I’m referring to modern psychotherapy as a whole.

For some reason, people think that modern psychotherapy is completely unrelated to psychoanalysis. One is the other’s grandchild. The vast majority of psychiatric residencies still require traditional psychodynamic training, which is normally learned before cognitive and behavioral theories. Although the precise amount of time varies, most residents spend more time on psychoanalytic theories, if only because a lot of residents stop reading for lectures a few months into the program. Clinical psychologists, of course, spend even more time on psychoanalytic ideas than their medically-trained siblings. But all the programs I’m aware of teach psychoanalytic theories before they teach cognitive and behavioral theories. Even then, clinical psychology programs wind up spending more time on cognitive/behavioral/whatever-the-new-secular-Buddhism’s-theory-name-is,
I’m not sure it really eradicates Freud’s influence — especially not in very gendered disorders like EDs.

That said, there’s always discussion about changing the curriculum to include more evidence-based medicine, and I think they just instituted something this past year. Fortunately, I’ve been out of the psychiatric game for a few years now so I’m not terribly up to date.

The reason why even Harvard psychiatry professors believe that talk therapy works due to the placebo effect is because a) none of the different types of talk therapies perform better than any of the other talk therapies,* b) the Eysenck research on psychoanalysis has not only been repeated, but is also been supported by research using similar designs to test the efficacy of modern psychotherapies, and c) studies comparing different varieties of talk therapies to “placebo doctors” (i.e., confederates paid to dress up in white coats and pretend they’re doctors) suggest that psychiatric and psychological training doesn’t improve patient outcome.

The thing is placebos really do work; patients really do get better.

The problem is that the majority of patients wind up like my parents — $100k+ in the red. And, statistically speaking, the only thing worse than debt for mental health is death.

I suspect that these structural relationships contribute to women’s comparatively poor mental health. I agree that there’s quite a bit of truth to the adage “men with mental illnesses get sent to prisons, while women get sent to physicians,” but I suspect the long-term financial hit that long-term talk therapy requires is still corrosive in its own right.

*Exception to the rule: phobias. Desensitization therapy does produce a statistically significant improvement than other types of psychotherapies. There’s probably more, but it’s 2:15 a.m. EST and I can’t sleep because there’s a six-inch gigantic flying cockroach in my apartment. While I have many, many mental health issues, surprisingly I’m not phobic. (Because D.C. used to be a swamp, we get the creepifying flying tropical cockroaches. They’re so huge that even my cats run away from them.)

/threadjack

Not exactly. Traditional Freudian psychoanalytic schools are rare, but psychoanalytic training is still a key component of psychiatric residencies — which is probably why neo-Freudian familial explanations are still so dominant in ED treatment. I don’t know about you, but I get nervous when I see arguments that bear an uncanny resemblance to evolutionary just-so stories.

agencies cant’ get government funds or from most grantors unless they are using evidence based practices.

Yup — which is why my parents wound up spending 100k+ on ineffective therapy. Wouldn’t that have been much better spent on abandoned Indian girls’ educations?

I obviously don’t know where you have been treated, but finding many Freudian therapists is not that easy anymore. Freud is taught but even his adherents have moved on. of course Freudian types are the farthest from using research and evidence in their work. I’ve not heard that any sort of Freudian style is the preferred treatment method for any problem. psychoanalysis is old school, and not in a good way.

mental health or illness is multi causal, always has been. there is likely more than one cause for most mental illnesses. An ED is more of a cluster of symptoms that has several possible and common causes. it is likely that some people have more of genetic predisposition than others which makes the research difficult along with mixing in different cultures, etc.

The problem is that making a fatally flawed theory “less bad” doesn’t make the theory less fatal. Or in the case of my ED treatment, less expensive: my parents effectively wasted $100k on treatment that’s as effective as a placebo. If mental health really matters, then mental health professionals really need to start holding themselves to the same standards the rest of medicine does. Otherwise, insurers are perfectly justified in refusing to cover non-pharmacological therapies.

Last time I checked, one twin can become an alcoholic and not another

…Which also doesn’t follow from combining the biomedical model of disease* with psychoanalytic views of family dynamics.

*I could explain more about the difference between mono/mono, mono/di, and di/di identical twins and their implications for neurological and psychological research, but that would probably be too tangential. Like many of my professional cousins in domestic mental health law and policy, I’m a tad skeptical about defining EDs, addictions, and PTSD, and most forms of depression as diseases instead of as illnesses. They seem to be oddly rational adaptations to toxic social values and situations more than anything else.

I don’t doubt this. But if family dynamics really is as important as you, Courtney Martin, and pretty much every other mental health professional I’ve ever interacted with says it is, then how do you explain the diversity of family dynamics? How does it account for the fact that one twin can get an ED, but not the other?

Families do trigger disordered eating, the media does, peer culture does — and as many have shown, religion has.

I agree with you on media and peer culture. I’m not sure if I know enough about the role between religion and food to really gauge whether or not religion causes EDs. The only book on religion’s role in EDs I’ve read is Bynum’s Holy Feasts and Holy Fasts, and I thought that was more about interpreting the meaning of voluntary starvation in medieval women rather than an argument that religion caused voluntary starvation in medieval women.

Families, I really doubt. Before being forced to drink the Kool Aid, family problems really only entered into our explanation of why we were hospitalized, not why we had the disorder. I suspect doctors miss the subtle distinction because Freud’s shadow continues to distort the professional lens through which they view clients. Although Luhrmann maintains that this common for psychiatric disorders without effective pharmacological interventions, I suspect it’s even more pronounced with EDs because of their gendered nature.

Here’s my really big question, though: how do the existing familial explanations differ from evolutionary just-so stories? Virtually all* of the research I’ve read supporting the idea of familial contributions is not only methodologically shoddy,** but also subject to a Judith Rich Harris-esque critique. If peer groups and media account for the domestic and international trends, then what are familial explanations explaining? Instead of causal explanations leading to the development of effective ED therapies, are they ultimately morality vignettes about what the role of women and children in families should be?

*The exception that proves the rule is the research on how family counseling to help teenagers reintegrate into their pre-hospitalization/treatment life. However, familial support during and after psychiatric treatment does not imply that flawed familial dynamics triggered the ED in the first place. It just implies that social support helps mental health.

**I am fully aware of how silly this sounds from someone in a profession that privileges arguments from authority.

I think the tendency is always to focus on one particular dynamic (cultural, psychological, physiological) at the expense of others. Almost everyone who writes about eating disorders does this — when of course, it’s a constellation of factors, all working together in different ways. Families do trigger disordered eating, the media does, peer culture does — and as many have shown, religion has.

Which is why, of course, a holistic approach that empowers those who struggle to fight back on multiple fronts is best. And I’m delighted Twisty worked so well for you!