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Preserving Our Humanity as Therapists.

Article  in  Psychotherapy Theory Research & Practice · June 2005

DOI: 10.1037/0033-3204.42.2.139

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Psychotherapy: Theory, Research, Practice, Training
2005, Vol. 42, No. 2, 139 –151
PRESERVING OUR HUMANITY AS THERAPISTS
NANCY MCWILLIAMS
Rutgers University
Psychotherapists have traditionally em-
braced core values and beliefs that dif-
fer significantly from many values and
beliefs that pervade contemporary,
commercially oriented Western cul-
tures. With their clients, therapists often
question or challenge the culture’s ma-
terialism, consumerism, appeals to van-
ity and greed, disdain of dependency
and vulnerability, and abetment of nar-
cissistic entitlement. Currently, how-
ever, psychotherapy is being reshaped
by descriptive psychiatric diagnosis,
pressures from powerful corporate in-
terests, and antagonism from influential
academic psychologists and is threat-
ened with becoming the servant of the
surrounding culture rather than its
participant/observer and critic. The
author notes symptoms of this trend
and offers ideas about reversing it.
As it has developed over the past century, the
profession of psychotherapy— until recently
composed mainly of practitioners influenced by
psychodynamic, humanistic, and existential
thinking— has been characterized by cardinal be-
liefs, attitudes, and values (Jensen & Bergin,
1988; Stern, 1996) that are strikingly at odds with
many beliefs, attitudes, and values that suffuse
contemporary, technologically advanced, market-
driven Western cultures. Although none of us can
stand fully outside our own culture, within the
larger social context, psychotherapy subcultures
have flourished as a kind of alternative sensibility
Nancy McWilliams, Graduate School of Applied and Pro-
fessional Psychology, Rutgers University.
Correspondence regarding this article should be addressed
to Nancy McWilliams, PhD, 9 Mine Street, Flemington, NJ
08822. E-mail: nancymcw@aol.com
Copyright 2005 by the Educational Publishing Foundation
0033-3204/05/$12.00 DOI: 10.1037/0033-3204.42.2.139
to the radically individualistic, consumeristic,
technocratic mass culture we inhabit.
Numerous seminal writers have tried to artic-
ulate therapeutic values, including, among others,
self-understanding (e.g., Blum, 1981), authentic-
ity (Bugental, 1989; Meissner, 1983), empathy
and compassion (e.g., Kohut, 1977; Rogers,
1951), egalitarianism (Sullivan, 1947), adaptation
to unchangeable realities (Freud, 1937/1971;
Stark, 1994; Yalom, 1980), growth in agency and
personal responsibility (May, 1958; Schafer,
1976), acceptance of normal dependency (Aron,
1996; Ghent, 1990; Kernberg, 1970), and respect
for others as subject rather than object (Agassi,
1999; Benjamin, 1997). It could be argued that
with every individual with whom they engage in
a deeply therapeutic way, therapists quietly chal-
lenge many of the more facile and potentially
destructive assumptions of the larger society (cf.
Aponte, 1996; Augsburger, 1986; Brace, 1992;
Christopher, 1996; Grant, 1985; B. Hansen,
2004; Harari, 1989; Meares, 1999; Messer &
Woolfolk, 1998; Rieff, 1966; Robinson, 1997;
Wachtel, 1997).
Thompson (2004) contended that because of
the centrality of an ethic of honesty in the original
Freudian project, psychoanalysis is inherently
subversive. In insisting that we try to tell the truth
about sexuality, aggression, dependency, narcis-
sism, and other features of human nature that
post-Victorians found less than seemly, Freud
(1937/1971) exposed some hypocrisies and con-
ceits of his era and culture. Whatever his own
blind spots, he set a tone for the attempt to get
beyond individual and cultural illusions into ter-
ritories that are unsettling and humbling and that
undermine the pieties and complacencies of both
scientific and popular habits of mind. Ultimately,
he related the project of trying to be honest to the
relief of psychological suffering, associating truth
with freedom in an ancient equation (Rieff,
1959). Brown (1994) has made a similar argu-
ment about the subversiveness of feminist thera-
pies, and writers from other perspectives have
made comparable observations (e.g., Cushman,
139
MCWilliams
1995; Frank & Frank, 1991; Hillman & Ventura,
1992; Wachtel, 1997).
Similarly, one can regard the culture of the
profession of psychotherapy, the culture of prac-
titioners, as inherently subversive. Its unconven-
tional project has been carried forward more or
less explicitly by most practitioners of psychody-
namic, existential, and humanistic orientations
and implicitly by many clinicians trained in fam-
ily systems and cognitive and behavioral ways of
working. Practicing therapists are all confronting
the same phenomenon, the troubled human ani-
mal, and striving to find ways to relieve emo-
tional misery, often in defiance of the pressures
and demands of the surrounding culture. Some of
the current stresses on practitioners may be inter-
preted as indicating that the dominant cultural
voices have identified this project as subversive.
Or perhaps those voices are now simply so ubiq-
uitous that their indifference to traditional thera-
peutic values undermines those values by starva-
tion and attrition, as psychotherapy is redefined
according to norms that most practitioners regard
as defensive, dehumanizing, alienating, inauthen-
tic, reductionistic, and even perverse.
This essay began as a speech to a like-minded
audience. In rewriting it for publication, I might
not have succeeded in expurgating a tone of in-
dignation about the current status of a profession
I cherish. I suspect that part of what makes some-
one an effective therapist is a passionate belief in
his or her way of working (cf. Helm, 2004).
Because I find it hard to leave such an attitude in
the consulting room, I ask more skeptical readers
to make allowances for my identifications and to
consider that it is more honest for me to be
frankly biased than to make putatively neutral
observations. I have organized the following ar-
gument in a case presentation format, with the
“disorder” construed as a societal problem.
The Presenting Problem
From my perspective, the main manifestation
of a threat to traditional therapeutic values is the
pervasive message that psychotherapists should
not be trying to understand and mend the broken
heart, or heal the tortured soul, or promote the
acceptance of painful realities. Instead, we should
be trying to medicate, manage, reeducate, con-
trol, and correct the irrational behavior of people
whose suffering is inconvenient to the larger cul-
ture. Few therapists oppose the judicious use of
140
medication, management, education, and even
control, but most of my colleagues have become
alarmed at the erosion of what have for decades
been the more fundamental aspects of our mis-
sion as psychotherapists: to understand; to help;
to speak the truth; to make a meaningful connec-
tion with our clients that fosters their sense of
agency, their capacity for enjoyment and mas-
tery, and their ability to tolerate grief and limita-
tion, whether or not their behavior is unconven-
tional and inconvenient according to ordinary
cultural norms.
The original popularity of psychoanalytic ideas
among American intellectuals and professionals
in medicine, psychology, social work, education,
and religion was a bit of a fluke. Psychoanalysis
was an anomalous visitor to the United States.
Americans have long been noted for optimism,
practicality, rationalism, materialism, privatism,
and (despite the individualistic language we in-
herited from Locke) stifling conformity (Bellah,
Tipton, & Sullivan, 1985; de Tocqueville,
1835,1840/2000; Riesman, 1950/1968). The psy-
choanalytic movement was hardly notable for a
comparable sensibility. Notwithstanding his
friendships with American intellectuals such as
Stanley Hall and James Jackson Putnam, Freud
viewed the United States with barely disguised
scorn; privately, he was known to refer to the
nation as “Dollarland.”
But Americans, whose Puritan origins were
rooted in a utopian project and who have had
recurrent romances with utopian movements
(Fogarty, 1972), crave the latest thing. When
psychoanalysis was the latest thing, many em-
braced it with uncritical enthusiasm— claiming
too much for it, treating competing ideas con-
temptuously, and making inevitable the disillu-
sionment that followed. Now that psychoanalysis
is no longer new, now that its quirkier ideas have
been debunked and its better ones have been
absorbed into the vast body of cultural assump-
tions that we think of as common sense rather
than psychoanalytic revelation, Freud’s cherished
movement has been relegated by many to the
dustbin of ancient and failed ideologies. Whether
or not psychoanalysis ever regains widespread
respect as a scholarly theoretical discipline, to me
there is a larger question: whether the general
psychotherapeutic sensibility that psychoanalysis
set in motion will be similarly devalued. If it
is, the life work of most of us in the therapy
professions, whether or not we identify with

the psychoanalytic tradition, will be seriously
compromised.
Context of the Problem
The influx of a European, mainly Jewish,
philosophically sophisticated sensibility into the
United States in the intellectual diaspora accom-
panying World War II lent a tone to scholarly
discourse that differs significantly from more
conventional American attitudes (see Ash, Soll-
ner, Mauch, & Lazar, 2002). The infusion of this
tone into American intellectual life, not only in
the psychotherapy-related fields but also in the
sciences, arts, humanities, and social sciences,
created a rich and fertile tension. The more Eu-
ropean sensibility, as it applies to the therapeutic
endeavor, embraces curiosity and awe about un-
conscious processes, assumes complexity, em-
phasizes identification and empathy, respects af-
fect, values subjectivity, appreciates attachment,
and embodies faith in a complex interpersonal
process that cannot be broken up into its compo-
nent parts without doing violence to the whole
(McWilliams, 2004). Now, as the generation of
Holocaust-displaced thinkers is dying out and the
influence of those intellectual heavyweights on
American discourse wanes, the pragmatic, ratio-
nalistic, conventional, logical–positivist, scien-
tistic sensibility that has historically been main-
stream in American universities seems to be
reasserting its dominance in ways that many ther-
apists find disturbing.
Symptoms
Cultural historians may ultimately conclude
that Freud’s most enduring impact on North
American culture was to increase our success at
selling cars. Advertisers and image makers have
mined psychoanalysis with breathtaking effec-
tiveness. Our sexuality, aggression, attachment,
emotional insecurity, envy, and narcissistic vul-
nerability have all been ingeniously exploited in
the service of commercial interests. Now that
pharmaceutical companies are permitted to ap-
peal directly to TV viewers, we are regularly told
that their products will cure most of the more
uncomfortable symptoms of being human. Let
me summarize some conclusions one can draw
from the current popular media and the tone of
contemporary political commentary, emphasizing
Preserving Our Humanity as Therapists
those messages that therapists have traditionally
regarded with considerable skepticism:
1. If you’re rich enough, you’ll be happy.
2. If you’re famous enough, you’ll be happy.
3. If you’re beautiful enough, you’ll be
happy (if not, there’s always cosmetic sur-
gery).
4. If you get enough sex, you’ll be happy.
5. If you can retire and play golf all day,
you’ll be happy.
6. You can do anything you set your mind to
do. (A staple of American child rearing yet
a blatantly psychotic belief!)
7. All problems are solvable by practical in-
genuity.
8. Everything that goes wrong is somebody’s
fault.
9. If something goes wrong, find out who is
to blame and sue them. If you get enough
monetary reparation, you’ll be happy.
10. The “American dream” is all about mak-
ing money.
11. The cure for a bad relationship is separa-
tion.
12. The cure for an unsatisfying job is quit-
ting.
13. The cure for workplace problems is
downsizing—that is, firing people, irre-
spective of their former contributions, loy-
alty, or personal situations.
14. People are naturally mobile and can relo-
cate easily in response to corporate needs.
15. Youth is preferable to age, and children
are resilient. We can displace them, dis-
rupt them, subordinate their interests to
our convenience, and they’ll recover just
fine.
16. Freedom inheres in having more choices
rather than in the capacity to decide what
is a choice worth having.
17. Image is more important than substance.
141
MCWilliams
18. Perhaps most ominous: You deserve it.
You’re worth it. You’re entitled.
Reviewing these messages, one can find sym-
pathy for people from culturally conservative
groups both inside and outside America who are
dismayed by such ideas, though the most com-
pelling rebuttal to these omnipresent secular
themes may be not religious or moralistic but
empirical; namely, the lack of evidence that liv-
ing by these precepts increases well-being (cf.
Lane, 2000). Most clinicians can attest that there
is massive evidence for the converse, for the
considerable satisfactions that ensue when people
acknowledge limitation, respect their interdepen-
dency, grieve over inevitable disappointments,
and tame their sense of entitlement.
With TV and video games doing so much child
rearing these days, the impact of commercial
pandering should not be underestimated. In ear-
lier eras, many similar ideas suffused American
popular ideology, but the rootedness of most cit-
izens in smaller, stabler extended families and
communities, along with their exposure to con-
tradictory messages from civic and religious
groups, diluted the power of such themes and
fostered a more balanced view of the value of
wealth, beauty, fame, sexual gratification, infinite
possibility, and boundless entitlement (Bronfen-
brenner, 1979; Glendon, 1991; Lasch, 1995; Put-
nam, Felstein, & Cohen, 2001). In some minority
subcultures, especially those with a central spir-
itual life, such counteractives still exist, but, over-
all, very few cultural forces are currently calling
these assumptions into question.
Until fairly recently, therapists could under-
mine the more pernicious effects of popular ideas
such as these, one patient at a time, and restore a
sense of perspective to people for whom the
dominant culture’s attempted solutions to the
problem of human suffering left their own suf-
fering unformulated, untouched, and unmitigated.
At this point, the power of mental health profes-
sionals to counteract the effects of the destructive
messages that pervade the so-called developed
societies may be declining. Assumptions that
used to characterize the culture of psychothera-
pists, distinguishing it from the culture of the
larger society, are starting to disappear.
Consider, for example, our once bedrock belief
in the value of the examined life. In a recent
perusal of therapy texts, I found that it had been
over 50 years since anyone had made a compre-
142
hensive, systematic argument for the advisability
of therapy for the therapist (Fromm-Reichmann,
1950). Yet for most of those years, the psycho-
therapeutic equivalent of the adage, “Physician,
heal thyself!” was a mainstay of clinical lore,
passed on by therapists, supervisors, teachers,
and colleagues to those pursuing their develop-
ment as a therapeutic instrument. Although most
explicit in analytic institutes, the notion that ther-
apists should undergo therapy themselves was
not restricted to the analytically oriented. Human-
istic therapists entered experiential treatments;
family therapists explored their family of origin;
Gestalt therapists attended intensive Gestalt
workshops. Most of us trained before the 1990s
assumed that the wisdom in the norm of self-
examination was so self-evident that we would
never have to belabor the point.
Yet, in recent years, advocacy of therapy for
the therapist seems to have been disappearing
from the professional scene. In graduate pro-
grams and medical schools, students are taught to
carry out assessments; to master manualized in-
terventions for discrete, reified disorders; to pre-
scribe medication; to observe the letter (though
arguably not always the spirit) of the ethics codes
of their professions; and to adopt careful risk-
management strategies. But they are not neces-
sarily urged to explore their own psychologies, to
find their own vulnerabilities, and to learn how it
feels to try to talk about their most private and
shameful shortcomings with an intently inter-
ested stranger. The erosion of the conviction that
one needs to experience therapy to provide it to
others is only one symptom of what has been
happening to psychotherapy in recent years. Here
are three events that raised my own conscious-
ness about what is starting to look like the hand-
writing on the psychotherapeutic wall:
1. A few years ago, while consulting with
psychiatrists in the inpatient unit of a well-
regarded, university-affiliated medical cen-
ter, I conducted two interviews with se-
verely disturbed patients in front of some
medical residents. Afterward, I overheard
one young doctor comment to another,
“That’s a great line that she uses! I’m gonna
use that line myself!” Curious, I asked the
resident which “line” of mine he was ap-
propriating. His response was, “It was your
question, ‘Can you say more about that?’”
He had been trained to ask questions like,

“Has it been more than 2 weeks or less than
2 weeks?” and to check off the relevant
criterion in the Diagnostic and Statistical
Manual of Mental Disorders (DSM; Amer-
ican Psychiatric Association, 1994).
2. Around the same time, a social worker I
supervise got a detailed directive from an
insurer, explaining that to stay on its panel
of approved providers, she should be calcu-
lating each client’s “improvement per dol-
lar.” The company helpfully supplied a for-
mula for doing so.
3. Last fall, one of my students reported that
on his internship at a state mental hospital,
he heard another intern—an intelligent and
rigorously prepared prospective psychol-
ogist—say to a colleague, “You know that
guy in Room 17? I think he has a delusion.”
“Yeah, I’ve noticed that,” his friend replied.
“And you know what?” the first intern con-
tinued, “I couldn’t talk him out of it!”
“Yeah,” his friend agreed, warming to the
topic. “I had the same experience!”
These and similar stories I hear from col-
leagues suggest that the moral and assumptive
center of psychotherapy has been stunningly al-
tered in a few short years. The commercial cul-
ture from which therapists traditionally have been
taken a critical distance seems to have devoured
us, redefining the complex project of psychother-
apy in terms of the most simple-minded notions
of how one person influences another and subor-
dinating the therapist’s humanity to the interests
of social control and short-term cost saving. It is
worth wondering why, in an era when psychol-
ogy has gone far beyond a narrow behaviorism
into cognitive, affective, and relational science,
the venerable concept of mental and emotional
health has been replaced by the term behavioral
health, implying that the clinician’s job is essen-
tially to make people behave appropriately. The
implicit metaphor for the therapist seems to have
changed from healer to technician.
Lest my remarks be misunderstood as an attack
on short-term and cognitive– behavioral ap-
proaches, let me emphasize that I am not chal-
lenging the value, where appropriate, of brief
therapies and empirically derived techniques for
targeting specific problems. Rather, I am con-
cerned with the overall atmosphere in which all
therapists now find themselves practicing. My
Preserving Our Humanity as Therapists
experienced cognitive– behaviorally oriented col-
leagues (e.g., Lazarus, 1996) feel similar conster-
nation at how psychotherapy is being divested of
its humane essence and reduced to a potpourri of
technical strategies, aimed at isolated symptoms,
in the absence of a concern for the larger human
context.
Suspected Etiology
Although this sea change—from therapy as
antidote to contemporary mass culture to therapy
as enforcer of its requirements— has been shaped
by countless tides, I focus on four central and
interconnecting influences. First, some responsi-
bility for the current state of affairs lies with the
shift in our diagnostic conventions from dimen-
sional, contextual, internally defined, and infer-
ential models of assessment to discrete, acon-
textual, externally defined, and descriptive
paradigms. The effort to redesign the DSM of the
American Psychiatric Association so that it
would be more useful to researchers—the guid-
ing principle of the seismic shift from the second
edition of the DSM (American Psychiatric Asso-
ciation, 1968) to the third edition (American Psy-
chiatric Association, 1980) and subsequent
editions— has had wide-ranging effects on clini-
cal practice. There is a vast critical literature on
the limitations of the DSM (e.g., Barron, 1998),
but my main point here is to suggest that this shift
in diagnostic sensibility was the start of a slippery
slope of devaluation of therapists’ humanity and
a consequent decline in their power to protect and
nourish the humanity of their patients. It clearly
feels that way to most clinicians I have met,
whose cynicism about the DSM and its uses has
created a “least stigmatizing but still reimburs-
able” rule of diagnosis. In other words, therapists
put their clients’ dignity and fiscal welfare ahead
of their scientific values, which would require
accurate use of DSM criteria.
Second, and probably most pervasive in its
effects, is the success of the “Jackson Hole
group” of think tankers in the 1970s in arguing
that health care should be funded according to
what is essentially a venture-capitalist model.
The accident that the American economy did well
during much of Reagan’s presidency seems to
have contributed to a belief in the magic of pri-
vatization (Kuttner, 1999). In the United States,
all kinds of enterprises that were once public, or
at least publicly regulated, have since been pri-
143
MCWilliams
vatized: Communications, transportation, utili-
ties, penitentiaries— even some public schools—
are being run by private contractors, and, in the
name of the overvalued concept of “choice”
(Schwartz, 2003), some elected officials are ar-
guing for expanding opportunities to send chil-
dren to private institutions rather than putting
resources into improving public education. It is
not uncommon in American politics to equate
public ownership or responsibility with socialism
or communism and to equate those systems with
tyrannical dictatorship. Conversely, market-
driven capitalism is conflated with democracy
and held out as the moral alternative to ideolog-
ical menace.
Ceding responsibility for health care to private
insurance companies, on the assumption that
competition between corporations would reduce
costs, seems in retrospect to have been a remark-
ably naive idea, one that most practitioners be-
lieve has had profoundly destructive effects on
both treatment and prevention of mental illness
(Chipman, 1995; Kirschner, 2001). Insurance
companies marketed their policies to employers
with assurances that these plans included “com-
prehensive mental health care.” Within months
after closing such deals, they began redefining
comprehensive mental health care as brief treat-
ment for discrete disorders and pharmacological
management of so-called “biologically based”
conditions. Thus, in a single stroke, they dramat-
ically reduced mental health services and contrib-
uted to an attitude of denial about the complex
etiologies of many conditions with a biological
component.
Almost half of those seeking therapy have a
personality disorder that meets DSM criteria;
many more have clinically significant personality
pathology (Westen, 1997; Westen & Arkowitz,
1998). But American insurance companies, hav-
ing persuaded employers that they could save big
money without sacrificing needed care, quickly
realized that personalities are not transformed by
brief, inexpensive interventions and unilaterally
opted to deny reimbursement for Axis II condi-
tions. In keeping with the profit-driven mission of
these corporations, “psychotherapists” morphed
into “providers” and even “vendors,” and vendors
who served the “consumers” of psychotherapy
for longer than a few sessions were unceremoni-
ously dropped from the lists of therapists whose
services insurance companies would cover.
Therapists are all too familiar with the conse-
144
quences. Some waste has doubtless been elimi-
nated, but at a terrible cost. Quality mental health
care, especially for minorities and poorer pa-
tients, is disappearing (La Roche & Turner, 2002;
Virnig et al., 2004). Sensitive, adequate psycho-
therapy for the seriously mentally ill is virtually
nonexistent (Whitaker, 2003). Hospitals struggle
to provide even minimal care. Individuals with
longstanding substance use disorders are “de-
toxed and rehabbed” within a week. Suicidal
people are kept in treatment facilities only until
they agree not to kill themselves, whereupon they
are discharged, often without follow-up psycho-
therapy. If they take their life successfully once
liberated from the insults of this experience with
the mental health system, at least the hospital is
not liable; the patient has been “treated,” and the
case is no longer on its rolls.
In supervision and consultation meetings
where practitioners once brainstormed to deter-
mine the best possible treatment for a given cli-
ent, they now spend their time comparing notes
on how to approach the relevant insurance com-
pany so that the client has some chance to get any
treatment at all. Rather than immersing them-
selves in the work for which they underwent a
long and demanding training, they devote inordi-
nate time to haggling with bureaucrats and writ-
ing vapid reports full of the insurance industry’s
favorite buzz words. What used to be a rich
professional lore about various intervention pro-
grams and treatment strategies has turned into a
shared expertise about the idiosyncracies of dif-
ferent insurance plans. The stress of all this on the
identity and self-esteem of therapists has been
severe (Donald, 2001; J. Hansen, 1997).
In the United States, the fact that medical ben-
efits are conferred by one’s employer means that
no one who develops medical insurance plans has
a long-term perspective: People change jobs fre-
quently enough that insurance companies have no
motivation beyond saving costs in the short term.
Benefit managers, who are evaluated on an an-
nual basis, have no incentive to pay for long-term
savings. The fact that psychotherapy demonstra-
bly reduces overall medical expenses (Dossmann,
Kuttner, Heinzel, & Wurmser, 1997; Gabbard,
Lazar, Hornberger, & Spiegel, 1997; Lazar,
1997) and probably reduces expenses for incar-
ceration, drug abuse, posttraumatic enactments,
and other costly accompaniments of psychopa-
thology, while increasing productivity and life
satisfactions that go well beyond simple symp-

tom reduction, does not figure into a private in-
surance company’s calculations. A close friend of
mine was hired as the CEO of a managed care
company insuring poorer families. She began her
tenure there by telling the staff, “We need to keep
in mind that while we want to make money, we
also want to do right by the people we insure.”
She overheard an employee whisper, “She won’t
last long.” He was right.
There may even be dispositional reasons why
people in the insurance industry devalue psycho-
therapy. The temperament that inclines one to-
ward corporate life may be significantly different
from the temperament that seeks a therapeutic
vocation. I recently asked a relative who heads a
major insurance corporation how psychotherapy
is regarded in his field. He was happy to educate
me, in memorable phrases such as “a load of
crap,” “a needless crutch,” and “a course in self-
indulgence for whiners.” Therapists and their pa-
tients should not have expected, and cannot ex-
pect for the future, a lot of sympathetic
understanding and support from that direction.
Third, we need to scrutinize the role of the
pharmaceutical industry, whose profitability de-
pends on framing problems in living as reified
“disorders” that can be treated chemically. It is in
the financial interest of both insurance companies
and pharmaceutical corporations to define mental
and emotional suffering in terms of physical pro-
cesses that can be targeted, chemically altered,
and “managed.” Despite the effectiveness of
medication for many conditions, troubling ques-
tions remain. Have we really had an epidemic of
attention-deficit/hyperactivity disorder over the
past 2 decades? Does that mean we should be
medicating vast numbers of children? What has
changed biologically that this generation has so
many diagnosable disorders treatable only with
drugs? Do 4-year-olds really display the symp-
toms of biologically based bipolar disorders for
which they will need a lifetime of medication?
Does the drastic increase in adolescent suicide in
recent decades mean that something ominous has
happened to the gene pool? Pharmaceutical com-
panies fund much of the research on questions
such as these, and we know which studies they
publicize. Psychologists should think critically
about a state of affairs in which so much basic
research is sponsored by investigators with a
huge financial stake in a particular outcome.
The context for the recent movement to estab-
lish “empirically supported” or “evidence-based”
Preserving Our Humanity as Therapists
treatments in our field includes the fact that re-
search psychologists have understandably wanted
to test the pharmaceutical industry’s claims that
chemical treatments are superior to psychothera-
peutic treatments. In demonstrating that psycho-
logical treatments can relieve depression as fast
as medication can, researchers have concentrated
on studying brief therapies. With remarkable
swiftness, their work was expropriated by insur-
ers to argue that if one must have psychotherapy,
there are empirically supported, short-term ways
to bring about changes that experienced practi-
tioners, not to mention several decades of out-
come research, have determined to require both
time and trust (Weinberger, 2004).
Fourth, the longstanding, worsening estrange-
ment between academic researchers and full-time
clinicians in psychology has reduced the chances
that academics will feel identified with and em-
pathic about the realities of clinical life. Given
pressures to get research grants, often privately
funded ones, that support the kinds of publica-
tions that secure tenure and promotion, even
those faculty members who wish to have a small
practice may be well advised not to do so (A.
Demorest, personal communication, March 27,
2002). An indirect result of such pressures is that
undergraduates aspiring to be therapists are in-
creasingly being taught by psychologists with
comparatively scant clinical experience and little
time to read primary sources in depth. Many of
my current graduate students complain that they
were never assigned anything by Freud, Rogers,
Erikson, Skinner, or Bandura, to say nothing of
Winnicott, Kohut, Perls, Ellis, and Gendlin.
The contempt of some academic psychologists
for their psychotherapist colleagues, along with
their distortion of what we believe and do with
our clients, is hard to miss. A subtle disdain for
practitioners suffuses some writing on evidence
in psychotherapy. Some researchers have a trou-
bling tendency to take the moral high ground and
accuse their therapeutically oriented peers of cre-
dulity to the point of malfeasance (e.g., Dawes,
1996; Lilienfeld, Lynn, & Lohr, 2004). There is a
vocal and powerful contingent in the American
Psychological Association (APA) currently argu-
ing that if a person comes to a therapist with a
condition for which an “evidence-based treatment”
exists and is treated in accordance with any other
approach, the therapist should be held in violation
of the APA ethics code and subjected to sanc-
tions. In recent months, spokespeople for this
145
MCWilliams
group have caught the ear of the popular media
(e.g., Goode, 2004), through which they have
been implying that conventional therapists are
undisciplined, lazy, exploitive, and antiscientific.
There has always been ample misunderstand-
ing between academic psychologists and clini-
cians. Even in my own practitioner-oriented grad-
uate program, one encounters versions of the
myth that the independent practitioner hangs out
a shingle, rakes in the money, fosters an unnec-
essary dependency that keeps the cash cows com-
ing back, and is accountable to no one. Some of
my university colleagues persist in assuming that
private practitioners treat mainly the “worried
well.” (Ironically, one could argue that it is psy-
chologists touting evidence-based treatment who
now treat the worried well, as they exclude com-
plexly disturbed individuals from their research
protocols; Westen & Morrison, 2001). Con-
versely, therapists envy professors’ freedom from
responsibility for the welfare of unhappy, de-
structive, and suicidal people. They may mini-
mize the unique stresses suffered by academics
and the legitimacy of their concern that psycho-
therapists document their claims. It is understand-
able that researchers are critical when therapists
ignore the empirical literature on therapy, and it
is equally understandable that therapists regard
academics as having little sense of the realities of
practice.
As the cognitive revolution in psychology has
illuminated unconscious cognitive and affective
processes that therapists have described in theo-
ries and metaphors for years (e.g., Magai &
Haviland-Jones, 2002; Westen, 1998), many
practitioners have hoped for a rapprochement be-
tween academic and therapist sensibilities. But
the recent co-optation of the prejudices of many
academic psychologists by the wealthy and po-
litically powerful insurance and pharmaceutical
corporations, in the service of their own agendas
and with widely perceived damage to patient
care, has painfully exacerbated the scientist–
practitioner divide.
For many decades, therapists seemed to be
winning the public-relations war against denigra-
tors of their efforts to take seriously the complex
subjective experience of people who suffer men-
tally and emotionally. At least we won some
important battles. Cultural attitudes toward men-
tal illness have clearly changed. In contemporary
European-influenced countries, patients are un-
chained and unlobotomized. Bipolar illness and
146
schizophrenia are seen as treatable conditions
rather than moral depravities. The addicted, once
simply condemned, are urged to get help. But just
as the stigma that has clung to the status of
mental patient for centuries was beginning to
disappear, a new, multidetermined, and econom-
ically overwhelming juggernaut has threatened
humane mental health care.
Of late, therapists are losing the public-
relations war, and we are not without culpability
in this loss. By not delivering on ambitious and
empirically unsupported promises, by talking to
each other more than to the educated public, by
isolating ourselves outside the disputatious class-
rooms of the universities and refusing to engage
in relevant academic controversies, by viewing
outcome research with indifference, by talking
about therapy in impenetrable jargon and imply-
ing that ordinary folk cannot be expected to grasp
such concepts, many practitioners have contrib-
uted to their own marginalization. If therapists
are to counteract the dehumanizing effects of the
antitherapeutic messages that pervade contempo-
rary life, they need to address these failings and
start fighting proactively on behalf of their val-
ues.
If I am any example, fighting is the last thing
therapists want to do. We prefer to find common
ground, to see the other guy’s point of view. Most
of us would rather spend our time learning how to
become better clinicians and passing on that wis-
dom than spend it trying to persuade people of
opposing sensibilities that what we do is valu-
able. But a lot is at stake in our profession right
now. Clinicians are in danger of being redefined
in terms of categories that make sense to the
powers that be in the larger culture and of losing
a valuable role as critics of the deleterious as-
sumptions of that culture.
Treatment Plan
The remainder of this essay contains ideas
about how clinicians can act on behalf of our
profession and the values that have traditionally
infused it. First, we need to join forces with
psychotherapists of other disciplines and compet-
ing orientations to articulate a vision of mental
health care that is more humane and less techno-
cratic. It is certainly possible for psychologists to
appreciate their own training without talking
down to colleagues in social work, education,
pastoral counseling, psychiatry, and psychiatric

nursing. We cannot afford interdisciplinary
squabbles when the survival of our work as a
fundamentally humane enterprise is at risk. The
beleaguered minority of psychiatrists who persist
in doing therapy, rather than the much more
lucrative business of serial medication consults,
is a valuable ally. In this political environment,
APA’s decision to seek prescription privileges
for psychologists— however sensible on its own
merits— has been politically disastrous, in that it
has escalated hostility between psychologists and
psychiatrists at a time when such turf wars are
tantamount to fighting over deck chairs on the
Titanic. Similarly, we need to appreciate that
practitioners of even starkly contrasting orienta-
tions within the psychotherapy community are
trying to grapple with the same human phenom-
ena and that there is wider agreement among
diverse clinicians than we might expect about
how long it takes to help someone with signifi-
cant psychopathology. We need to unite against
influences that diminish what any of us can do for
our fellow human beings.
Second, we need to challenge current claims
that traditional and longer-term therapies are not
evidence based. There is more evidence for the
effectiveness of analytic and experiential thera-
pies than for any other approaches, given that all
the research on therapy outcome conducted be-
fore the cognitive– behavioral movement picked
up steam was done on dynamic and humanistic
treatments, and researchers consistently found
evidence of their effectiveness (Doidge, 1997;
Seligman, 1995; Smith, Glass, & Miller, 1980;
Strupp, 1996; Wallerstein, 2001). There is emerg-
ing empirical evidence that long-term and inten-
sive therapies are more effective—and probably
ultimately more cost effective—than the brief
interventions favored by managed care compa-
nies (e.g., Blomberg, Lazar, & Sandell, 2001;
Target & Fonagy, 1994). And there is a robust
empirical basis for traditional psychotherapies in
the research literatures on attachment, emotion,
perception, memory, defense mechanisms, infant
and child development, interpersonal relations,
brain function, and personality. Researchers may
reasonably chide therapists for not staying cur-
rent with data on specific, empirically tested,
symptom-targeted treatments, but their enthusi-
asm for the techniques they investigate should
not obscure the fact that therapists’ more generic,
holistic, traditional approaches are also grounded
in evidence (Goodheart, 2004).
Preserving Our Humanity as Therapists
The most consistent finding in the outcome
literature is that the quality of the relationship
between therapist and patient has more impact on
outcome than any other variable (see Norcross,
2002). Messer and Wampold (2002) have con-
cluded that instead of choosing a therapist on the
basis of expertise in empirically supported treat-
ments, prospective clients should check out cli-
nicians’ reputations within a community of prac-
titioners and select a well-regarded therapist
whose theoretical orientation resonates with their
own outlook. In addition, there is research show-
ing that both pretreatment qualities of clients and
stable characteristics of the therapist as a person
contribute significantly to psychotherapy out-
come (e.g., Shahar, Blatt, Zuroff, Krupnick, &
Sotsky, 2004). Such findings support clinicians’
longstanding concern with the implications of
personality differences for treatment as well as
their faith in the relationship to carry the thera-
peutic power.
Scrutiny of the vast data set from the National
Institute of Mental Health study on the treatment
of depression (Blatt & Zuroff, 2004) has also cast
doubt on the assumption—a handy assumption
from the perspective of drug companies and in-
surance cost cutters—that symptom reduction is
the best indicator of change in psychotherapy.
Therapists have been saying for decades that loss
of symptoms does not necessarily equate with
cure. So have friends and relatives of the un-
treated “dry drunk” whose sobriety has not re-
duced the dysphoria that initially attracted him or
her to addictive substances. Even if we accept the
medical model that has so dominated our profes-
sional metaphors, we may note that no physician
would equate the relief of the symptoms of an
illness with its eradication.
Third, we need to press for more research, but
it should be research that avoids the artificialities
of requiring participants to have single, delimited
disorders with no comorbidity. Such clients are
virtually unknown to therapists (Hufford, 2000).
It must be research that includes follow-up stud-
ies, that appreciates the complexity of the treat-
ment process, and that controls for the “alle-
giance effects”— effects of the theoretical
identification of the researcher—that currently
account for 85% of outcome (Luborsky et al.,
1999). It should be designed to study clinical
phenomena as closely as possible to how they
occur in more natural settings.
It is time to reduce our homage to research that
147
MCWilliams
generalizes findings from culturally modal partic-
ipants to those of markedly discrepant age, race,
socioeconomic status, educational level, physical
condition, and ethnicity (Bernal & Scharró-del-
Rio, 2001). It is even time to raise questions
about randomized controlled trials (RCTs), the
ostensible gold standard of psychotherapy re-
search. We now know that different types of
patients respond to participation in RCTs in dif-
ferent ways. For example, those with elevated
perfectionistic strivings are relatively unrespon-
sive to treatments over which they feel little con-
trol and during which their progress is frequently
evaluated. Although RCTs have good internal
validity, their external or ecological validity is
questionable. Blatt and Zuroff (2004) noted,
Though random assignment to treatment groups can control
for a number of potential experimental artifacts, it may also
induce other experimental artifacts as a consequence of the
meaning to the patients of participating in a design in which
they feel controlled, observed, and evaluated beyond what
would occur in a more natural treatment relationship. . . .
Further, if one of the goals of treatment, in addition to the
reduction of symptoms, is to enable individuals to assume
responsibility for their lives—to develop a sense of agency—
this sense of agency may be compromised by a therapeutic
experience in which the patients are essentially passive in the
selection of the type of treatment they receive and in the
decision when to terminate the treatment process. (pp. 43– 44,
italics added)
At the same time, the mental set that defines
science so narrowly that only artificially opera-
tionalized concepts can be studied needs to be
exposed as a caricature of science. Naturalistic
observation has a long and distinguished position
in the history of science, despite the bias against
it held by many academic psychologists. In the
current climate, a Darwin or Lister or Pasteur
would never be funded. Psychologists should in-
sist that pharmaceutical companies publish neg-
ative findings of the research they underwrite
rather than only the studies that support their
fondest claims for their favorite medicines—
otherwise, money will trump truth every time.
We need to question the routine medicating of
younger and younger patients, when the data are
not yet in on long-term effects of early drug
treatment, and to insist that professional evalua-
tors of children’s problems be given enough time
with each child and family to make a discerning
judgment about the recommendation of psycho-
therapy medication or both.
Finally, therapists need to be politically proac-
tive, to take their concerns to ordinary people and
148
enlist their enlightened self-interest on the side of
investing in the survival of a humane, sophisti-
cated psychotherapy. Although practitioners have
far less money and a much less effective organi-
zational base than the corporate interests that
have been undermining psychotherapy, they have
the advantage of trying to tell the truth. Even
people who hate paying taxes are not likely to
believe that there is a pill for everything or that
the pain of a lifetime can be eliminated with a
few sessions of manualized cognitive– behavior
therapy. Like most of us, they prefer to see doc-
tors who take time to listen, who go beyond the
manual, who treat a person, not just a diseased
organ.
Prognosis (Guarded)
Self-observation and self-report have limita-
tions, but when all is said and done, clients know
when therapy has been useful (Seligman, 1995),
and they spread the word. On the simple ground
that they help people, I expect that the traditional
psychotherapies, and the values they honor, will
survive. But they may do so only outside the
health care mainstream. In response to insurance-
driven limits on treatment, some professionals
have already redefined what they do as “coach-
ing,” an activity that can be marketed to those
who can pay out of pocket. Other therapists sim-
ply reduce their fees for less wealthy patients
who need more comprehensive, personalized
treatment than their health plan offers (though
there is a limit to how generous clinicians can be
without becoming self-defeating). We all find
ways to adapt, to keep doing what we value,
whatever the social context. Whether therapeutic
values can enter public discourse and influence
how mental health questions are viewed nation-
ally, however, remains to be seen.
In my more optimistic moments, I see some
signs of a turnaround. Public opinion seems to be
moving toward holding drug companies more
accountable. Books are forthcoming in which
practitioners and researchers try to talk with each
other (Goodheart, Kazdin, & Sternberg, in press;
Norcross, Beutler, & Levant, in press). Stanley
Greenspan (Greenspan & Shanker, 2004) is
spearheading an international effort to develop a
classification system that goes beyond the DSM,
one that will reflect rigorous research in psycho-
pathology and therapy outcome, take seriously
the subjective experience of the patient, and de-

fine the goals of therapy as including improved
affect regulation; attainment of realistic self-es-
teem; growth in the sense of agency; integration
of complex representations of self and other; abil-
ity to empathize; increased capacity for love,
work, and play; and other traditional therapeutic
aims. He plans to interest the media and the
American Congress in this document.
If we in the United States can reverse the trend
toward making psychotherapy just another tech-
nology of control, such a movement may have a
ripple effect worldwide, one that can begin to
counteract the existing ripple effects of the dam-
aging forces I have enumerated. I am hoping that
the values that brought most clinicians to the
difficult but rewarding work of psychotherapy
can be reclaimed despite the power of the sub-
stantial interests now threatening them. By taking
on the hypocrisies and conceits of our own era
and culture, perhaps we can do a better job of
preserving our humanity in the therapeutic role
and, in the process, inoculate our clients against
the worst aspects of living in this confusing and
fragile world.
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