Monday, November 01, 2010


When I was a graduate student at the University of Chicago, a very long time ago, it was common for undergraduate acquaintances to have, and talk about having, a shrink—a psychoanalyst. I never saw much evidence that psychoanalysis was improving their psyches to any significant degree, which led me to suspect that the real function of the shrink was to make the patient feel better, and perhaps more important, by paying attention to him or her. A friend who was getting his doctorate in psychology asked one of his professors what the evidence was that psychoanalysis worked, read the articles the professor suggested, and concluded that the evidence was that it didn't; I take that as at least mild support for my interpretation of the role of the shrink.

So far as I can tell by very casual observation, the shrink has pretty much vanished from that particular role, being replaced by the trainer, aka coach, someone hired to provide advice to his client on how to live his life. As best I can tell, being hired for that job does not, in practice, require any evidence of expertise in living one's own life.

Nor does it require the eight years of medical school plus residency that were the entry requirements for becoming a shrink, but not truly essential for the job of making clients feel as though someone is paying attention to them. It's nice to see progress in the world.


jimbino said...

You are so right. Psychoanalysis, like Transcendental Meditation, is no more than a religion and, as such, offers nothing that can't be obtained through the "examined life."

William H. Stoddard said...

Medical school has not been a requirement for the function you describe for a long, long time. It's performed by "clinical psychologists," who take undergraduate degrees in psychology and then take the Ph.D. or Psy.D. (not the M.D.) in clinical psychology, after which they administer the "talking cure." Or, these days, engage in "cognitive-behavioral therapy," which seems in practice to have a fair bit of the group therapy version of the talking cure stirred in. In the meantime, the people with M.D.'s still become psychiatrists, but their practice focuses on prescribing psychiatric medication. At least the ones who are paid by MediCal/Medicaid see their patients for 20 minutes, once a month, to keep track of how they're doing.

Now, I can say that psychiatric medication has advanced tremendously over the past quarter century. The credit for that goes to the pharmaceutical companies, of course.

In the meantime, the clinical psychologists are finding less work available to them, because government agencies and insurance companies are increasingly likely to think that a clinical social worker costs less and does the job just as well.

Gray Woodland said...

Certainly the only person I ever knew who trained as a 'coach' was also almost preternaturally skilled at turning her own life into a train wreck.

She was in her previous career a counsellor, and by all reports a very effective one. The sympathetic ear is not the least of talents, and is quite good at getting others attributed to it by default.

I wonder if coaching will ever shake off its own brand of credentialism, though, since the seeming of special expertise may well offer a kind of placebo effect for the coachee.

Patri Friedman said...

Don't tar all shrinks with the same feather. Psychoanalysis is bogus, and coaching is too new to have been studied (and I wouldn't be surprised if it didn't work), but some forms of therapy, such as CBT, have multiple large scale trials showing effects. Just because there is quackery in a field doesn't mean there isn't value.

I wish there were more studies about what worked and people read them more, but I still think it is the case that moving from certification to competition in the market for listening improves quality. (and decreases education cost as you point out)

US said...

"I never saw much evidence that psychoanalysis was improving their psyches to any significant degree, which led me to suspect that the real function of the shrink was to make the patient feel better, and perhaps more important, by paying attention to him or her."

I'm not sure if I understand what you mean. In my eyes, perhaps the most important part of any psychiatric treatment is to make you feel better. That's especially the case if you feel so bad that taking your life is a relevant option you consider from time to time. If talking to a shrink makes you feel better, it's kinda 'working'. And it makes perfect sense that one of the mechanisms that makes it 'work' is that the people doing the talking feel that they get paid attention to, because humans like attention and feel better if we get it.

If the criticism is that all it does is to 'make people feel better', that's not exactly a strong criticism. I'd focus more on the fact that it's very expensive.

US said...

Another point related to Patri Friedman's comment: If there's no illness to treat or no truly significant issues, which would presumably be the case for most of those undergraduate acquaintances, which in my mind looks mostly like spoiled rich kids anyway, and a lot of people like that go see a shrink, the effect a shrink can have/actually has on an individual with actual problems can get lost in the noise.

Rex Little said...

Certainly the only person I ever knew who trained as a 'coach' was also almost preternaturally skilled at turning her own life into a train wreck.

I know someone just like that, too. My wife and I were slack-jawed when we heard that large companies were paying this woman to be a "life coach" to their employees.

Anonymous said...

After 30 years of working in education and dealing with psychiatrists who purportedly treat children, I've arrived at the conclusion that they know little or nothing about the science of behavior change, exclusive of drug treatment. I'll refer to an MA-level therapist trained in applied behavior analysis before I'll refer to an MD.

Jonathan said...

"Anyone who goes to see a psychiatrist ought to have his head examined."

(Attributed to Samuel Goldwyn)

Anonymous said...

A helpful way to think about psychotherapy is in a Hayekian manner. For example, it must first be recognized that the mind is sufficiently complicated (nearly as complicated as the extended order) that "Keynesian-type" psychotherapies will be overly simplistic, and possibly ineffective or harmful.
Improvement in the patient can not necessarily be attributed to the psychotherapy and measuring the effects of psychotherapy are just as difficult as measuring the effects of a Keynesian stimulus to an economy. It's nearly impossible to determine if the improvement in the patient is due to the psychotherapy or other factors (like market factors) that happen outside of therapy.

A successful psychotherapy will have a capitalist, anarcho-capitalist and Hayekian look and feel and describing what that looks like to someone who hasn't actually been involved in it is difficult; sort of like explaining to someone what anarcho-capitalism would look like. I'm not a specialist in psychotherapy so I wouldn't be good at explaining how it works.

I can say simple things about psychotherapy to argue that it should work and may work. For example, thinking and talking through one's personal problems with another can be helpful, but it depends on how well each other communicate, and specifically how well the helper listens. Certainly some people are better at listening than others.

Just as in any field, specialization can lead to improved skills and greater productivity.
Psychotherapists are just specialists in listening and helping people with certain types of personal problems. There are many different types and like Patri says competition is probably the best way to find out who those people are.

Once you boil it down to this level, one can ask more general questions such as:

- What makes any specialist successful?
- How should one go about gaining skills to become more productive?
- And, what type of environment best allows people to gain those skills (i.e. government or lack there of)?

Finally, here are two questions that a psychotherapist might ask you in response to your questions of him.

How much does David Friedman's degree from the University of Chicago help him teach law and economics?

Where and how did David Friedman get so good at what he does?