Clearly it's all of the above. It's important to be a good listener — but lots of bartenders and hairdressers are good listeners too. It's important to accurately apply the "technology" of psychotherapy — but self-help books, apps, and now AI "therapists" can as well. It's important to provide a "container" or protected space for emotional vulnerability and honest introspection — but churches, temples, ashrams, and some healthy families provide this too.
The unique value of skillful psychotherapy is the combination of all of these, and more. It's knowing when to use the "technology" and when not to. It's knowing when to listen and when to talk. It's knowing how rigidly to maintain the "container," and how safe it needs to be. And it's knowing when to get out of the way, and let the person heal themself.
Evidence based medicine is an ideal, not a rigid standard. Systematic research, case reports, and anecdotal experience are all valuable, and all limited. We still need to use our perception, empathy, and humanity when we connect with others and try to help them.
Drew makes a "sensible and sacrilegious point" that good, effective psychotherapy defies the rigid structures of evidence-based medicine (EBM) in favor of focusing on patient-centered flexibility. As other commenters (Susan R Johnson and Sobshrink) have noted, though, the critique of using EBM tools to evaluate the care of the soul is not new.
As Irvin D. Yalom, a prominent existential therapist and emeritus professor of psychiatry at Stanford, has written, empirically validated therapies (EVTs) like brief cognitive-behavioral therapy (CBT) have significant drawbacks when applied in psychotherapy. Yalom laments that the focus on EVT “has had enormous recent impact—so far, all negative—on the field of psychotherapy.” He points out that CBT’s narrow evidence base does not always translate to real-world effectiveness, particularly in treating complex, chronic psychological issues. According to Yalom, patients often require nuanced, individualized support that these protocols simply can’t provide. Yalom even goes further to note that EVT’s design means that clinicians follow manuals and protocols, often to the detriment of long-term, genuine therapeutic growth (Yalom, 2002, The Gift of Therapy, p. 227).
This approach is part of a broader pattern across the medical and mental health fields, where attempts to systematize care with standardized tools often miss crucial, subgroup and other context-specific elements. Sander Greenland, a leading epidemiologist and statistics reformer, takes this notion even further, explaining that methodologies, including randomized trials and statistical models, are only tools — and every tool has its limitations. Greenland, relaying philosopher of science Paul Feyerabend's message, argues that “every methodology has its limits” and that we should avoid “believing that a given methodology will be necessary or appropriate for every application” (European Journal of Epidemiology, 2017). When it comes to care work, whether mental or physical, that means that being overly reliant on formal methods risks ignoring the complex, human elements of each case.
In this sense, Drew’s approach advocates a form of “constrained anarchism,” as Feyerabend would put it, in which therapists can best serve their patients by allowing the science to inform, but not dictate, the treatment process. Anthropologist Anna Tsing’s concept of the “art of noticing” (Tsing, 2015, The Mushroom at the End of the World) also describes the value of this humanistic approach, highlighting how the open awareness of individual and cultural contexts is an “essential scientific practice” (Clancy, 2023, Period: The Real Story of Menstruation, p. 112).
What Drew is suggesting — and Yalom, Feyerabend, Greenland, Clancey, and Tsing all seem to support in their own contexts — is a holistic psychotherapy. Some comments seem to misconstrue this as necessarily an unscientific one, but nothing could be further from the truth. By maintaining openness to observing empirical evidence before their eyes and ears, and adapting course in response, therapists can embrace scientific rigor in a deeper sense than through rote adherence to EBM/EVT methods. This is not shamanism; it is the scientific method.
References
Yalom, I. D. (2002). The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. New York: HarperCollins.
Greenland, S. (2017). “For and Against Methodologies: Some Perspectives on Recent Causal and Statistical Inference Debates.” European Journal of Epidemiology, 32(1), 3–20.
Tsing, A. L. (2015). The Mushroom at the End of the World: On the Possibility of Life in Capitalist Ruins. Princeton University Press.
Clancy, K. B. H. (2023). Period: The Real Story of Menstruation. Princeton University Press.
So much of what you have written applies to primary care, too. At the risk of being called a bad doctor, I'd say that many doctors give too much service to the evidence and not enough to the patient they are applying the evidence to. People have different abilities to tolerate
-med A or B
-taking more than N meds
-taking meds more than once/day
-affording med A
-doing the lab monitoring required
-having their blood pressure or pulse at goal
-the burden of getting in to see me or to the lab
-the quirks of my personality
-the lack of attention to some other problem that focussing on their CHF causes
There are no trials of me paying more attention to the person in front of me vs me paying more attention to the evidence when these two priorities conflict to see how the same set of patients does over time with the differing priority from their primary care doctor. Trials solve many of these problems by not including patients with them or by making the med free.
I'm 77. When I was in my 20s I experienced several episodes of anxiety. Each time, symptoms such as nausea, dyspepsia, and sleep pattern disruption subsided after a calming conversation with a medical professional. All I needed was reassurance that something was not drastically wrong with my stomach. When I was 30 years old I sustained a back injury. While hospitalized, I decided to peruse books about nutrition to learn how to improve and protect my mental and physical health. One of the most useful books I read early on was 'Nutrition and Your Mind: The Psychochemical Response' by George Watson, PhD.
I strongly recommend a more recent book, published in 2023. 'Omega Balance', by Australian zoologist Anthony Hulbert, PhD contains two chapters about how the fatty acid profile of our modernized, industrialized food supply affects brain function.
I had a short manic episode after eating beef jerky. Come to find out that's not all that rare. People react to the nitrates/nitrites in cured meats with mania. Celery powder is added to cured meats and people don't realize it's very high in nitrates. So I'm not surprised at what you say you went through with the garbage food we so trustingly eat.
Something I wonder about is _how_ long is necessary. I hear about people “regularly attending therapy” for *years* and then wanting their kids to start regularly attending therapy too. At some point it starts to resemble religion-just a regular “practice” or service they are attending and passing on to their children. From a therapeutic perspective-isn’t the goal to function eventually _without_ the therapist?
KPL: You are 100% correct that the goal is to function without the therapist. One of the first lessons we therapists learn in graduate school is, "You start discharge/discontinuation planning from the very first session."
One thing to consider about 'how long': What is the issue/issues that are bringing the person to therapy in the first place. Have they had life long trauma? Do they have effective supports in their life (family, friends, etc.)? Are they dealing with an issue that traces back from childhood and has continued throughout their life course? All of these issues can lead to an increased amount of time neccessary for effective therapy.
In my experience, the time a person spends in therapy is the time they feel is necessary. I've had patients who have come for 5 or 6 sessions and feel ready to go on and I've had patients that I see for years at a time.
Due to my approach to therapy, I never push clients to discontinue. I may suggest it or offer it as an option if it seems they're ready to launch. And we always schedule a 'check-in' session a few months down the road (I'm always happiest when they call and say, "Hey, I don't need it. I'm doing great!")
Therapy can be a lifelong journey; but generally it's short lived or a series of short-lived in and outs.
I know that for me therapy is not about making money. I've seen patients for a $1 due to their circumstances or waived their co-pay, or negotiated a lower, easier for them fee. I realize that not a lot of clinicians do this as it is their livelihood. But when we make the relationship too business like, we lose that personal side and try to push for more sessions and more time with them just to pad our income.
As a practicing psychotherapist of over 40 years, I agree that it is the relationship or "match" that matters most. Psychotherapy is really an art as much as a science. I too taper, somewhat admittedly instinctively, different approaches and timing for different patients. Maybe a few generations ago in a world where people lived with or near scores of relatives, therapy wasn't really needed. A loving aunt or wise old grandfather or admired cousin could provide understanding, support and guidance. Within the culture that most of live today, we lack those natural connections, so we turn to therapists. And with the right patient/therapist match, it can work to make sense of one's life and reach desired potential in many life arenas.
Let's define our terms. "Evidence/science based" therapy doesn't mean rigid manuals with no room for professional judgment or customization for each patient's needs or lack of appreciation for the therapeutic relationship. It's simply about whether there is any valid evidence that a particular therapy is safe and beneficial when compared with no treatment (or another treatment).
Therapists tend to have faith in their treatments. Science demands PROOF (evidence). Some psychotherapies turn out to be ineffective and even harmful for certain patients. For example, Patients with borderline personality disorder used to be treated mostly with psychoanalysis. The analysts were very bullish about this. Research then showed that many patients with BPD actually got worse with psychoanalysis, and did better with more structured skill-building therapies (DBT, MBT, CBT etc). Good practitioners of those approaches care about the therapeutic relationship and make adjustments to the "manual" based on patient preferences. But their overall approach is based on research EVIDENCE that it is largely safe and effective for those patients. It's a good thing.
This is basically a long argument in favor of . . . what is that word I'm thinking of?
Shamanism. That's it. Or faith healing (a kind of talk therapy). Or becoming a Buddhist. Or almost anything that creates an inner dialogue with an outer world. Meditation. Yoga. Religious retreats. Work retreats.
Personally I think mental health happens, and only happens, once a person (customer, patient, disciple, devotee, client) takes steps to conquer his own Ego and embrace his own Heart. Ideally this occurs before he reaches the age of 22 or so.
It really is as simple as that (not easy, just simple: there's a difference).
The next step, or concurrent step, is to embrace one's own body, no matter its form, and embrace the physical world around you. Another word/concept for this is gratitude.
The third (concurrent step) is to surrender to the Cosmos of Chaos (Chaos happens all the times), and the Cosmos of Grace (guidance & acceptance).
Finally, awash in gratitude, guided by Grace, extend generosity to the Universe.
You'd be surprised how healthy you will be, in mind and then body.
Cf. Jonathan Shedler: https://jonathanshedler.com/writings/, especially "The Therapy Relationship in Psychodynamic Therapy versus CBT." He's also on X.com. (I've sometimes thought that maybe in my next life I would come back as a therapist! Too late for this life.)
That's all fine, we know that. We just need to stop calling it "medicine" and "science", and recognise that the DSM is a block of junk and wasted paper and computer time, and admit that the human mind is entirely determined by our environment and the environment of modern civilisation sucks bad for a majority of civilisation.
I'm an atheist, but I like the Krishna saying:
"It is no measure of health to be well adjusted to a profoundly sick society."
Our mental "health" industry is 100% a lie, it's mostly not the humans that are unwell, but the society. One can TAME a human to survive this evil civilisation, but that's not a "cure" or "health", it's taming/domestication.
Civilisation is anti-health and anti-biology, and ultimately anti-scientific. Yes we use tools to escape nature and biology, these tools can be said to be "scientific" but they create anti-science for humans.
I so agree with Drew..... I remember attending a "evidence based" training on a approach to therapy.. and discovering that the "training' consisted of teaching the attendees to view a video, and "see" the symptoms the same way the trainer did... once you consistently "see" the same features, you get to "pass" and become certified in the technique. (note that there was no study to validate the original premises, only studies to show that participants score consistent with the trainer, after the process of "training".. Then they publish papers showing the evidence base that they basically constructed... No "end point" studies.. Do people actually get better, objectively, not just self report, just studies showing that they could train people to answer in a pre - prescribed way..... I would argue that therapy is closer to an art, than a science... imagine trying to design a study to evaluate the quality of Rembrandt? You depersonalize it in the process....
"In the medical world, we can be sure that statin drugs will work just about the same in all patient populations."
Not true. Drug main effects reflect the tyranny of the mean. There is enormous within-group variation in response to both medications and psychotherapy. The words "ON AVERAGE, treatment X works better than no treatment" means only that.
Both physicians and psychotherapists squirm a bit under scientific scrutiny. Many like to say that what they do is "too complicated" to be studied by standard research methods. This is nothing more than professional arrogance ("Just take my word for it!"). When Hans Eysenck challenged the psychoanalysts to "prove" that their therapy works back in the 1950's, heads exploded, but the psychotherapy research literature has illuminated important truths. Science, like everything, has its limits, but if we want people to trust us, we need to offer more than a parental "Because I say so" when they ask reasonable questions about our methods and prescriptions.
Agree, and would add that a psychotherapist should be trained and value “talk therapy,” but also trained in and value the rigorous evaluation of neuroscientific research and psychopharmacology. Clinical acumen requires knowledge of how the brain and mind function in health and illness as a foundation for working with each patient. EBM has become a naughty word associated with the business of medicine - brought back from corporate angst and coding manual, one finds richness and finesse of an ever-changing approach to patient care. It’s hard work, but the best way to deal with the body in all forms of patient care.
So well said Kristen! The paradigms of self, mind and brain can all be useful lenses for understanding and managing our struggles in life. We're complex beings and there is a lot to know about.
When I first started seeing my psychiatrist 12 years ago for GAD & OCD tendencies she told me immediately that I needed a therapist in addition to seeing her. They are both a perfect mix for me. My therapist is more soft love and my psychiatrist is tough love which I need! I would like to think that each patient’s care is customized to what they need, not what a book tells the doctor or therapist.
Doesn't this just mean that I could become a therapist by learning active learning? No need for PhDs. And another problem. How do you as a field expel all the self-help scammer and fraudsters? Even with it being "evidence-based" scammer and fraudsters are everywhere. How can you be sure that if you go into therapy that will not get into some religious cult that wants to train you to become the good religious Samaritan? How can you seperate the sense from the nonsense if you lower the criteria for being a therapist even more than it already is? I would rather talk to my friend who listens well and show the appropriate empathy than pay 9000 euros for a therapist that can sell their own ideology and dogma as a therapy because he/she has trained to be an active listener?
Answer: it's all nonsense. The fields of "mental health" are a scam for endless profits, endless, because ultimately, NONE of the "treatments" work, they are ALL life-long management, that means life-long profits.
The only way to "heal" mental health is to entirely change our life context, and/or accept taming/domestication to accepted social norms. Few people can achieve that.
We are a MEGAFAUNAL species, not ants, bees, crows, which live in crowded societies. We are existing in a life contrary to our evolution, so we are all endlessly "unwell".
You are missing the value of intelligence and adaptation. “Endless unwell” is a ticket to extinction. It says nothing about the capacity to survive and even thrive under severe conditions. You can see adaptation occur naturally even with animals.
The mind can not outdo biology. Biology is evolved, our evolved mind is now completely suffering artificial society. Homo sapiens did not evolve to live like ants in ant hills, so we ail.
Evidence Based Medicine *should* take into account the individual preferences of the patient... That's a fundamental tenet of evidence based medicine as I know it. Hence if your patient has a hate on CBT, it's totally inappropriate, no matter what evidence is out there. To me tailoring psychotherapy to the individual is at the heart of EBM, and the evidence is that the therapeutic alliance is the driver of successful psychotherapy. So I wouldn't be throwing EBM out with the bathwater... I wonder whether the author truly knows what EBM is? That the individual patient's preferences and values are just as important as what the 'evidence' says? The author seems to have a distorted view of EBM, admittedly based on the way it is practiced in physical medicine, but no less perverted for that. Psychotherapy that doesn't acknowledge EBM is in the dark ages, even if the evidence is a case series of n=1 or anecdotal, it's still evidence. Otherwise it's not therapy, it's faith healing.
Should add that the clinician's expert opinion is also just as important as the 'evidence' - the evidence actually plays a minor role compared to clinician's values and patient's values! In EBM in its pure form.
I worried a lot as a new young Dr (the 1980’s) that patients confided some extremely personal concerns and that I wasn’t trained in psychotherapy. I discussed this with a psychiatrist and was told that the best evidence available showed that just listening is helpful. I took that onboard and developed a reputation as a “listening Dr.” I moved on to develop the concept that just listening endlessly doesn’t define or solve problems so I developed questions about different areas of a person’s life and the aim to help them understand where they are at, where they want to be and to find their solutions about how they wanted to get there. What kind of training produces “psychotherapists” who won’t listen and then wish to pigeon hole a patient into therapies which don’t fit?
Clearly it's all of the above. It's important to be a good listener — but lots of bartenders and hairdressers are good listeners too. It's important to accurately apply the "technology" of psychotherapy — but self-help books, apps, and now AI "therapists" can as well. It's important to provide a "container" or protected space for emotional vulnerability and honest introspection — but churches, temples, ashrams, and some healthy families provide this too.
The unique value of skillful psychotherapy is the combination of all of these, and more. It's knowing when to use the "technology" and when not to. It's knowing when to listen and when to talk. It's knowing how rigidly to maintain the "container," and how safe it needs to be. And it's knowing when to get out of the way, and let the person heal themself.
Evidence based medicine is an ideal, not a rigid standard. Systematic research, case reports, and anecdotal experience are all valuable, and all limited. We still need to use our perception, empathy, and humanity when we connect with others and try to help them.
Drew makes a "sensible and sacrilegious point" that good, effective psychotherapy defies the rigid structures of evidence-based medicine (EBM) in favor of focusing on patient-centered flexibility. As other commenters (Susan R Johnson and Sobshrink) have noted, though, the critique of using EBM tools to evaluate the care of the soul is not new.
As Irvin D. Yalom, a prominent existential therapist and emeritus professor of psychiatry at Stanford, has written, empirically validated therapies (EVTs) like brief cognitive-behavioral therapy (CBT) have significant drawbacks when applied in psychotherapy. Yalom laments that the focus on EVT “has had enormous recent impact—so far, all negative—on the field of psychotherapy.” He points out that CBT’s narrow evidence base does not always translate to real-world effectiveness, particularly in treating complex, chronic psychological issues. According to Yalom, patients often require nuanced, individualized support that these protocols simply can’t provide. Yalom even goes further to note that EVT’s design means that clinicians follow manuals and protocols, often to the detriment of long-term, genuine therapeutic growth (Yalom, 2002, The Gift of Therapy, p. 227).
This approach is part of a broader pattern across the medical and mental health fields, where attempts to systematize care with standardized tools often miss crucial, subgroup and other context-specific elements. Sander Greenland, a leading epidemiologist and statistics reformer, takes this notion even further, explaining that methodologies, including randomized trials and statistical models, are only tools — and every tool has its limitations. Greenland, relaying philosopher of science Paul Feyerabend's message, argues that “every methodology has its limits” and that we should avoid “believing that a given methodology will be necessary or appropriate for every application” (European Journal of Epidemiology, 2017). When it comes to care work, whether mental or physical, that means that being overly reliant on formal methods risks ignoring the complex, human elements of each case.
In this sense, Drew’s approach advocates a form of “constrained anarchism,” as Feyerabend would put it, in which therapists can best serve their patients by allowing the science to inform, but not dictate, the treatment process. Anthropologist Anna Tsing’s concept of the “art of noticing” (Tsing, 2015, The Mushroom at the End of the World) also describes the value of this humanistic approach, highlighting how the open awareness of individual and cultural contexts is an “essential scientific practice” (Clancy, 2023, Period: The Real Story of Menstruation, p. 112).
What Drew is suggesting — and Yalom, Feyerabend, Greenland, Clancey, and Tsing all seem to support in their own contexts — is a holistic psychotherapy. Some comments seem to misconstrue this as necessarily an unscientific one, but nothing could be further from the truth. By maintaining openness to observing empirical evidence before their eyes and ears, and adapting course in response, therapists can embrace scientific rigor in a deeper sense than through rote adherence to EBM/EVT methods. This is not shamanism; it is the scientific method.
References
Yalom, I. D. (2002). The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. New York: HarperCollins.
Greenland, S. (2017). “For and Against Methodologies: Some Perspectives on Recent Causal and Statistical Inference Debates.” European Journal of Epidemiology, 32(1), 3–20.
Tsing, A. L. (2015). The Mushroom at the End of the World: On the Possibility of Life in Capitalist Ruins. Princeton University Press.
Clancy, K. B. H. (2023). Period: The Real Story of Menstruation. Princeton University Press.
(Drawn from https://wildetruth.substack.com/p/limited-limits.)
So much of what you have written applies to primary care, too. At the risk of being called a bad doctor, I'd say that many doctors give too much service to the evidence and not enough to the patient they are applying the evidence to. People have different abilities to tolerate
-med A or B
-taking more than N meds
-taking meds more than once/day
-affording med A
-doing the lab monitoring required
-having their blood pressure or pulse at goal
-the burden of getting in to see me or to the lab
-the quirks of my personality
-the lack of attention to some other problem that focussing on their CHF causes
There are no trials of me paying more attention to the person in front of me vs me paying more attention to the evidence when these two priorities conflict to see how the same set of patients does over time with the differing priority from their primary care doctor. Trials solve many of these problems by not including patients with them or by making the med free.
I'm 77. When I was in my 20s I experienced several episodes of anxiety. Each time, symptoms such as nausea, dyspepsia, and sleep pattern disruption subsided after a calming conversation with a medical professional. All I needed was reassurance that something was not drastically wrong with my stomach. When I was 30 years old I sustained a back injury. While hospitalized, I decided to peruse books about nutrition to learn how to improve and protect my mental and physical health. One of the most useful books I read early on was 'Nutrition and Your Mind: The Psychochemical Response' by George Watson, PhD.
I strongly recommend a more recent book, published in 2023. 'Omega Balance', by Australian zoologist Anthony Hulbert, PhD contains two chapters about how the fatty acid profile of our modernized, industrialized food supply affects brain function.
I had a short manic episode after eating beef jerky. Come to find out that's not all that rare. People react to the nitrates/nitrites in cured meats with mania. Celery powder is added to cured meats and people don't realize it's very high in nitrates. So I'm not surprised at what you say you went through with the garbage food we so trustingly eat.
Something I wonder about is _how_ long is necessary. I hear about people “regularly attending therapy” for *years* and then wanting their kids to start regularly attending therapy too. At some point it starts to resemble religion-just a regular “practice” or service they are attending and passing on to their children. From a therapeutic perspective-isn’t the goal to function eventually _without_ the therapist?
KPL: You are 100% correct that the goal is to function without the therapist. One of the first lessons we therapists learn in graduate school is, "You start discharge/discontinuation planning from the very first session."
One thing to consider about 'how long': What is the issue/issues that are bringing the person to therapy in the first place. Have they had life long trauma? Do they have effective supports in their life (family, friends, etc.)? Are they dealing with an issue that traces back from childhood and has continued throughout their life course? All of these issues can lead to an increased amount of time neccessary for effective therapy.
In my experience, the time a person spends in therapy is the time they feel is necessary. I've had patients who have come for 5 or 6 sessions and feel ready to go on and I've had patients that I see for years at a time.
Due to my approach to therapy, I never push clients to discontinue. I may suggest it or offer it as an option if it seems they're ready to launch. And we always schedule a 'check-in' session a few months down the road (I'm always happiest when they call and say, "Hey, I don't need it. I'm doing great!")
Therapy can be a lifelong journey; but generally it's short lived or a series of short-lived in and outs.
I know that for me therapy is not about making money. I've seen patients for a $1 due to their circumstances or waived their co-pay, or negotiated a lower, easier for them fee. I realize that not a lot of clinicians do this as it is their livelihood. But when we make the relationship too business like, we lose that personal side and try to push for more sessions and more time with them just to pad our income.
Hope that answer helps!
As a practicing psychotherapist of over 40 years, I agree that it is the relationship or "match" that matters most. Psychotherapy is really an art as much as a science. I too taper, somewhat admittedly instinctively, different approaches and timing for different patients. Maybe a few generations ago in a world where people lived with or near scores of relatives, therapy wasn't really needed. A loving aunt or wise old grandfather or admired cousin could provide understanding, support and guidance. Within the culture that most of live today, we lack those natural connections, so we turn to therapists. And with the right patient/therapist match, it can work to make sense of one's life and reach desired potential in many life arenas.
There is a Spiritual side to health that is often overlooked.
Let's define our terms. "Evidence/science based" therapy doesn't mean rigid manuals with no room for professional judgment or customization for each patient's needs or lack of appreciation for the therapeutic relationship. It's simply about whether there is any valid evidence that a particular therapy is safe and beneficial when compared with no treatment (or another treatment).
Therapists tend to have faith in their treatments. Science demands PROOF (evidence). Some psychotherapies turn out to be ineffective and even harmful for certain patients. For example, Patients with borderline personality disorder used to be treated mostly with psychoanalysis. The analysts were very bullish about this. Research then showed that many patients with BPD actually got worse with psychoanalysis, and did better with more structured skill-building therapies (DBT, MBT, CBT etc). Good practitioners of those approaches care about the therapeutic relationship and make adjustments to the "manual" based on patient preferences. But their overall approach is based on research EVIDENCE that it is largely safe and effective for those patients. It's a good thing.
This is basically a long argument in favor of . . . what is that word I'm thinking of?
Shamanism. That's it. Or faith healing (a kind of talk therapy). Or becoming a Buddhist. Or almost anything that creates an inner dialogue with an outer world. Meditation. Yoga. Religious retreats. Work retreats.
Personally I think mental health happens, and only happens, once a person (customer, patient, disciple, devotee, client) takes steps to conquer his own Ego and embrace his own Heart. Ideally this occurs before he reaches the age of 22 or so.
It really is as simple as that (not easy, just simple: there's a difference).
The next step, or concurrent step, is to embrace one's own body, no matter its form, and embrace the physical world around you. Another word/concept for this is gratitude.
The third (concurrent step) is to surrender to the Cosmos of Chaos (Chaos happens all the times), and the Cosmos of Grace (guidance & acceptance).
Finally, awash in gratitude, guided by Grace, extend generosity to the Universe.
You'd be surprised how healthy you will be, in mind and then body.
Cf. Jonathan Shedler: https://jonathanshedler.com/writings/, especially "The Therapy Relationship in Psychodynamic Therapy versus CBT." He's also on X.com. (I've sometimes thought that maybe in my next life I would come back as a therapist! Too late for this life.)
That's all fine, we know that. We just need to stop calling it "medicine" and "science", and recognise that the DSM is a block of junk and wasted paper and computer time, and admit that the human mind is entirely determined by our environment and the environment of modern civilisation sucks bad for a majority of civilisation.
I'm an atheist, but I like the Krishna saying:
"It is no measure of health to be well adjusted to a profoundly sick society."
Our mental "health" industry is 100% a lie, it's mostly not the humans that are unwell, but the society. One can TAME a human to survive this evil civilisation, but that's not a "cure" or "health", it's taming/domestication.
Civilisation is anti-health and anti-biology, and ultimately anti-scientific. Yes we use tools to escape nature and biology, these tools can be said to be "scientific" but they create anti-science for humans.
Sounds like you describe a lot of what people refer to as “public health!” 😉
I so agree with Drew..... I remember attending a "evidence based" training on a approach to therapy.. and discovering that the "training' consisted of teaching the attendees to view a video, and "see" the symptoms the same way the trainer did... once you consistently "see" the same features, you get to "pass" and become certified in the technique. (note that there was no study to validate the original premises, only studies to show that participants score consistent with the trainer, after the process of "training".. Then they publish papers showing the evidence base that they basically constructed... No "end point" studies.. Do people actually get better, objectively, not just self report, just studies showing that they could train people to answer in a pre - prescribed way..... I would argue that therapy is closer to an art, than a science... imagine trying to design a study to evaluate the quality of Rembrandt? You depersonalize it in the process....
"In the medical world, we can be sure that statin drugs will work just about the same in all patient populations."
Not true. Drug main effects reflect the tyranny of the mean. There is enormous within-group variation in response to both medications and psychotherapy. The words "ON AVERAGE, treatment X works better than no treatment" means only that.
Both physicians and psychotherapists squirm a bit under scientific scrutiny. Many like to say that what they do is "too complicated" to be studied by standard research methods. This is nothing more than professional arrogance ("Just take my word for it!"). When Hans Eysenck challenged the psychoanalysts to "prove" that their therapy works back in the 1950's, heads exploded, but the psychotherapy research literature has illuminated important truths. Science, like everything, has its limits, but if we want people to trust us, we need to offer more than a parental "Because I say so" when they ask reasonable questions about our methods and prescriptions.
Agree, and would add that a psychotherapist should be trained and value “talk therapy,” but also trained in and value the rigorous evaluation of neuroscientific research and psychopharmacology. Clinical acumen requires knowledge of how the brain and mind function in health and illness as a foundation for working with each patient. EBM has become a naughty word associated with the business of medicine - brought back from corporate angst and coding manual, one finds richness and finesse of an ever-changing approach to patient care. It’s hard work, but the best way to deal with the body in all forms of patient care.
So well said Kristen! The paradigms of self, mind and brain can all be useful lenses for understanding and managing our struggles in life. We're complex beings and there is a lot to know about.
When I first started seeing my psychiatrist 12 years ago for GAD & OCD tendencies she told me immediately that I needed a therapist in addition to seeing her. They are both a perfect mix for me. My therapist is more soft love and my psychiatrist is tough love which I need! I would like to think that each patient’s care is customized to what they need, not what a book tells the doctor or therapist.
Doesn't this just mean that I could become a therapist by learning active learning? No need for PhDs. And another problem. How do you as a field expel all the self-help scammer and fraudsters? Even with it being "evidence-based" scammer and fraudsters are everywhere. How can you be sure that if you go into therapy that will not get into some religious cult that wants to train you to become the good religious Samaritan? How can you seperate the sense from the nonsense if you lower the criteria for being a therapist even more than it already is? I would rather talk to my friend who listens well and show the appropriate empathy than pay 9000 euros for a therapist that can sell their own ideology and dogma as a therapy because he/she has trained to be an active listener?
Absolutely.
Answer: it's all nonsense. The fields of "mental health" are a scam for endless profits, endless, because ultimately, NONE of the "treatments" work, they are ALL life-long management, that means life-long profits.
The only way to "heal" mental health is to entirely change our life context, and/or accept taming/domestication to accepted social norms. Few people can achieve that.
We are a MEGAFAUNAL species, not ants, bees, crows, which live in crowded societies. We are existing in a life contrary to our evolution, so we are all endlessly "unwell".
You are missing the value of intelligence and adaptation. “Endless unwell” is a ticket to extinction. It says nothing about the capacity to survive and even thrive under severe conditions. You can see adaptation occur naturally even with animals.
The mind can not outdo biology. Biology is evolved, our evolved mind is now completely suffering artificial society. Homo sapiens did not evolve to live like ants in ant hills, so we ail.
Evidence Based Medicine *should* take into account the individual preferences of the patient... That's a fundamental tenet of evidence based medicine as I know it. Hence if your patient has a hate on CBT, it's totally inappropriate, no matter what evidence is out there. To me tailoring psychotherapy to the individual is at the heart of EBM, and the evidence is that the therapeutic alliance is the driver of successful psychotherapy. So I wouldn't be throwing EBM out with the bathwater... I wonder whether the author truly knows what EBM is? That the individual patient's preferences and values are just as important as what the 'evidence' says? The author seems to have a distorted view of EBM, admittedly based on the way it is practiced in physical medicine, but no less perverted for that. Psychotherapy that doesn't acknowledge EBM is in the dark ages, even if the evidence is a case series of n=1 or anecdotal, it's still evidence. Otherwise it's not therapy, it's faith healing.
Psychology IS the dark ages. Just a scam that deserves no credibility or degrees.
Should add that the clinician's expert opinion is also just as important as the 'evidence' - the evidence actually plays a minor role compared to clinician's values and patient's values! In EBM in its pure form.
I worried a lot as a new young Dr (the 1980’s) that patients confided some extremely personal concerns and that I wasn’t trained in psychotherapy. I discussed this with a psychiatrist and was told that the best evidence available showed that just listening is helpful. I took that onboard and developed a reputation as a “listening Dr.” I moved on to develop the concept that just listening endlessly doesn’t define or solve problems so I developed questions about different areas of a person’s life and the aim to help them understand where they are at, where they want to be and to find their solutions about how they wanted to get there. What kind of training produces “psychotherapists” who won’t listen and then wish to pigeon hole a patient into therapies which don’t fit?