The profession of psychotherapy may soon find itself on the couch in the role of patient, facing the federal government as its analyst.
In three separate actions, the government has begun to ask the most fundamental question about psychotherapy in its many forms. Does it really work? And, if not, should tax dollars be paying the nation's psychiatric bills?
First and most ambitious of the tests is a Senate bill that would establish a federal commission to determine which kinds of therapies, if any, are safe, effective and appropriate for use -- the same sort of rigorous questions that federal regulations routinely ask about drugs.
Second, The National Institutes of Mental Health has embarked on a project that is enormous by past standards of research in psychotherapy -- a six-year controlled study of how well five different therapies can succeed in treating severe depression. The pilot studies in the three years are scheduled to cost $3.4 million.
Third, the Alcohol, Drug Abuse and Mental Health Administration is planning similar controlled test of its own. Gerald Klerman, director of ADAMHA and chief mental health officer of the government, said his agency will go ahead with its tests of psychotherapy even if the Senate bill fails.
If the government succeeds in testing the effectiveness of the so-called "talk therapies," it may be an intellectual as well as financial turning point for the 100-year-old profession. As Nicholas Cummings, past president of the American Psychological Association, said it is possible that long-venerated practices such as Freudian psychoanalysis, ancestor of all modern therapies, may be found useless under scrutiny.
The government's interest in testing psychotherapy began when, in late 1978, the Senate Financing Committee held hearings to try to determine how much to pay for psychotherapy under Medicare and Medicaid.
Those hearings surprised senators, staffers and committee workers because witnesses from within the profession itself came forward to testify that no public support of psychotherapy is justified. The evidence for psychotherapy is confused and scientifically unsound, expert witnesses said, and does not show which therapies work and which don't. There is little or no information, for instance, that would allow the govermnent to chose between Freudian analysis and "primal scream" therapy.
"I believe that the scientific evidence for psychotherapy cannot justify support of it," testified Donald Klein, head of the New York Psychiatric Institute.
NIMH reported on how well 600 Community Mental Health Centers around the country are doing: "Unfortunately, the effects . . . upon the emotional well-being of their clients and their communities are not known at this time. Questons about the effectiveness of basic mental health treatment tools such as psychotherapy remain unresolved."
The Senate committee also heard quoted comments from a number of eminent psychiatrists including Jerome Frank of John Hopkins, Hans Strup of vanderbilt, Norman Brill of UCLA and Lester Luborsky of the University of Pennsylvania. All questioned the scientific basis of psychotherapy.
Some critics warn that blanket federal coverage could result in public dollars paying for some of the more controversial of the 250 therapies now available -- such as the "hot tub," where shoals of nude men and women talk out their troubles in a great wooden bath, or "rage therapy" in which physical assaults are directed at a extremely shy person to provoke a "healthy" outburst, or "sex surrogate therapy" where patients pay for sexual services, under the psychotherapist's aegis.
"When you get into the touchie-feelie kinds of therapies," said Donald Langsley, president of the American Psychiatric Association, "you have an awful hard time distinguishing between things that are for the patient's benefit, and things that are for the therapist's benefit . . ."
Psychotherapy is now a $2 billion-a-year business in America, but since it hasn't been recognized by insurance companies and many doctors as a "medical" discipline, insurance coverage is still spotty.
Medicare for the elderly fully covers only the work of psychiatrists whose patients are hospitalized; work outside the hospital is reimbursed only up to $250 per patient per year.
Rates charged by psychiatrists around the nation vary from $45 to $75 per hour, while psychologists charge, on the average, about $10 less.
Treatment by psychologists, who by definition have no medical degree, is not covered under Medicare unless ordered and supervised by a doctor.
Medicaid coverage for the poor is determined by the states, and varies widely. Health insurance for government employes, on the other hand, fully covers psychiatric treatment.
The Senate hearings opened the door on a rancorous backroom debate that has been going on among therapists themselves for decades. After the hearings, the Finance Committee tabled the Medicare coverage question and, instead began to draft legislation to put psychotherapy itself to the test. That bill was introduced last month by Sens. Spark Matsunaga and Daniel Inouye, Hawaii Democrats.
The committee's chief health counsel, Jay Constantine, wrote to Klerman of ADAMHA:
"Based upon evaluations of the literature and testimony, it appears clear to us that there are virtually no controlled clinical studies, conducted in accordance with generally accepted scientific principles, which confirm the efficacy, safety, and appropriateness of psychotherapy as it is conducted today. . . .
"Out concern is that, without the validation of psychotherapy . . . and in view of the infinite demand which might result [from wide Medicare coverage], we could be confronted with the tremendous costs, confusion and inappropriate care."
Over three decades, about 700 studies have evaluated the worth of psychotherapy and a majority of the results were positive. But, as the Senate committee learned, even psychotherapy's staunchest allies find that most of the studies were full of holes.
More that 250 therapies have sprung up like mushrooms in this lack of critical light. Morris Parloff, NIMH's chief specialist in psychotherapy research, has said, "No form, of therapy has ever been initiated without a claim that it has unique therapeutic advantages. And no form of therapy has ever been abandoned because of its failure to live up to these claims."
Among the 700 studies, most were small and uncontrolled without a comparsion group, and often accepted, as evidence the simple report of a patient that he feels better. Many even accepted the therapist's assessment of whether a patient had been helped.
Langsley of the American Psychiatric Association says there are enough positive, controlled studies among the 700 to demonstrate that psychotherapy works.
"But," he adds, "now the problem is specificity. What for what? That is the question. What kind of therapy should be used for what kinds of illness, and who can do that therapy well? We must try to answer these questions."
Parloff of NIMH says: "The question 'Does psychotherapy work?' is a dumb question for which I have a dumb answer. Yes, we now have evidence from controlled studies that show psychotherapy is better than nothing.
"But this means almost nothing. What therapy works for what problem? What's the best treatment for schizophrenia, depression you name it? We don't know.'
In a recent review of the studies, Parloff noted a number of what he called "puzzling" conclusions:
That different forms of therapy made no difference in effect. All the schools of therapy seemed to give the same results.
That the length of treatment didn't seem to matter. Short and long treatments had the same effect.
That the amount of experience a therapist has did not seem to matter. Different levels of experience produced the same effects.
In addition, Parloff noted that psychotherapy now is heavily preoccupied with treatment of the mildest difficulties -- everyday anxiety and depression as opposed to the severe disorders, which now are usually treated with drugs.
Klein of the New York Phychiatric Institute, one of the most outspoken critics, believes that the demonstrated benefits of psychotherapy may come from something very simple -- something that could be supplied just as well by ex-patients or preachers or friends as by those who have degrees in psychology: Friends support to overcome "demoralization."
"No matter what a patient's illness," Klein said, "when he gains an ally who is understanding, who is supportive, who is projecting hope, then that kind of anti-demoralization is effective."
Another critic within the profession is well-known author Thomas Szasz, who wrote "The Myth of Mental Illness."
"Phychotherapy," Szasz said, "is simply a name we give to two people talking to each other. It's like 'holy' water -- it's just water. It doesn't exist unless you believe in it, 'Kosher' pickles -- they are only pickles.
"If psychotherapy is only two people talking together, why doesn't the government fund two friends who help each other by talk?"
Szasz feels that the origin and character of psychotherapy is essentially religious, something like a Jewish-born form of the Catholic confessional.
"I think psychotherapy may be helpful in the same way that prayer is helpful," Szasz said. "And obviously people have been going to church and coming out feeling better for a long time.
"People do find it helpful, but that is simply because anything and everything is helpful in getting through life. People find it helpful to get married, and people find it helpful to get divorced. They find it helpful to go on vacation, and find it helpful to come home. And drinking. Smoking. Then look at how much people get out of not drinking and smoking!
"This is the whole point -- you have to believe. It is just the same as a religious intervention. It is the believing that brings help."
Rumblings of skepticism in the profession began as far back as 1952, when Hans Eysenck at the University of London reviewed some 7,200 cases in 19 different studies, comparing patients who had received therapy to those who were on waiting lists and had received no therapy or drugs. Sixty-four percent of those who got therapy showed some improvement. But 72 percent of those who got no treatment showed improvement.
That bombshell has been followed over the years by many more. Jerome Frank of Johns Hopkins tested psychotherapy against sugar-pill placebos. To one group of patients he gave a pill, calling it "a new pill not yet on the market." To the others, he gave psychotherapy. Then a "discomfort index" measured the patients' level of ansiety and the like.
The placebo-takers quickly dropped from a starting point of 35 on the "discomfort index" to 15. After three years their anxieties rose gradually to 25. The patinets on psychotherapy started at a level of 40 on the index, and over a five-year period slowly dropped to 25. In other words, not much difference.
Another negative study, carried out by Hans Krupp at Vanderbilt, asked medical schools in Nashville to choose their best psychotherapists and asked Vanderbilt to choose their best-liked humanities professors. The psychotherapsts treated 15 patients and the English, philosophy and other professors counseled 15 patients.
Strupp found that the popular professors performed as well -- as the respected psychotherapists -- the improvement in both sets of 15 patients was about equal.
Perhaps the final indignity was a five-year study at the All-India Mental Health Center in Bangalore. The center put patients randomly into two groups -- those to be treated by Westtern-trained therapists and those to be treated by the native Ayurvedic healers.
The native healers produced improvement or partial improvement in 90 percent of their cases. The success rate for the psychotherapists was identical.
The only difference between the two was that the witch doctors sent their patients home a little sooner.
The negative studies have haunted the profession for years, and helped on the government action. Two other important factors were the introduction of psychoactive drugs in 1955, and the push by the professon to get insurance coverage.
The drugs, such as lithium carbonate, dopamine, and the tricyclic anti-depressant, worked an instant change in the treatment of mental illness in America. In the first controlled studies of any kind in the profession, the drugs were shown very effective in relieving the symptoms of even severe illness.
Within a few years, the drugs were able to reduce the population of U.S. mental hospitals from 560,000 to less than 200,000 even though the incidence of illness stayed stable. The effectiveness of the drugs became a standard for "talk therapists" to measure up to.
The major factor in government action has been the profession's drive to get public and private health insurance to pay for psychological treatment. Insurance companies have been reluctant to go along, largely because of the ill-defined nature of psychological illness and treatment.
As Blue Cross spokesman Ray Freson put it, "With psychotherapy, the problem is that the psychiatrists can't specify the problem, or the likely outcome, and can't give a good description of the method in between, either."
Notwithstanding the debate, the psychotherapy business is booming.There are now more than 50,000 practicing psychologists and 30,000 psychiatrists in America, treating 5 to 10 percent of the entire adult population.
If the government succeeds in its plans to test the results, the entire art and industry of therapy will likely be altered.