Jonathan Shedler, Ph.D. is a critic of many aspects of today's practices in psychotherapy, and many of his views are similar to my own. He recently listed what in his view are the main factors in the dramatic decline of quality psychotherapy (I thank Dr. Steven Reidbord for calling this to my attention):
Deep intrusion of health insurance agendas into psychotherapy and its training
Dramatic decline in reimbursement. Psychologists in managed care paid 70% less
than 1980s. “Best and brightest” now choose other careers
Out-of-control proliferation of for-profit graduate training programs that
admit and graduate anyone who can pay
Influx into psychotherapy professions of vast numbers of practitioners who lack
adequate training and aptitude
Pharmaceutical marketing/PR campaigns changed public perceptions, normalized
meds and seeking MH care from primary care doctors as solution for problems in
living
Therapy researchers operate in academic silos with little knowledge of
psychotherapy and no contact with real-world psychotherapists. Most “therapy”
research irrelevant and useless to clinical practitioners
Conflation of psychological problems with DSM diagnoses (by health insurers and
academics researchers both)
Conflation of psychotherapy “outcome” with DSM symptom lists (driven by health
insurers and academics researchers both)
Rise of social media therapy influencers and their self-promotion (“the death
of expertise”)
Intense politicization of therapy professions; emergence of a training culture
that incentivizes “right” politics & ideology over professional competence
Impact of tech companies/private equity. E.g., lowest tier therapists
recruited, marketed, paid like Uber drivers. Advertising deliberately erases
distinctions between levels of training and experience
Low or no barriers to entry; MH field is low hanging fruit for all manner of
self-promoters and opportunists
“Clinical supervision” no longer a clinical training relationship with skilled
clinical teacher/mentor, but often reduced to an administrative function by
clinics/agencies
Runaway bureaucratization—inordinate time spent on
forms/paperwork/documentation/ever-expanding bureaucratic requirements that
neither benefit patients nor develop clinical skills in therapists
Extreme gender imbalance in training programs (classes often >90% female)
with resulting loss of balance and perspective. Male students routinely report
feeling unwelcome/marginalized/silenced
Increased emphasis in training programs on paint-by-numbers “manualized”
therapies in place of fundamental psychological principles and core
psychotherapy skills
Endless proliferation of “new” therapy brands/models/acronyms instead of
emphasis on fundamentals skills. Virtually all are repackaging of
well-established principles, endlessly reinvented/rediscovered by people
lacking profound knowledge
Rampant denial of the role of unconscious mental life
–and neglect of personality & personality pathology.
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To those I would add seeing people's problems as "all in their heads" while ignoring family systems and sociocultural issues.
