The Dismantlement of Psychotherapy
Saving Talk Therapy
by Enrico Gnaulati, Ph.D.
A Review by Pam Munter
Enrico Gnaulati is on a mission. In Saving Talk Therapy (Beacon Press, 2018), the California-based clinical psychologist presents a persuasive case for the importance of psychotherapy, not only to the individual, but to society as a whole. Due to escalating economic pressures and the rise of the ADD culture, traditional psychotherapy has been in gradual decline for the past 40 years. He writes, “Nowadays, people don’t ‘go into therapy’…they ‘receive mental health interventions.’” Regardless of the severity of the problem, time with a psychologist or psychiatrist is often just a session or two, thanks to domination by the powerful insurance companies that control reimbursement.
Gnaulati begins his treatise with a history, starting with Freud, of course. Psychoanalysis is not the same as psychotherapy, the former based on an exploration of unconscious forces. The patient reclines on a couch and free associates, the process often taking years. But after World War II, the critical demand for mental health services required a rethinking of this inefficient and often expensive intervention. Along came clinical psychologists such as Carl Rogers, who advocated a client-based process, the cornerstone of which was interaction. The underlying principle was that the client was fully capable of solving his own problems with the help of the therapist using “unconditional positive regard” to support the client’s genuine self. It was more egalitarian, the doctor and the client in face-to-face discussions. Others spread the humanistic precepts through existential assumptions—that the client (not the “patient” as characterized in psychoanalysis) needs to be an active participant in her own growth, that she is responsible for making choices, that the primary goal of therapy is to help the client live a more authentic life. In this approach, the client works in partnership with the therapist to discover what really matters to him.
There have been numerous studies suggesting that persons not receiving psychotherapy are twice as likely to visit a physician’s office for no clear-cut medical reason. Some even conclude that up to 60% of visits are for psychological reasons alone.
At one time, the government recognized the value of this process. Congress enacted freedom-of-choice legislation that mandated mental health treatment on a parity with medical coverage. It brought what was once an elite process to almost everyone. But as disbursements rose, the health maintenance organizations (HMOs) arrived on the scene. While controlling costs, it limited access. Now, the therapist had reams of paperwork along with the uncomfortable ethical bind of violating the client’s privacy. Authorizations were truncated, made by clerks in another state. No longer was therapy over when the client recovered; it stopped when the HMO said it did. The author calls this “substandard treatment” and emphasizing “profits over quality care.”
According to Gnaulati, the devastating blow was dealt by the release of Prozac and its offshoots in the late 1980s. Many people who had come into therapy to rebuild their lives could now just take a pill. Instead of discovering the underpinnings of self, the focus was symptom reduction. For many, it was enough. The client felt better without making inconvenient and possibly painful changes to her life. Today, mood-altering drugs are ubiquitous, heavily marketed on television. However, not all psychological disorders are chemically based.
He acknowledges that drugs are demonstrably effective in treating psychosis. “Nevertheless, medications are massively overprescribed because the pharmaceutical industry’s profitability depends on the casual normalizing of everyday unhappiness, sadness, shyness, aggression, forgetfulness and distractibility.”
“Oddly, Americans are relying more on psychiatric drugs at a time when scientific findings and investigative news reports are calling into question their safety and effectiveness.” Many have been found to be addictive and can lead to more serious side-effects. Drugs like Prozac have been linked to a higher risk of suicide, for instance.
Changes in the practice of psychotherapy are systemic. In response to the marketplace, university clinical training programs have moved to the hard-core research-based technique known as cognitive-behavioral therapy. Conventional therapy has long defied measurement of outcomes other than the subjective report of clients. But now, he says, training programs now lack “intellectual diversity.”
Cognitive-behavioral therapy (CBT) consists of client adherence to specific goals that are behavioral in nature, e.g., “I will talk to a co-worker five times this week.” It’s agenda-driven and has little in common with traditional methods. When finished, the client has no further insight into herself, the patterns in her life or who she is but the precipitating offending thoughts have been modified. Gnaulati, however, says its limited efficacy is likely due to the therapeutic properties of the relationship, itself, the same “secret sauce” that has long been the foundation of conventional therapy.
What’s missing in cognitive-behavioral therapy is what’s essential to the process itself, he notes. A fundamental therapeutic task is to instill in the client a “psychological mindedness,” creating value on introspection and awareness. Good therapy, he tells us, requires two real people in the room, doing away with “therapeutic detachedness and professional aloofness” and the importance of injecting humor into the room.
His arguments are cogent and well-written, dissecting the many sides of this complicated phenomenon. Then Saving Talk Therapy is a good read for both lay people and the mental health professional. As with many books of this nature, he is trying to include too much in too few pages. There seem to be two books here: one is the persuasive arguments to bring the more client-friendly humanistic-existential psychotherapy back to life. The other is a discussion of what comprises good psychotherapy, including suggestions for specific approaches by the therapist. The former is of general interest but his language becomes more stilted when he moves on to therapist criteria.
Why is in-depth psychotherapy important? “A vital democracy requires authentic selves.” Psychotherapy not only confirms the essence of humanity but can help that person become a more productive contributor to society. “Psychotherapy imbued with humanistic ideals instills a capacity for empathic concern in clients who then become citizens opened up to greater caring for the emotional well-being of others.” Therapy requires a global approach, not a mere tinkering with specific behaviors, and demands an acceptance of the inherent complexity in all of us.
Gnaulati contends that we should all lament the decline of long-term, in-depth psychotherapy. It’s a rewarding experience for those who undergo the process, transformative in the best sense of the word.
Pam Munter has authored several books including When Teens Were Keen: Freddie Stewart and The Teen Agers of Monogram (Nicholas Lawrence Press, 2005) and Almost Famous: In and Out of Show Biz (Westgate Press, 1986) and has been a contributor to many others. She’s a retired clinical psychologist, former performer and film historian. Her essays and short stories have appeared in over 70 publications. She has an MFA in Creative Writing and Writing for the Performing Arts and is a Pushcart Prize nominee. Her memoir, As Alone As I Want To Be will be published by Adelaide in October.