34th St, Manhattan, New York.

Dear Editors,

Hi to all, and a special hello to colleagues from the Dublin Counselling and Therapy Centre whom I met while training there in 1994.

I worked in Limerick for thirty years and in January 2004 we moved to New York as a middle-aged couple leaving an adult family in Ireland. My husband commenced work at United Nations Headquarters while I set about finding us a place to live. Eight months later we are enjoying New York living. I do some volunteer work with senior citizens in the locality and some support work with spouses of U.N. staff. I have discovered a centre in Soho which offers a large range of courses including Chinese Healing Practices, Eastern Mystical Christianity and Mongolian Throat Singing! I also get a chance to read the New York Times which brings me to the purpose of this contact.

Recently, I read a report by Benedict Carey about the annual meeting of the American Psychological Association held in July 2004 in Honolulu. The Association, with a membership of more than 150,000 is the largest professional association of psychologists. The topic being discussed was the nature of psychotherapy. Is it an intuitive process, more art than science? Or is it more a matter of a therapist following specific procedures that reliably help people get better? The debate caused acrimony. On one side are experts who argue that what therapists do in their consulting rooms should be backed by scientific studies proving its worth. On the other are those who say that the push for evidence threatens the very things that make psychotherapy work in the first place.

Over the past decade a group of academic researchers has argued for the instruction manual approach, compiling a list of short term therapies that studies have shown to work for a variety of mental disorders. For example, Cognitive Therapy in which the clients learn to refute pessimistic or degrading thoughts, and Exposure Therapy in which they overcome anxieties by gradually learning to face the situations they fear. This evidence-based approach has already had a significant impact in the market place.

In America, many of the country’s mental health insurers base their coverage for psychotherapy on what the research says and expect their therapists to practice techniques that are backed by studies. Many insurers now require therapists and patients to document the therapeutic process, providing evidence that what is talked about in the consulting rooms is working. Dr. J. Viccaro, a psychiatrist, and President of Pacificare Behavioural Health a large mental health insurer, has said that his firm closely monitors how well each patient is doing. The idea is to make the therapist accountable for patient outcomes.

Some of the country’s top clinical psychology programs place strong emphasis on evidence-based therapies. In a field where practitioners are used to following their own instincts, this ‘show me’ approach has stirred outrage. They say that the healing they offer is too complex to be captured in standard studies and that to justify it to a third party is a breach of patient privacy. Dr. G. Gabbard, a psychiatrist and psychoanalyst who teaches therapeutic techniques at the Bayor College of Medicine in Houston, said. ‘The move to worship at the altar of these scientific treatments has been destructive to patient and practice because the methods tell you very little about how to treat the real and complex people who actually come for therapy’.

The champions of the empirical approach say that, despite sceptics’ complaints, accountability has brought more credibility to the profession. Insurers and policy makers are gradually becoming more convinced that psychotherapy is a rigorous treatment, not indulgent and open-ended. Recently researchers have been trying to find some accommodation between the two camps on what it is about any therapy that makes it effective, rather than holding one method above the other. Studies suggest, for example, that factors like how motivated clients are, their readiness for change, the gifts of the therapist, and the strength of the bond between client and therapist all make a difference in whether psychotherapy is successful. Perhaps the only emerging consensus among the experts is that research into psychotherapy should not solely rely on clinical trials in which one group of people is given a treatment and then compared with others who received a placebo. The chaos of real life somehow has to be included.

I find myself with a foot in both camps. I agree somewhat with the empiricist but would not agree that these therapies be used in a rigid manner. Instead, they should be considered as tools with which we construct an individually tailored therapy. Another issue that this article raises for me is the intrusion into the therapy room of the insurance industry and the potential danger of that. No doubt in Ireland as in America the debate will emerge and raise controversy.

Best regards

Grainne Doyle


Grainne Doyle