Saving Talk Therapy: How Health Insurers, Big Pharma, and Slanted Science are Ruining Good Mental Health Care

Having been in practice over 40 years, I was very pleased to read Enrico's reminder of the importance of the humanistic and depth approaches to the practice of psychotherapy. In the future, (which is rapidly approaching) an informed culture will demand that this type of therapy be the "standard" for truly helping our patients and the society as a whole. This is, and should be, a must-read for mental health professionals and patients alike. One cannot overstate the usefulness of active engagement, authenticity and the judicious use of humor in helping people.

Gnaulati has written a valuable account of how talk therapy has been methodically misrepresented as not supported by research and set aside for short-term, manualized therapies that don't actually live up to their "evidence-based" claims. He explains clearly the research conundrum, the forces that prefer to push talk therapy to the periphery, and describes the evidence for these therapies of depth and relationship. An important book that's a wakeup call about a mental health system crisis that is growing in the U.S.

This is a wonderful book, written by a thoughtful and insightful psychotherapist.I am a psychologist and psychotherapist, I identify as primarily humanistic and secondarily psychodynamic, and agree with the majority of the author's thoughts and conclusions. It is really difficult to find psychotherapists who practice real talk therapy, related to a variety of factors that the author outlines.Because I agree so much with what the author has presented, I will focus on some areas I feel he neglected, or was not up to date.The author criticizes the current overfocus on CBT and short, structured treatments. Working at the VA, however, I have observed that a large minority of patients actually improve significantly with these treatments. When they do improve, they note that they have learned coping skills that help them feel in control of their symptoms, whereas before their symptoms were uncontrollable. Also, some patients want to work in a brief and problem-solving manner, they don't want, or need, extended psychotherapy, although this could be helpful in areas beyond symptom management. So, CBT is very useful for some patients.Which brings me to the central issue the author missed, in my opinion. Psychological treatment is beginning to fragment into 1) treatment of diagnosable mental disorders, which is short term and structured and paid for by insurance companies, and 2) psychotherapy for the sorts of issues described by the author, the problems of living, sometimes severe, that all of us have, to a greater or lesser extent, including crises that precipitate a desire to enter psychotherapy. The author is advocating #2, as am I. And much of #1 can be treated in the second matter, and often more profoundly and definitively. However, this longer, less structured, open ended psychotherapy is no longer being paid for by insurance companies, and unfortunately, organized psychology has colluded in it's demise with the overfocus on diagnosable mental disorders treated in short term, structured, time-limited therapy, the so called "evidence based treatments."So we are talking apples and oranges and I see no way that this is going to change. It is heartbreaking. I see it every day at the VA. Patients who need longer term care, including for ptsd, and are terminated from treatment because they have reached "maximum treatment benefit" (i.e., a certain number of sessions). Fortunately, I work in a spinal cord injury center and these same constraints are not placed on my work, but I am very aware of what is going around me and how a large number of veterans (and in the non-VA world, regular citizens) have no access to the help that they really need - unless they have significant financial resources.In my mind, then, talk therapy is dying, and there is no stopping it, just as psychodynamic therapy has been replaced by cognitive-behavioral therapy. Perhaps there will be a small number of psychotherapists from various disciplines who will be able to make a go of being talk therapists, but this will not be the norm. It is incredibly sad to me, knowing how transformative 'real" psychotherapy can be.

This book echoed thoughts and feelings I've had, as a therapist, for years. It includes some history on how the mental health system has become what it is today. I highly recommend this book if you are a therapist or want some perspective on the mental health system.

Saving Talk Therapy is sounding an alarm, exposing the ills of our current quick-fix attitudes in current society, with big pharma supplanting talk therapy as the go-to antidote for behavioral health. When did this happen? Why is media filled with alluring ads convincing an anxious public that we need to be medicated to function in a stressful world? Why are psychologists pushing cognitive behavioral therapies that are protocol-driven resulting in dubious results?What happened to meaningful talk therapy that is void of timelines, workbooks and rote forumulae? The author Enrico Gnaulati, PHD makes strong arguments for a more humanistic, empathetic approach to therapies that involve “genuine emotional engagement from the therapist”.The first third of the book provides the fascinating evolution of psychotherapy from The Freudian days of detached couch talk to more connected, empathetic setting that were promolgated by Freud’s successors. The history of mental health has included assimilation into pop culture and waves of experiemental therapies with the aim of relieving mental distress. But as talk therapy grew in popularity, with the 1950s being the golden era of psychotherapy, so did the proliferation of pharmaceuticals, offering a quick and easy way to achieve wellness. While pills began to supplant psychotherapy, taking “Prozac” and other SSRIs, anti-anxiety depressant medications started to become normalized. Through the efforts of effective marketing, sales pitches and captivating TV ads, instead of addressing core issues the hard way (talk therapy), people saw pills as a quick, painless solution for their anxiety, depression and other issues that became something to reject rather than identify as part the human condition. What was once a a lifeline for those who truly needed anti-psycohtoic medications prescribed by trained psychiatrists became a commodity for greedy big pharm and compliant primary care physicians. This has lead to an epidemic of overprescribing, drug dependency and other unintended consequences of “casual use of medication”. With the increase of the “biomedical revolution”, talk therapy began to take a back seat and changes in the insurance industry exacerbated the problem as "managed care" began to impede on a psychologist’s ability to make autonomous decisions based on cliental needs. Instead insurance imposed rationed care, cutting reimbursement rates on an already underfunded industry. Prozac, which touted the cure for depression was considered a wonder drug in the late 80s, though time would reveal that the miracle med had a dark side.The author discusses various therapies that have been widely adopted in recent years, most notably cognitive behavioral therapy, known by the acronym CBT. Anyone who has ever looked for a therapist online may have seen this term listed as part of a practitioner's repertoire. The reason for the proliferation of CBT can be attributed to its linear, finite nature that follows a formula and provides a timeline for treatment. Its expedience makes it appealing from a fiscal standpoint. However, the author argues that it is far less effective than humanistic, empathetic approaches that gets to the core of existentialism. Therapies cannot be boxed into quick-fix 12 sessions if longterm mental health is the objective. There are too many variables, circumstances and situations that mandate more flexibility and tailored approaches to psychotherapy. In the chapter entitled Cognitive Processing Therapy: The VA’s Flawed Solution to Postraumatic Stress Disorder (PTSD), The author cites the VA’s use of a condensed version of CBT that had a very high failure rate among veterans and proved to be an ineffective, time wasting approach that failed to properly address the complexities of those diagnosed with PTSD.In the last third of the book, the author Enrico Gnaulati, PHD offers compelling ideas for authentic, effective psychotherapy. He samples sessions he had with some of his own clients. He discloses myriad therapeutic approaches including the employment of the gentle voice of authority, the power of self disclosure, connectivity, relatability, tailored feedback and being a good, caring listeners. His methods seem like common sense to me and I would guess most people reading this book would concur. But why are empathetic therapeutics so underfunded? Why are medicines and SSRIs promoted by primary care physicians and insurance companies but good old-fashioned talk therapy is not?I think Saving Talk Therapy provides a platform for meaningful discussion regarding how we deal with mental health, day-to-day stresses and other human conditions that make people feel stuck, hopeless, debilitated, and intractably unhappy. Everyone at one point or another will face seemingly insurmountable challenges in life that might require some sort of intervention.There is a place for psychotropics and the author is not advocating for its removal as a therapeutic option, but he does suggest that quick fixes do not lead to longterm resolution, mental wellness and intrinsic happiness.I enjoyed reading this well researched and organized book. It’s easy-to-read and understand and provides much food for thought. You don’t have to be a therapist or be in therapy to appreciate the thought that went into this comprehensive critique of a complex but urgent topic that one way or another concerns us all.~ Kort