The phrase “It’s just about how you look at it.” holds a special place in the psychotherapy profession and is expressed in many forms to convey that all problems can be dealt with in a short period of time if only they can be perceived and rationalised differently.
There is a hustle culture in the mental health profession. It presents a panacea of the modern era mental health healing through the ‘quick-fix’ system of care that focuses on structured and timely management of symptoms. Famously dominated by (but not limited to) the umbrella of cognitive and behavioural therapies, this outlook not only assures relief against every diagnosable condition mentioned in nomenclatures such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) but also claims a strange prestige over other modalities of psychotherapy.
The ‘quick fix’ model of mental healthcare is hailed as a revolution of our times for its speedy delivery of intervention-based, energetic work and measurable results. Its philosophy offers a problematic promise of ‘cure’ by correcting behavioural ‘dysfunctions’ and reinstating the ‘deviant’ person back into society.
This is a golden egg for mental health marketing and manualised, structured therapies have promised only a surge in profits by offering a ‘package system’ of fleeting and pre-decided number of therapy sessions. Consequently, as many critics suggest, not only has this blanketed the authentic nature of psychotherapy by disregarding the complexity of healing processes but also fogged the importance of therapeutic relationships and the diverse factors which characterise individual psychologies.
Critiquing the theory of therapies such as Cognitive Behavioural Therapy (CBT) or the Rational Emotive Behaviour Therapy (REBT) is not in the scope of this article. There is an abundance of such criticism ranging from Aaron Beck’s foundational errors to Albert Ellis’s notorious manner of confronting in therapy. The scope is rather to challenge the institutionalisation and over-idealisation of these approaches as “one-size-fits-all” and how they contaminate the perception of distress. Where did it all begin? How did we arrive at this fast-paced world of squeezed ‘packages’ of sessions, and more importantly, is there still hope?
‘Quick fix’ as an ideology
What Irvin Yalom calls the ‘managed-care movement’, did not emerge out of the blue. It breathes a specific ideology that accounts for its widespread distribution of a conservative view of psychology. The foundation of behaviourist and cognitivist schools was more of a reaction to the thesis of psychoanalytic thought asserting that the human psyche is not so submerged and synthesized after all; it’s observable, repairable and measurable in less time through speedy changes.
The notion of hyper-rationality operates behind these methods which received global popularity during their emergence in 19650s. It posits that mental health problems are not as complex as they seem. They can be attributed to faulty thinking resulting in behavioural consequences that further corrupt the self-concept of the person. If the person could be assisted in grasping and altering these ‘dysfunctional thoughts & beliefs’ and adapt a rationalising attitude towards life, they can be free of ‘negativity’.
This transformed academic and public perceptions about mental health by shifting emphasis from distress embodied in a diverse set of interpersonal and socio-cultural roots to the surface of an individual’s perception about the self and their place in the world. Every anxiety is worthy of being challenged to an introspective debate of what it says about us. The keyword here is ‘control’ and the message is that healing is futile if one can’t control everything that one thinks and does and the goal is to be ‘happy’ and ‘productive’.
The over-hype of quick-fix ideology places a unique pressure of ‘cure’ on the person by offering an oversimplified dichotomy of survival (you either reclaim control or suffering is likely). This, of course, mirrors the ‘either/or’ lens of the current diagnostic guidelines (you either have a disorder or you don’t). Hence, it was evident that such psychotherapies become the favourite of the biomedical model and were clubbed alongside medication being the only treatments which can pass the “scientific” test. But this is where things get tricky.
Questioning the ‘evidence’ in ‘evidence-based’
The rise in advertising of such modalities depended on a public dismissal of depth approaches such as psychoanalytic, existential or humanistic therapies which were thought to have lost a questionable race for an obscure trophy: ‘evidence’. The preoccupation with evidence-based treatments became a badge of honour for many psychotherapists without anyone questioning what this evidence actually stands for.
The efficacy of short-term, manualised therapies depends upon the onus of ‘outcome research’ which requires asking people through screening questionnaires if they felt better after a number of sessions compared to people who usually receive no treatments at all.
But as efficient as such a methodology is to test medical treatments, the same doesn’t work for psychotherapy because the latter is highly complex and subjective in its experience. For therapies that are labelled as ‘evidence-based’ treatments, ‘evidence’ only includes effects that can be quantified through rigorous statistics based on symptom-relief.
This only recently raised eyebrows as many professionals from all backgrounds started to question the uninformed fixation over empirical research in psychotherapy. One paper quotes, “If we merely correlate the patient’s values or preferences with pure scientific facts, we will stand deprived of the possibility of engaging in a genuine ethical dialogue between the ethos of the respective psychotherapy schools and the patient values”.
“I do not know why anybody is interested in ‘evidence’ at all,” says psychoanalyst, Adam Phillips, in an interview, “It doesn’t mean it’s irrelevant whether it works, but I think the criteria for what it is for it to work are very singular and individual.” This has been validated by many studies constantly showing why it is never the tools and techniques but non-specific factors such as therapeutic alliance, genuineness and empathy that facilitate change and healing.
With more than a thousand outcome studies, CBT became the “only scientific treatment” for depression and later extended this claim to most ‘conditions’. These assertions failed as many people could benefit only for a short period of time until their problems re-emerged. Many studies, such as these, refute the very claims over which ‘evidence-based therapies’ were established. In contrast, long-term effects, using the very same methodology, were noted within large populations who worked with depth therapies.
It’s important to note here that these findings don’t “expose” CBT or other therapies as a failure. They rather show that the obsession with a strictly objective methodology to “measure” an interaction which is very intimate, interpersonal and influenced by social and cultural subjectivity, will backfire. This may not have changed therapy, but it definitely changed the persona of a therapist.
Decoding the notion of “evidence” in evidence-based therapies, psychologist Jonathan Shedler writes, “‘Relevant scientific evidence’ no longer matters, because proponents of so-called evidence-based therapies ignore evidence for therapy that is not pre-scripted, manualised therapy.” He further argues, “‘Clinical judgment’ also no longer matters because clinicians are expected to follow manuals rather than exercise meaningful clinical judgment. They are being asked to function as technicians, not clinicians.”
What are we missing out on?
“We are so much more than sources of evidence or collections of symptoms to be managed,” writes psychotherapist, Linda Michaels, in a long essay over the importance of depth psychotherapies which suffered a serious ignorance in the last century and continue to do so. This is also due to time-bound rapid treatments being favoured by capitalist economies which demand brisk profits over less time putting a criterion to wellbeing that is all about being functional.
But time itself creates pressure and urgency for results as shown by research analysing the effect of time in psychotherapies. What else do we miss out on when we discuss the kind of work often lost in this hustle culture?
“Visible symptoms are not the whole truth, they signal a deeper suffering,” says Sumaiya Baba, a psychodynamic psychotherapist from Kolkata addressing the importance of looking beyond symptoms. “When we fail to address and acknowledge this in psychotherapy, we risk estranging our own self and repeat patterns of suffering. While behavioural or cognitive techniques teach us sophisticated coping strategies to deal with the day to day hassles, or to control our anxiety, if we avoid accessing the underlying feelings like anger and fear, we’ll constantly be afraid of a psychological eruption.”
Quick fix systems do not give much consideration to the fact that healing is a prolonged intersectional process which takes place in a sociopolitical microcosm. “In my experience, psychoanalytic work also takes into account the impact of our socio-economic and cultural identities. The one-size-fits-all approach can be terribly discriminative particularly in a society like India with several social margins,” Sumaiya adds.
Contemporary textbooks in psychology and psychiatry continue to omit such nuances citing evidence-based therapies as the first line of ‘treatment that works’. “Young therapists such as myself are prone to feeling lost and vulnerable. The urge to quickly master techniques and uniformly impose them across the human personality somewhere results from this vulnerability. There is a mutual resistance to come closer to the complex, incoherent and messy human psyche which deserves to be felt, known and expressed in a safe environment.”
Knowledge, expertise, privilege and power are also vital components of depth approaches. Sumaiya explains, “Depth psychotherapy works with the relational model wherein the professional is not the all-knowing, omnipotent therapist but a collaborator in the journey. We aren’t distant or neutral but take into account our own feelings and responses towards the patient to better understand this alliance and in turn the other person in the room.”
“The therapist must strive to create a new therapy for each patient,” Yalom writes in his acclaimed text, Gift of Therapy, stressing over the loss of spontaneity in psychotherapy by the overuse of manualised therapies. This also extends to the significance of inclusivity within therapeutic work where not only clients’ background forms the essence of the relationship but so does their tendency to narrate stories and draw meanings from them.
This is not to say that therapies such as CBT or REBT aren’t efficient in their own way or the professionals who make use of them do not care about their clients. It is to argue that claiming their framework to colonise all forms of suffering may not be in anyone’s interest nor does undermining other forms of therapy that differentiate in philosophy.
The difficulty in long-term work falls parallel to issues of accessibility and affordability especially in colonised countries but it is also essential for every approach to undergo a contextual adaptation through which it becomes attuned to the community’s cultural and political lives. The decolonization of psychoanalytic thinking in India and other non-European countries are hopeful examples.
In the rush to mitigate symptoms, we seem to have ignored the stories embodied in them. If we continue to impose manualised approaches and their theories as the only possible explanation of human psyche, we might anticipate a scary future for mental healthcare which psychotherapist, Nancy McWilliams articulated well in a lecture, “I worry that the tendency to treat a symptom as a thing in itself rather than a part of a person’s complex and unique individuality may reproduce a generation of therapists whose main response to suffering will be, ‘there is a manual for that’.”
Prateek is a mental health activist and writer pursuing a masters degree in clinical psychology. His work covers an intersection of mental health and psychiatry with sociopolitical issues and human rights.