I started this blog with enthusiasm, as a way of sharing my thoughts as I was exploring what we know about how people diagnosed with mental illness get better. I hoped that by getting clear I would find a focus and direction for developing and improving in my work, and that by sharing a summary, this clarity might also help other practitioners. This blog has been languishing while I have been lost in the metaphoric Amazon, but here’s an update.

Unlike many other areas of medicine, where such a pursuit is a relatively simple journey with well marked sign posts and a road well travelled, this journey has been a murky, muddy, poorly lit path with lots of scrub bashing required.

I have discovered that despite millions of dollars spent on research in the last 50 years, we are no better at treating mental illness now, than we were then.

Gene studies, Neuroscience and exploration about how the brain works has been fascinating, but it has made no difference to patient outcomes.

The promise of medications that work like antibiotics to cure a complaint, is a bubble that has well and truly burst, with placebo being the biggest winner. The strategy of throwing every new drug at every condition to see what happens has been pretty interesting, and probably been driven more by the practitioners desperation and anecdotal observations than any decent science. The result has arguably put the biggest dent in the rationale for diagnostic categories. If you say you can observe benefits of antipsychotics in depressed patients and vice versa… well isn’t that like saying antihypertensives have some effect in Influenza??? You’d have to wonder if we are trying to cobble some therapeutic effect from a side effect, rather than an explainable physiological biochemical intervention. As studies emerge with concerns for long term follow up, particularly of children who were exposed prenatally, we will likely see the pendulum swing in the benefit/risk debate about when to treat.

What has gone wrong? Where is the hard science? The indisputable ground on which to make decisions about patient care.

Well, as Deep Thought famously said: “I think the problem, to be quite honest with you, is that you’ve never actually known what the question is.”

I myself am just sitting with that one, and don’t claim to have had a bolt of lightening about the question. The experience I have in the face of this though, is like working with a family where all the logical attempted solutions to say a child’s behaviour have actually become part of the problem and there’s a big tangly mess of action and reaction, and the best thing to do is to down tools and start again, and a big part of this is to help the individuals give up their certainties about how and why the problem began.

In starting again, there are some things we can say about psychotherapy with certainty:

That the therapeutic alliance is of primary importance, but that the qualities the therapist brings to this alliance are vastly under researched.
That no one model is superior to another when put under scrutiny that controls for quality of study design, therapist allegiance to the model being tested, and comparison to a bona fide treatment.
That therapist allegiance has a robust influence on effective outcome, but is vastly under researched.
That most therapists do not improve with years of experience, implying that their education and continuing professional development, must not be currently focussed on what is responsible for effectiveness.

That feedback is a good starting point, but we need to know more about what to do with that feedback.

The difference between a good therapist and an average therapist is far greater than the perceived difference between models that has been exhaustively investigated, but we know very little about what the good therapist is doing that the average therapist isn’t.

Theres still a lot we don’t know about. We know almost nothing about people who get worse with treatment. The only things I’ve seen written about this phenomenon, generally follows a demeaning, paternalistic bent around the fact that these people are not psychologically minded or sufficiently cognitively sophisticated to be helped by therapy.

We don’t know much about people with severe mental illness who do actually get better. The people who are literally “cured”. It is usually said that they can’t really have had that severe diagnosis in the first place. Then they are dismissed.

I think that we need to think differently about the whole issue, and to start asking different questions…. but what? What do you think?