Mark: Well, one sort of comment, I guess, to make is you've emphasized safety in the book throughout and certainly you're doing that here, and it is the foundation, the bedrock, of effective psychotherapy; rapport, genuineness, the things that Rogers talked about are generally recognized as important. But in the process of emphasizing the safety, there's also a sort of consummate downplaying of technique, at some level saying it's hard to tell one from another -- although you did acknowledge that CBT therapists look very different than dynamic therapists, and I think that would be hard to miss if you knew anything about those. It seems to me that the story of the last 20 years, particularly as the concept of empirically validated psychotherapy has really risen to prominence, is saying what parts of the technique -- not the foundation of safety -- but what technique, what aspects of that are important? And where are they important, for what problem?
Jonathan Engel: I think you're right. Let me ask you, it's certainly a reasonable question, but I have to tell you -- and, Mark, feel free to disagree with me -- do you see that in the literature? Do you see very fine pointed articles about specific therapeutic technique? In my reading, what I got struck again and again was, I would see technique emphasized in a specific case; someone would write up a particular case study and often they would try to place the content of the patient in a particular context or something. But what I didn't see people doing was emphasizing a specific technique over another technique. It seemed to be more broader philosophical differences they had.
Mark: [unclear] link broader philosophical differences -- and I'm not talking about tiny little fine points -- maybe the best case is something called DBT, Dialectical Behavioral Therapy; where basically you have very broad concept, cognitive behavioral intervention originated by Ellis and Beck, that sort of a thing, married to something which was not ever part of CBT, a different kind of approach, a mindfulness approach actually drawn from a religious practice. And what you end up with is something that is demonstrably, scientifically shown to be effective for work with a very troubled population of people who are suicidal, self-injuring, things of that nature. That's an innovation, and it's a technically driven innovation.
Jonathan Engel: Right, as opposed to a philosophically driven one.
Jonathan Engel: You're right, that's a very good example, I wish I'd put that in the book; it's a very good example. Do you see that happening a lot, Mark, or is that sort of a specific isolated example?
Mark: Well, I think that there are a lot of versions; so I think part of the problem here is deciding how broadly to draw your groups; and, of course, all the different authors, as you point out, there's a tremendous amount of ego involved and everyone wants to be seen as an innovator. So it's not really probably fair to say that everybody is an innovator, but it does seem to me that there are technical innovations, so I'm drawing the groups, I think, a little finer than you might.
I see, basically, an emergence of something that I've written about as post-cognitive therapy. So DBT is one of them, but we would also want to include something like Jeffrey Young Schema therapy. There are a lot of extensions of cognitive behavioral therapy that are taking technical approaches from other schools, many of which have to do with mindfulness. Steve Hayes' acceptance and commitment psychotherapy is another form of that, where it's a marriage of things from two approaches and it's worked with in an empirical format, so there's a literal scientific research being done to establish that the new technique is effective…
Jonathan Engel: It's superior.
Mark: Yeah, either as good or better.
Jonathan Engel: And do you have a sense that these new techniques are superior in a specific situation or are they generally superior, given a certain class of patients or clients?
Mark: Well, to kind of meet you in the middle, because I do think that the biggest innovation is the incorporation of sort of acceptance or mindfulness in with the CBT, and what you're really seeing is some people are ready to get right down to work, and for that sort of a person, if their problems are not too amazingly deep, cognitive approach can be very effective.
If you've got people that are much more disturbed in one form or another -- and I don't mean that in the sense of psychoses, they could just be very difficult coping strategies such as self-injuring behaviors and things of that nature -- it's harder to take something that's very procedural and formal, like cognitive behavioral work seriously.
And in that kind of example, it's very helpful to have something else that a protocol is pushing you towards. You know, don't start with this very formal stuff, meet the person where they are. If their major problem is that they cannot organize themselves to take on something real formal, then give them what they need, which in this case is something which is going to help them to be calmer, to approach the work more calmly. And maybe later, in an evolutionary process, they can come back to something like straight up cognitive behavioral. That's acceptance and commitment in a nutshell, if you will, and it serves as a model, at least in my mind, for a way to think about what you might call post-cognitive psychotherapy.
Jonathan Engel: That makes a lot of sense. I'll have to add another chapter.
David: Well, we're probably getting close to the place where we're going to be winding down, but before we do, I think maybe we need to look at the cross currents of economics as they're playing out in our culture; economics of psychotherapy, of medication, of the insurance industry. You're about to write a book kind of looking at a lot of that from a general healthcare perspective, but what about when it comes to psychotherapy? What's played out in the last 20 years and where do you see it going?
Jonathan Engel: It's had a profound effect, I mean there's no question I think it was the death knell for psychoanalysis. If you look at one of the fun little statistics I had in this book was that the greatest concentration of analysts in the United States at the peak of analysis in the early 1960s were in Washington, D.C. and in Westport, Connecticut, not [unclear] on a per capita basis; so there were more analysts, obviously, as a crude number in Manhattan and Los Angeles, but on a per capita basis.
And it seemed to be directly attributable to the federal insurance plan in D.C. and the General Electric insurance plan in Fairfield County, Connecticut. And both of those plans paid for unlimited therapy sessions; you could go 250 times a year and it covered the entire cost. And to some degree the analysts went where the money was. You can't have a successful analytic practice if you can't find patients who are willing to pay for it, and there were relatively few people who could pay, and there were very, very few insurance companies that would cover that level of therapy. But the federal government for some reason had a very, very generous plan.
That's all finished; it's totally gone and it's one of the reasons, I think, why we've gone toward shorter term psychotherapy; I happen to think it's as much economic as it is anything else. It's very hard to get therapy covered equitably with other sorts of health care. There's sort of constantly a fight, every time we have a health reform battle going on in Congress, as to where do you fit mental health and mental health services in there.
During the Clinton Health Reform Bill 16 years ago, the one that we all think of as Hilary Clinton's bill, that was 1993 -- what is it now, 2009, so 16 years -- Tipper Gore, of all people, Al Gore's wife, took a strong advocacy position on mental health. She had suffered on and off from, I don't know if it's chronic depression or if it's bipolar, but there's some depressive disorder going on there, she's never been very transparent about it. But she clearly had a strong interest in mental health, and she really advocated very, very strong that there be powerful mental health benefits in that bill. In the end, they couldn't really deal with it because they went with this whole managed competition approach, this [unclear] approach. And managed competition deals with measurable outcomes and they decided it was just too difficult to measure outcomes when it came to mental health and mental health modalities. So essentially it got carved out, it wasn't really included in that bill.
And this seems to be the story of mental health. If you're a bean counter, if you're an outcomes expert, if you're someone who's measuring mortality, morbidity, re-hospitalization statistics, all the basic measures of healthcare efficacy, mental health just doesn't fit nicely. It's too hard to measure what success is; it's too prone to bias, it's too prone to self-reporting, conflict of interest. And I think we're going to continue to have that problem.
I think Americans as a whole are much more sympathetic to the need for mental health, there's far less stigma associated with being in therapy. I think this recent war, frankly, in Iraq and Afghanistan has once again galvanized the nation into understanding the critical role of mental health care. There's some incredible statistics, something like 15-20% of all returning GIs from Iraq are diagnosable as suffering some form of PTSD, which is just stunning. And that number is sort of making it out to the papers and I think many, many Americans, particularly sort of very working class Americans after all, who are supplying the GIs going over to Iraq -- it's not wealthy people -- and those families are really very open about the needs for mental health care and they're really very demanding in the need for mental health care to provide for the VA, whatever it may be provided.
So the country is aware of it but I think that the payment industry hasn't really quite figured out how to factor it in. It's too difficult to measure in a very rigorous way and it's too prone to abuse. So we'll see what happens.
David: One of the themes that runs through the book, too, is this competition interplay between the different disciplines with psychology kind of moving in on psychiatry's turf and social work moving into psychology's turf; and we haven't talked about the whole sort of master's level explosion of counselors, and licensed professional counselor is a designation that's becoming more frequent across the country. Well, in the context of those sorts of turf wars, I'm going to be doing an interview sometime pretty soon with… there's a whole question of whether or not psychologists should move towards being able to prescribe medications.
Jonathan Engel: That fight's been around now, I think, for 15 years.
David: Yeah, do you have any comments on that?
Jonathan Engel: I think they should, I mean with the proper training. And it may be that you want to keep certain kinds of medications, particularly like addictive opiates and certain kinds of tranquilizing drugs, maybe you want to monitor them, regulate them more carefully. When you look at the training that a Ph.D. psychologist has gone through and you look at their outcomes rates, their efficacy rates, and their level of expertise, it just seems like an artificial distinction in my mind to say that they lack the M.D. and therefore they shouldn't be prescribing. I think they're as close to mental illness and, more than that, in a funny way, fewer and fewer M.D. psychiatrists are actually doing therapy these days. It's the economic truth of the profession; they can make more money as psychopharmacologists than they can as psychotherapists.
As a result, they are becoming more and more distant from observing on a day to day basis the true effect of the medication. That is, if you're a therapist and you're seeing a patient on a weekly or even a bi-weekly basis, and you put them on a new antidepressant or a new anti-anxiety formulation, you see it immediately. You're seeing them in your office twice a week; you are immediately perceiving that something has changed. I mean it's quite different.
If you're a psychopharmacologist, and you're just interacting with a patient once every four weeks or even six weeks or eight weeks, you're largely relying on hearsay, on word of mouth. That is, the patient comes in and you look at your chart and you say, "Oh, I see two weeks ago we raised your dose of Paxel. Has it helped?" Well, now you're going back eight weeks and the patient says, "Yeah, I seem to feel a little better."
Whereas the psychotherapist, who is probably either a social worker or a psychologist, saw it right away. And in many ways, it's the psychologist who, I think, is better able to evaluate the efficacy of the drug. It's a bizarre situation, where the person doing the prescribing is not the one really having the primary interactions with the patients. It's not a great recipe, when you think about it, and it's largely economically driven and turf driven, obviously. So, yes, I would definitely push psychologists in that direction.
By the way, this goes beyond simply mental health; the other big fight right now is should physician assistants and nurse practitioners have prescribing privileges. Certainly for most drugs it doesn't -- maybe there's some kind of drugs that are highly regulated, you want to be careful with them. But it is just patently absurd if your primary caretaker is a nurse practitioner and not M.D. -- and more and more of the primary care being delivered in this country is being delivered by non M.D.s -- and they're seeing legions of viral and bacterial infections walking into their office every day, to not grant them the power to prescribe Amoxicillin is absurd, I mean, it's just absurd. If you're looking at your seventh ear infection that morning, and to say you're not adequately trained or qualified to be prescribing a dose of Amoxicillin, it really becomes silly.
So I think we are going to move in that direction. I think we're going to see a broadening of prescription privileges, maybe even hospitalization privileges over the next 20 years. But the doctors have a lot to fight over; they've been fighting this war for a long, long time and they've gotten very good at fighting this war.
David: Okay, as we wrap up here, Mark, do you have anything more for Dr. Engel?
Mark: Not really. I just want to express my gratitude for your taking the time to come and talk with us today. It's really been a wonderful experience reading the book and talking with you.
Jonathan Engel: Well, I have to tell you, I've learned a fair amount today, and it does make me think if I come out with a second edition, I'd like to sit down with both of you and particularly with you, Mark, because maybe I'd like to structure a chapter called "Post-Cognitive Therapy," because I really do feel like I perhaps missed a piece of the story here in the last 10 years.
David: Wonderful, thank you both. Dr. Jonathan Engel, you've been very generous with your time, thanks so much for being our guest today on Wise Counsel.
Jonathan Engel: Good, a pleasure.
David: I hope you found this interview with Dr. Jonathan Engel to be informative. I was glad for the additional perspective that my colleague, Dr. Mark Dombeck, brought to our discussion. We could have gone on for quite a bit longer, inasmuch as there were other historical developments covered in the book that we just didn't have time to go over in the interview. I can recommend the book to you if you're interested in getting a broad historical overview of psychotherapy in this country, or at least Dr. Engel's take on it.
You've been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today's show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the Mentalhelp.net home page.
If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at shrinkrapradio.com. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.