David:Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
On today's show we'll be talking about the history of psychotherapy in the United States with Dr. Jonathan Engel. Jonathan Engel holds a Ph.D. in the history of science and medicine from Yale, and has written extensively about the historical development of U.S. medicine and health policy. Most recently, he's authored the 2008 book, American Psychotherapy: the Rise of Psychotherapy in the United States. His previous books are Doctors and Reformers, Discussion of Health Policy 1925 - 1950, Poor Peoples Medicine: American Charity Care Since 1965, and The Epidemic: A Global History of AIDS. He's a professor of health care policy and management at Baruch College in New York City. I'm joined on the call by Dr. Mark Dombeck, one of the creators of Mentalhelp.net and Wise Counsel editor. Now, here's the interview.
David: Dr. Jonathan Engel, welcome to the Wise Counsel podcast.
Jonathan Engel: Thank you, nice to be here.
David: First of all, I want to congratulate you on your book American Therapy, which is about the rise of psychotherapy in the United States, and I can only imagine what a huge job it must have been to take on a project of this magnitude, and that it wouldn't have been easy to decide what to focus on and what to leave out.
Jonathan Engel: Yes, I've written a bunch of books now and for this book I had the largest rate of shrinkage from material to finished product. And what do I mean by that? When I research a book, I collect an enormous amount of material, hundreds and hundreds of pages xeroxed from various archival sources, and old journal articles, and chapters of books that I want to reference. And for this project I had almost 40 or 50% more material than I'd ever collected before, just milk crates full of it. For example, my bibliography; if you take a look, I've gone through something like 300 books, it was just absurd. And then when I started to write, it shrunk down; I might have hundreds of pages of material that would turn into three pages of written manuscript, and I'd never had this before.
And what I realized was going on was that first of all, therapists and psychiatrists and psychologists like to write, so everyone who's ever seen six patients decides that they have some brilliantly unique insight and they decide to write a book about it. So there's huge numbers of books out there that are really not particularly original.
But second of all, is that remember what historians do is they to look at change over time, that's what makes history interesting. It's not that there was stasis -- that's why you can summarize the entire Ming dynasty, which lasted for 600 years, in two pages because nothing really changed. So historians are very interested in when things change, and when you look at psychotherapy, in many ways, not so much changed. Huge numbers of people have written, but when you really began to get some perspective, over the last 100 years there were really only three or four major developments worth talking about -- maybe five if you have to start counting the drugs, which isn't really part of psychotherapy. There was less there than met the eye. So while there was a mountain of research to do, when you really started trying to create a story out of it, the story was simpler than you would have thought.
David: Well, that's interesting. I need to quickly mention here that I also have Dr. Mark Dombeck on the line with us, who I've invited to be my co-interviewer. And like myself, Mark is also trained as a clinical psychologist; moreover, he's one of the creators of Mentalhelp.net, the site where this interview will appear, and given his role of developing content for Mentalhelp.net, I think he has an unusually good grasp of what's going on in and around the field of psychotherapy. So I'm going to be sort of the main question asker, but I really want to invite Mark to jump in as much as he feels led to do, as I welcome the additional perspective that he can bring to our conversation. Are you there, Mark?
Mark: I am there, David, and I just wanted to thank you for letting me sit in on this and to Jonathan for participating. I really do appreciate it. Mentalhelp.net is very much a psychotherapy focused website, inasmuch as we emphasize psychotherapy whenever we can, although we're covering a broad range of things that have to do with mental health. So when David brought the possibility of this interview to my attention, I thought, yes, we should do this, absolutely.
David: Great, okay Jonathan, perhaps we can start with you giving our listening audience a bit about your background. I have the impression that you're not a psychologist yourself, but that your training is in the history and philosophy of science. Do I have that right?
Jonathan Engel: That's right, yes; I'm really a historian, that's exactly it. So my Ph.D. is in history of medicine and the life sciences, and actually my undergraduate degree was also in the history of science; I've always done it. So I have a lot of natural science in my background; I took a lot of semesters of biology and biochemistry, but I'm really trained as an historian. And then, to make matters slightly more complicated, I actually have an outside MBA in health policy and management, and my teaching career has actually always been management students. The students I teach are all doing either a master's in public administration or a master's in health care administration. But I've always written history; it's the way I tend to think about the world, it's the way I make sense of the world is how things have changed and developed over time. And it's the way I tend to make sense of other people, too. It's a little bit, I suppose, like a therapist, I'm interested in their stories and how people's own lives have played out.
David: Oh, yes, you could have been a therapist with that kind of interest. And I believe you've written other books that examine broad social issues, for example you did a history of AIDS, a history of charities in the US and so on.
Jonathan Engel: That's right, so usually almost always around health and health care, the history of health policy, history of social welfare, that kind of stuff. Right now I'm writing a big book on the history of the whole U.S. health system since 1968, so everything that's happened in the last 40 years: changes in payments, changes about medical research, changes in training, the whole medical profession, foreign medical graduates, everything that has just changed. And our system has changed a great deal over the last 40 years, not to mention at least five different serious efforts to bring in some sort of national health insurance program, all of which have fallen flat on their face.
The book that most people use as kind of a broad, general introduction to the U.S. health system is called The Social Transformation of American Medicine by Paul Starr. That book, which is still sort of the bible of the field, he really finished the research for that book about 1977 and published it in 1982; and that means that almost all that material is now over 30 years old, and the world and the U.S. health system has changed profoundly in the last 30 years. To practice medicine in 1973 is very, very different than practicing medicine in 2009; and to run a hospital in 1973 is very different than running a hospital in 2009. It's just really a different world.
David: Yeah, so it really all needed an update. What drew you to write a book on psychotherapy? How did that come to be on your radar?
Jonathan Engel: You know that's an interesting question, I'm not sure what prompted it. My undergraduate thesis had been on Freud and my graduate dissertation had been on mental health policy; I looked at de-institutionalization. So I started out a little bit interested in mental health; then I departed from it for the last 15 years and I always thought I wanted to get back to it. And one of the things I realized was that there are many, many biographies of Freud out there obviously, and a huge number of people have written about psychoanalysis. But, of course, if you know anything about therapy, psychoanalysis plays only a miniscule role in delivery of therapy today. I think my statistic is, there are about 650,000 practicing psychotherapists in the country, of whom probably fewer than 250 -- that's one tenth of one percent -- are actually making a living primarily practicing orthodox psychoanalysis. Even though it looms very large in the popular mindset, the reality is that if you're looking at therapeutic modalities and venues that it essentially doesn't exist at all any more.
And then the other thing is that very little psychotherapy is actually delivered by psychiatrists today. Despite the fact that a huge number of people who focus on mental health focus on psychiatry, the reality is the vast majority of mental health care today is delivered either by psychologists or even more likely by social workers or licensed clinical social workers or even lay therapists. So if you're really interested in how people are getting their mental health, to focus on either Freud or psychiatry is only telling a teeny, teeny piece of the picture; despite the fact that both those groups -- the Freudians and the psychiatrists -- are disproportionately influential in the delivery of mental health care and psychotherapy.
But it just seemed like there was a much bigger story out there than had been told, and the story had a lot to do with social workers, and it had a lot to do with very kind of pragmatic, eclectic approaches to therapy. These days it has a lot to do with cognitive behavioral therapy and humanistic therapy; that even though it's kind of fun and sexy to study Freud, the reality is that Freud is now 110 years old -- it's been 115 years since he wrote his first book -- and he really is less and less relevant and germane to the conversation.
David: Okay, I know I have some psychoanalysts in the audience who are probably rolling; they're spinning in their chairs.
Jonathan Engel: I'm sure they are.
David: I think there's a real value in getting an outsider's view and, personally, I learned some things from reading your book even though I'm a long time insider. I think I could have benefited from reading it while in graduate school because you provide a relatively compact history or overview of the psychotherapy enterprise in this country as a social movement. For example, I got my graduate training in the mid '60s and did several years of internships in VA hospitals, and your book provides a context that I wasn't aware of at the time; mainly that World War II created a huge demand for mental health professionals, and that the VA system was given a substantial amount of money to train psychologists and to…
Jonathan Engel: I guess what I would say would be World War II gave an awareness of the huge demand; we probably had always had the demand, but I think as a nation we were unaware of the demand. And what World War II did is it really brought it to our attention.
David: And somehow I was a child of all of that.
Jonathan Engel: Where did you do your training, David?
David: University of Michigan; so a number of VA hospitals in and around Ann Arbor, Michigan. Mark, how about for you? Did you learn anything new or get a different perspective on the profession as a result of Jonathan's book?
Mark: I absolutely did. You know one of the things that has sort of shaped my view of the history of psychotherapy is that like you, David, I'm a clinical psychologist. My training was out of UCSB and San Diego State University in the early '90s. And as a clinical psychologist, you learn to think about this through the lens of your field, so as Jonathan's book is approaching this kind of outside -- certainly from a field -- but outside of a practicing therapeutic field, I found the larger contribution of the different fields that participate in psychotherapy to be really enlightening. For instance, there was a whole chapter on how the social work field had evolved and contributed to psychotherapy; and that was information I've known about but you really drew that out in the book, and I was very appreciative of that.
Jonathan Engel: Thank you. You know, what's interesting about the social workers is at the onset of clinical social work, sort of in the 1930s, there was a need to distance themselves from the psychologists and the psychiatrists; to sort of say, "Well, what we're doing is something very different here; we're not trying to compete with you." But of course, that was not really quite true; in fact, they were ultimately competing with them and ultimately, in fact, they would come to really dominate the field of therapeutic delivery.
So they would say, "Well, we look at the whole context, we put the patient in the social context." In fact, it turns out that social workers are not particularly good at placing people in a social context. If you can do some very objective studies of the way therapy is delivered, it's actually very, very hard to tell, just from observing people, what their own educational training was. In other words, if you watched a blind videotape of a social worker delivering psychotherapy and of a psychologist delivering psychotherapy, it would be very hard for you to be able to tell just from watching the therapy sessions, what kind of training background the two came from. It turns out they're really doing often very similar things.
And even worse than that, if you ask people to self identify which school of thought they use -- are they a humanist, are they a behaviorist, are they a cognitive approach, or psychodynamic -- they may say, "Oh, no; I'm very much a psychodynamic therapist. This is what I do, I really believe in these structures and these models." And then when you actually watch people and observe people behind a one-way glass or something, it turns out it's often quite hard to tell what kind of therapy they're actually practicing.
So what we know is that there are good therapists and bad therapists; what's harder to say is that there are good approaches to therapy and bad approaches to therapy.
David: Okay, this begins to get into an area that I'm really interested here. As insiders, there might be places where Mark or I would quibble with you about some of the details, but let's start off with the good news, which I think comes through most strongly in your final chapter which I think you were just talking about -- which is that psychotherapy works. This is the conclusion you came to after fairly extensive review, right?
Jonathan Engel: Oh, absolutely. I looked at a huge amount of outcomes data going all the way back to 1928, the earliest article I found, the earliest study that was done of Freudian analysis as early as 1928 in Berlin; and then really the real outcomes data starts percolating out in the late 1950s and early 1960s. And there's a great deal of consistency to these outcome studies, which is that about two thirds of people who enter therapy, for whatever range of complaints, report feeling improved -- they were self reporting, but they reported they feel better after about six months or less, so that's two thirds.
Of course, the great question is what if they hadn't gone into therapy? And the answer is that it's about one third; so about one third of people who report psychological distress of one form or another will improve over about two years. About two years later if you ask them, are you still feeling distressed, are you still feeling anxious, or dysphoria? And they'll say, no, I'm feeling better; a lot of that seems to have worked their way out. If you go into therapy, it seems to be two-thirds, so you're doubling your odds. That's the good news; the bad news is that we can't seem to get it above two-thirds, and it doesn't seem to be particularly dependant on what field of study or what methodological approach the therapist used. Although there seems to be a slightly lower success rate for orthodox Freudian analysis insofar as it's still practiced, and a slightly higher success rate for cognitive behavioral therapists who are working with anxious patients and specifically on anxiety disorders. The CBT seems to work a little better.
David: You know, I think both Mark and I had the impression that your review of the literature wasn't altogether up-to-date, I mean up to the 2000s; that a lot of it seemed to be earlier than that. And so, for example, in terms of the two-third, Dr. Scott D. Miller, who I don't think you reviewed, he wrote a book in 2000 that was updated in 2004 called The Heart and Soul of Change, and he reviews meta-research on psychotherapy and concludes that 80% of psychotherapy clients benefit compared to untreated samples. The other piece that I'd like to say kind of relates to something you said earlier, which is some therapists are better than others -- just like some auto mechanics are better than others -- and if you look at the therapists who are consistently successful, then the success rates are very good indeed.
Jonathan Engel: That's exactly right. So that two-thirds number comes out of a very, very broad sampling; and it's sort of as a meta-analysis that comes out of a lot of things. You're right about Scott Miller; I was a little bit confused how he got his numbers. I didn't take a close look at the meta-analysis that he used. I was wondering if he was being somewhat selective in what was going in there. The other one that was just a very recent study that came out, I think, in the last two years -- which didn't make it to the book -- about long-term psychodynamic therapy, so more Freudian, which suggested that the long-term success rates of longer term therapy -- that is, over two years in length -- did seem a little bit better; that is, it may be that short-term therapy was as good as long-term therapy in short run results, but if you looked at kind of the sticking power and the staying power, the people who had done longer term therapy seemed to be able to effect greater, deeper change that seemed to stay with the patient.
On the other hand, that particular study was done by a long-term therapist, and one has to wonder a little bit about bias in the study. What is certainly true -- and this I can tell you, I appreciate the fact that you're right, that I couldn't cover all of the literature out there so I may have missed some pieces -- but what is certainly true was that any of the studies which are relying on self reported data from the therapists, in my opinion, need to be thrown into the garbage. First of all, obviously, there's a huge conflict of interest. If you ask a healer of any sort, have you been successful, they have an enormous interest in saying yes; I mean this is their livelihood and this is their reputation. But more than that, even if it's not a conscious bias, it's very, very hard for them to know when they've succeeded. The single best way of knowing that someone feels better is to ask them, do you feel better?
Jonathan Engel: And if you ask an outsider, does that person feel better, they can make a good faith guess since they seem to feel better. They say they're happier; their affect seems a little brighter, their demeanor seems a little more alive and animated. But it's certainly not as good as asking the person him or herself; and it's certainly not as good as asking the person him or herself in a very, very safe and protected environment. That is, if you've developed a long-term relationship with your therapist and you have a lot invested in that relationship, and the therapist says to you, have I been successful in helping you, it's a very loaded question. What if deep down you think, well, no, you haven't been, but I don't really want to hurt your feelings. I consider you my friend, I consider you my therapist, my confidante. So it needs to be a very safe outside person who asks that question; the therapist is the wrong person to answer that question. And yet a huge number of the outcome studies rely on exactly that approach, of asking the therapist how successful have you been. I just think there are just so many methodological errors there, you can catalog them.
David: Yeah, it s a difficult area to research because the whole therapeutic enterprise is so complex. Mark, do you have any comments about this?
Mark: Yeah, well maybe this is a good place to kind of step back for a moment and talk about what the major schools of therapy are, because that's certainly a big theme of the book. And it also gets very much to the question of how each school of therapy judges its success, because it's only recently -- since probably the ascendance of behavioral and cognitive behavioral therapies -- that psychotherapy has really been studied in a systematic way and in an empirical way. And that also gets to the question of the last 20 years, because that research pace has really accelerated.
Jonathan Engel: That's right. If it was any one thing that pulled me into this area, it was knowing some people who had done est in the 1970s; I'm old enough to know people who were involved in est. And I always thought there was something kooky about it. I mean I couldn't quite put my finger on it, but there was something slightly cult-like about people going off for these retreats and I didn't quite get it. So I was kind of interested and I knew there'd been some other sort of kooky things that went on the '60s and early '70s -- Primal Scream and some of the Gestalt workshops -- so if there was anything that got me into it, it was that; it was this idea that there are so many different approaches to therapy out there and I was sort of curious to catalog them and see how they change over time.
If there was any big insight I had as I wrote the book, it was that, in fact, there were really only two or three approaches; that most of these so-called schools of therapy were, in fact, really highly derivative of an existing school of therapy; that an awful lot of people were out there claiming to be very original, but in fact were saying something awfully similar to what someone else had said. I'd always thought Aaron Beck was an extremely original mind in the history of psychotherapy -- and I still think he is, I think he's quite brilliant -- but he was saying an awful lot of things that Albert Ellis had said 25 years earlier. He was just doing it a little bit more rigorously. And frankly, if you go back, Albert Ellis is saying a fair number of things that Alfred Adler was saying 30 years before that. So it just turned out, [unclear] that talks about that shrinkage in my research; that again and again what seemed like something very new was turning out to be not quite so new at all.
That said, there were three approaches, I would say, that were really different enough to really call them schools. One was the psychodynamic approach, the classic Freudian approach; the second was the whole humanistic approach which I want to talk about in a second; and the third was cognitive behavioral therapy. And the three are truly autonomous and it would be very hard to confuse a real cognitive behavioral therapist with a real Freudian. What they do is just awfully different.
That said, I think that there's an awful lot of therapists out there who really would call themselves eclectic; they'll use what works. They sometimes use a little of the cognitive approach, they sometimes use more of a psychodynamic approach. It isn't just one. But those were the big three that I came up with, and then more or less in conjunction with medication, so that's another big approach. Are you combining with medication or electric shock or something like that?
One of the things I found frustrating was everyone seemed to agree that humanism and humanistic psychotherapy was a legitimate school, and you had to go back to Carl Rogers and this was something uniquely American, a true departure from Freud and a true departure from the American Freudians. And yet when you really tried to bear down as an outside reader into what the humanists were saying, there didn't seem to be very much of a there there.
Really, try to spend some time reading Carl Rogers -- and Carl Rogers wrote a lot, he was one of these people who just couldn't stop writing -- and yet when you really try to bear down, well, Dr. Rogers, what exactly are you doing? When a patient comes in to you, how is that you apply this unique and new approach? And he actually would rarely answer the question. He would say, well, you need to consider the patient as a whole person. Well, I don't think anyone would disagree with that; the Freudians wouldn't disagree with that. Well, you need to come to the patient where he is at; the patient needs to feel heard. Well, I think a Freudian would probably tell you the patient needs to feel heard. In other words, every time Rogers tried to say, this is what I do that's really very different, when you step back for a second it doesn't sound so different. I think a cognitive therapist would say the patient needs to feel heard; I think everyone would say the patient needs to feel heard. So actually I found humanistic therapy very elusive.
David: Well, let me just step in here because I think there is a major point of difference that occurs to me, which is that a major difference between Rogers' approach and the psychodynamic one is that the psychoanalyst saw his job as to offer interpretations, to kind of figure out the underlying mystery of what was really going on in the patient's unconscious and to bring that out, both through free association but also through his own very shrewd interpretations. Whereas Rogers actively resisted the idea of interpreting or that he was bringing expertise about that person's inner life. Rather he was trying to create an environment in which that person could discover for themselves, to kind of draw out their own sense of what was going on. That, to me, seems like a major difference.
Jonathan Engel: A very clear difference.
Mark: Maybe another way to sort of phrase that is, philosophically, the humanistic movement as embodied in Rogers' work is something that is technical almost by the absence of observable technique. Sounds a little bit funny, but that's really very much the case. So for instance with the Freudian and with the cognitive approach and with even the systems theorists -- who you don't seem to recognize directly, and they're in sort of the family and ecological stuff -- you have always the case that you've got an external force who's applying an intervention; it's much closer to a medical model. With Rogers, you're really getting to a place where what you're trying to do to remove things that are keeping people from growing into what they need to be. So it's an anti-intervention if you will, and I had difficulty with that part of your book.
Jonathan Engel: Okay, that's fair, that's very fair.
David: I have to say I'm really pleased to hear you say there are three broad movements and you've named humanism as one of them because personally I've been very allied with that branch. I think often it's given short shrift. And the other thing, while we're talking about Rogers -- I'm not sure that you are aware of this, many people are not -- is that I think Rogers deserves an awful lot of credit for the fact that there is research on psychotherapy because he was, as far as I know, he was the first one to insist on taping therapy sessions for research study. He maintained that there was no way that the field could advance if we relied totally on the self-report of psychotherapists, which is kind of what you've been saying. And so he's really the one who introduced recording. Today no students in psychotherapy are probably trained without doing audiotapes and videotapes and getting feedback from supervisors; whereas the psychoanalysts originally they felt like, hey, this is more like confession; it's sacred, nobody from outside the session should be privy to this information.
Jonathan Engel: That's right. You know, I knew that Rogers had had sessions taped; I didn't realize he was the first, to be honest. But to go back, if you start trying to view these certain schools with too great an orthodoxy and too rigid parameters, it does fall apart. So even someone as orthodox as Harry Stack Sullivan -- and he would absolutely have identified himself as an orthodox analyst -- and the fact is, if you look at some of his great contributions, they begin to look awfully humanistic.
So, for example, one of his big insights -- and I think I wrote about this in the book -- was that often the nurses on the psych wards at Sheppard Pratt seem to be more effective than psychiatrists. And what he realized was that often there was a class distinction going on; that the patients were often very working class and the psychiatrists were obviously drawn from a rather elite, educated class. But the nurses were really more natural peers of the patients, and that often the patients trusted the nurses more than they trusted the psychiatrists. And Sullivan, to his credit, had the insight to see this; that there was a trust building up and that that trust was a necessary prerequisite to effective therapy.
But isn't that trust and that validation, isn't that exactly what Rogers was claiming to do? I mean, that whole notion of feeling validated that is: I'm not sitting in judgment of you, you're here to feel comfortable -- as you point out, Mark, removing a methodological impediment here. So if someone as orthodox as Sullivan could be claiming to try to validate his patients' being, their sense, it does begin to show you how tricky it is to draw these sharp lines.
David: I think you're right, I think there is continuity and, as a matter of fact, I think many people in the humanistic side of things would claim Sullivan, just as the psychoanalytic side would claim Sullivan. I've heard people in the humanistic camp kind of claim Sullivan as one of the early people.
Jonathan Engel: Oh, that's interesting. Somehow I missed that in my research.
David: At least that's my impression, that's sort of the context within which I know Sullivan.
Mark: Sullivan is probably also claimed by some systems people, inasmuch as a lot of his writings have to do with identity as a social process. It's almost an ecological view and we just -- well, David just recently did an interview with Jürgen Kriz.
David: Yeah, Jürgen Kriz, a German psychologist.
Mark: Right, and also someone whose work is very much grounded in Rogers' work, in the person-centered approach; and he was very busy extending Rogers and recognizing Rogers as an early instance of a systems theorist.
Jonathan Engel: Now, that's interesting. How? How does he justify that?
Mark: It gets back to the kind of ecological approach. I haven't read the book, so I'm not sure that I can articulate it as well as Dr. Kriz would, but it's there.
David: Yeah, he did articulate it well in the interview and I'm not sure I can play it back well enough to articulate it either: looking at the person as a system that's moving towards wholeness, integration. I'm not going to do it justice here, so let me just shift ground a little bit and, while we're talking about things that seem maybe a little bit underserved, I was surprised -- and of course you had to be selective, I mean there's so much. Sigmund Koch years ago sat down to write a book about psychology; it was going to be one book and it ended up being a series of, I think, more than 20 books and became a lifetime project. In talking about psychoanalysis, you don't seem to touch upon object relations and people like Winnicott and so on. So while you say that psychoanalysis is dead, as a therapy it certainly is dwindling in terms of orthodox psychoanalysis, but as a theory of personality development it seems to me it's still very alive for many people.
Jonathan Engel: I think you're absolutely right. You're right. As an approach to the psyche and as a theory of personality and of emotional development, not only would I say it's alive, I would suspect it's really still the dominant strain. In fact, I think if you talked to an awful lot of people about their whole emotional psychic development, they're really referring back to Freudian idioms even if they don't know it. Everyone who talks about the importance of childhood experiences, people who sort of harp on parental inputs, they're really more Freudian than I think they understand. I have to tell you, just a slight tangent -- I don't know if you've both read Freakonomics, that was a best-seller about two or three years ago.
David: Yes, I did.
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