“This modest and inconspicuous doctor published a 2018 guide for lay people, describing simple methods for helping people with mental health problems, entitled Where There Is No Psychiatrist.”
patent No. 5231:n 1847, the United States Patent Office registered the invention of a rocking chair with a fan. The inventor, Charles Horst, placed a traditional rocking chair on a solid base, equipped it with a massive arm and, using a complicated mechanism of levers and gears, transferred the energy of the chair to a fan placed above the head of the person using it. People, however, did not regard this impressive invention as particularly useful. Perhaps it did not seem that the work of fanning oneself was excessively burdensome; maybe would-be customers concluded that the level of complexity of the invention in relation to its benefits was absurd. As such, rocking chairs with fans never became a fixture in our homes. Common sense protects us quite effectively from being surrounded by similar gadgets. However, this does not always extend to other realms of life.
Common Sense and a Healthy Psyche?
An area where common sense is particularly difficult to harness is when it comes to our mental well-being. The emotions that seem to dominate our reason (the incomprehensible impulses to which we succumb) and the amazing qualities of the mind still make our own psyche seem mysterious and impenetrable. In trying to understand ourselves, we fall prey particularly easily to suggestive narratives, and we are often persuaded to perform actions that differ little from rocking in an armchair in order to cool our faces with a fan. Today, there are well over 600 different psychotherapeutic modalities available on the market, often offering completely different ways of understanding the psyche and treating mental illnesses and disorders. Many are extremely complex and are akin to washing one’s hair with a 24-finger robot controlled by a microprocessor.
The absurdities which have become established in the sphere of mental health and traditional psychotherapy can be seen through the prism of simple but unconventional actions which are taken and the effects that they have. An interesting example of this is the work of Vikram Patel, an Indian psychiatrist who is revolutionizing the treatment of mental illness. Patel spent two years in Zimbabwe, a country where only ten psychiatrists at the time were working to treat a handful of wealthy patients. During this same period, only one or two psychiatrists were working in Afghanistan, Rwanda, Chad, Eritrea, and Liberia. It is estimated that even in Western European countries, only half of the population has access to professional mental health services. Meanwhile, the number of patients with mental health problems in the poorest areas of the globe was (and still is) overwhelming, even though some once mistakenly believed that depression and some other mental illnesses only existed in wealthy communities.
Patel, like a veritable David bravely facing the power of Goliath, decided to change this state of affairs. His logic was totally different from the reasoning of the inventor of the rocking chair with a fan; Patel recognized that if there were uncomplicated, effective, and inexpensive methods of psychiatric help which could be provided by less highly-trained people, then they should be identified and taught to primary healthcare and social workers. This modest and inconspicuous doctor published a 2018 guide for lay people, describing simple methods for helping people with mental health problems, entitled Where There Is No Psychiatrist. Initially used in the poorest regions of the world and then translated into several languages, it is now available free of charge in over 70 countries.
Patel did not stop at the textbook. He created a system and methods of training ordinary people to help the mentally ill, and, crucial for our consideration, he conducted systematic research on the effectiveness of such assistance. His work, published in the most renowned medical journals such as The Lancet, has led to several unambiguous findings. First, less-specialized professionals, such as social workers and counsellors, can be equipped with the essential skills to help people with mental health problems. Second, the content of such interventions should be relatively simple, short, and manageable in a routine healthcare setting. And, finally, these methods of assistance are universally applicable and are not culturally-specific.
The Endangered Psy-complex
Patel’s publications did not only give him recognition around the world; they also brought him many enemies. His work undermined the position of psy-complex representatives, the supreme, unquestioned experts on mental suffering—and also its greatest beneficiaries. When it turned out that primary care workers can achieve the same—or even significantly better—results than highly-trained specialists in many interventions, the psychotherapeutic establishment was hardly pleased. However, this did not stop Patel. In his opinion, there is great potential for reforming the architecture of the mental healthcare system. For most people with mental health problems, the first level of care should not be a hospital or clinic but, rather, his or her own apartment and a primary care health professional.
Patel emphasizes that many psychiatric practices, such as long-term psychoanalysis or regressive therapy, lack evidence and scientific basis: “Typically, such practices are offered only by private practitioners, who have completed a course somewhere and charge huge amounts of money. To me, these are people who are preying on vulnerable people with mental health problems, and I think we should reject this kind of charlatan practice.” He continues: “Part of the problem is that mental health care systems are so weak everywhere that it offers a much larger space for charlatans with no scientific base to establish a foothold. You would never see this, for example, in cancer therapeutics, and that really is a reflection of how weak evidence based mental health care is in most parts of the world.”
The Efficiency of Laymen
One of the first comparisons, which yielded somewhat shocking results for professional therapists, showed that, in reality, these therapists do not have any unique skills when compared to ordinary people with minimal knowledge and goodwill. Meta-analysis revealed, similarly, that differences in results obtained between experienced and inexperienced therapists are far less than most would expect. Another meta-analysis demonstrates a similar lack of differences in effectiveness for certain age groups. The same study shows that professionals, non-professionals (trained with professional methods), and students (in their later years of studies) achieved similar effects when providing therapy to children and adolescents. Subsequent studies bore even worse news for professional therapists. Not only was there no relationship between the therapist’s experience and education and the outcome of the therapy, in some cases, paraprofessionals were even better perceived by patients than professionals.
The results of a 1995 review of all previous studies comparing the skills of amateurs, semi-professionals (e.g. trained volunteer therapists), and professionals can be described as devastating. Amateurs—without training or supervision—were able to induce the desired changes in patients’ behavior on a par with professionals.
Furthermore, a recently published first systematic review of research and a meta-analysis of changes in the biological markers among psychotherapeutic patients suffering from depression showed that—contrary to popular belief—psychotherapy has little or no effect on the patient’s biology. Published in December 2020 in the prestigious Psychological Bulletin, an extensive meta-analysis of 1,125 research studies conducted over the past 50 years, which examined the efficacy of various methods of helping self-harmers and potential suicides, showed that the effectiveness of all tested methods is very low, and that their effects do not persist for very long following intervention. Moreover, there are no significant differences between the different methods; for example, long-term and expensive psychodynamic psychotherapy is as ineffective as cheap and swift peer intervention. Most striking, however, is the discovery that the effectiveness of these methods today is as low as it was 50 years ago. Half a century of research and improvement in methods has not even taken us one step further.
Why, then, with simple, effective and cheap solutions at our fingertips, do we persist in cultivating complex, costly, and inefficient methods that resemble the bizarre inventions described earlier? The first reason has already been pointed out by Vikram Patel; there are many people who derive significant material benefits from these methods and owe their social position and status to them. Equally important, however, is a belief in collective common sense and the conviction that an invisible hand in the market effectively removes unfavorable and ineffective solutions. After all, the visibly bizarre nature of the electronic cat stroker dissuades us from buying it, so why would we not see the absurdity of the psychotherapy offered to us? The answer is quite simple: It is because we do not have enough data and knowledge. The belief that early childhood experiences determine most of our problems as adults may sound convincing; however, in light of research results, it is even more absurd than periscopic glasses designed for people of short stature. Here, common sense is not enough—just as it is not enough in analyzing microbes or in evaluating the effectiveness of vaccines.
Evidence-based practices, which are gaining in popularity, have foundations built on empirical data. Unfortunately, these foundations often elude common sense. Still, their popularity has brought about an approach that imitates evidence-based practice. Psychotherapy is no exception. Its supporters, when gathering powerful evidence to use in marketing their services, most often ignore studies showing the negative effects of psychotherapy. They very often sidestep an obligation to declare conflicts of interest, and detailed analyses show that only a small part of the research used in the propaganda surrounding therapeutic culture has any kind of value. On the other hand, solemn declarations of the efficacy of psychotherapy are routinely made by the professional groups that benefit from its continued existence.
Horst’s rocking chair surely works. It is not a perpetual motion scam, and it cannot be accused of lacking a certain functionality. Similarly, many therapeutic schools are not entirely ineffective. However, it is worth making an analogy: If car mechanics in Town A make engine valve adjustments through the exhaust pipe, it takes them two weeks and costs quite a lot, but this does not mean they are not able to do it. But if the mechanics in neighboring Town B unscrew the cylinder head cover and adjust the valves in half an hour and for one-tenth of the sum demanded by the mechanics in Town A, then convincing customers of the superiority of regulating valves through the exhaust pipe cannot be justified.
While using a rocking chair with a fan or servicing a car engine through the exhaust system may be harmless quirks with minor consequences, playing with bizarre psychotherapies does not always end innocently. A few studies on the negative effects of inappropriate psychotherapy show that at least 10% of patients experience them, with 5% considering them as permanent negative effects. The most common negative effects are a deterioration in the patient’s condition and the aggravation of symptoms with which they presented for therapy. We should also include negative personality changes, such as increased neuroticism, increased chronic stress and depression, and decreased self-esteem and conscientiousness. As a result of psychotherapy, the consumption of alcohol and other psychoactive substances may increase, feelings of helplessness may be heightened, and anxiety and anger may intensify. Moreover, functioning as part of a family and social environment may deteriorate, and, in extreme cases, psychotherapy may even lead to suicide. Interestingly, many psychotherapists are not aware of the possible occurrence of such effects and do not inform their patients about them, being themselves convinced that psychotherapy is merely—at worst—a harmless conversation.
Therapeutic culture boasts about a position which until recently could only be enjoyed in our communities by priests who have persuaded us to suspend our rational judgments regarding their activities. But would one ever think of taking the views of a meat producer on a vegetarian diet seriously? And how would one relate to the opinion of a petrol station owner on the subject of electric cars? We generally are suspicious of pharmaceutical companies that try to sell us their products. Perhaps we should bring this same circumspection to the claims offered by therapists.
Caveat Emptor! Buyer Beware!
This ancient and widely accepted principle, which is understood by almost every seller and buyer, has governed our economic relations for centuries. According to this principle, we have a certain distrust of those who want to sell us something. They, in turn, go to the trouble of gaining our trust. And yet we make far-reaching exceptions for certain retailers and service providers. Among these exceptions, the representatives of the psy-complex occupy a prominent place. They fill the covers and interiors of magazines, weeklies, and even the daily press. It is their gentle, warm voice in radio broadcasts that scares us with warnings about the consequences of “unprocessed” childhood trauma. Their faces, full of care, appear on our television screens, arousing anxiety among workaholics and those who are victims of procrastination, those who are sexually overactive and those who are frigid with fear, while simultaneously reaching out a helping hand and offering a solution. It is a great success—not only commercially but also for the culture of psychotherapy. It serves its representatives unconditionally but not always the patients.
We live in the time of the blossoming and domination of therapeutic culture. Many appreciate it, while others warn against its oppressive nature. Regardless of which group to which we belong, more than once in our lives, we will meet this culture’s invitations to participate. When accepting these invitations and sitting in one of the hundreds of bizarre armchairs offered by psychotherapists, or lying on a fanciful therapeutic couch, it is worth asking ourselves if we know what purpose they were designed for. Maybe we never needed their services to begin with—and only required an ordinary chair where we could sit down, take a rest, and have a talk.
Tomasz Witkowski is a psychologist and author. His latest book, which was published last year, is Shaping Psychology: Perspectives on Legacy, Controversy and the Future of the Field.