An Interview with Jonathan Engel, Ph.D. on the History of American Psychotherapy
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Jonathan Engel, Ph.D. about his book "American Therapy" concerning the history of American psychotherapy. Dr. Mark Dombeck is also present as a co-interviewer.
Dr. Engel is a medical historian with an extensive natural sciences and business administration background. He teaches health care administration and management through the School of Public Affairs of Baruch College in New York City. He is currently writing about about the history of American health care changes over the last 40 years; an attempt to supplement and extend the existing "bible" of American health care history, "The Social Transformation of American Medicine", published in 1982.
In American Therapy, Dr. Engel traces the development of psychotherapy in the context of American health care The process of researching this book was interesting to him in that there was a lot of "shrinkage" involved. Though there was voluminous material to look at, he found much of it to be redundant. In many cases, therapists who had claimed to have founded breakthrough approaches to therapy were revealed to have simply contributed minor extensions of previously existing ideas. In, Dr. Engel estimates there have been three or four, maybe five unique approaches to American psychotherapy that are worthy of being recognized as distinctive.
The idea for a history of American therapy came to him when he thought about the disparity between how the average person thinks of psychotherapy (e.g., in Freudian terms) and the reality of modern therapy where the few remaining orthodox Freudians make up a minuscule percentage of working therapists. There was a rich history involving multiple professions and various approaches to therapy that the general public was not necessarily aware of.
Dr. Engel suggests that though modern therapy is performed by many different professions, who profess a variety of techniques, in practice, most therapies are virtually indistinguishable In his opinion, though there are true technical differences between therapy approaches which are important to take into account, the contribution of technique is generally dwarfed by the importance of non-specific factors of empathy, warmth, safety and rapport between therapists and patients. No good or effective therapy can be delivered without these factors being present.
It is clear that therapy works. Dr. Engel's extensive review of the literature shows that a consistent two thirds of patients who enter therapy report feeling better six months later (compared to one third of would be patients who do not enter therapy and who still report feeling better six months later without intervention). The approach or technique doesn't seem to matter all that much, except that orthodox psychoanalysis seems to be less effective than some other approaches, and cognitive behavioral therapy (CBT) specific to anxiety disorders is slightly more effective than other approaches. Despite much work to try to improve the overall success rate, psychotherapists have not been able to increase the efficacy of their offerings. That last one third of patients seem to be resistant to therapeutic intervention. Dr. Van Nuys offers additional research suggesting that the actual psychotherapy success rate is higher than that reported by Dr. Engel.
Dr. Dombeck suggests that it is important to talk about the actual distinctive schools of psychotherapy, which include (in Dr. Engel's scheme): 1) Psychodynamic and Psychoanalytic approaches, 2) Humanistic psychotherapy, and 3) Cognitive and Behavioral Psychotherapies. Dr. Engel offers a criticism of Carl Rogers' Humanistic approach suggesting that it appears to be quite fuzzy and indistinct. Drs. Van Nuys and Dombeck speak up to defend Rogers, pointing out that while other approaches to psychotherapy offer authoritative interventions designed to change the patient in some manner, Rogers was convinced that the better way to approach the therapy process involved helping the client to change him or herself; this being accomplished by providing a safe and receptive environment. Roger's techniques thus do not appear to be techniques as they are non-directive by nature.
The theme of American psychotherapeutic pragmatism is discussed. Essentially, working therapists have tended to become eclectic, using the what they perceive to be the best techniques from different therapy approaches in an effort to best get the job done. The foundational requirement remains empathy, safety and warmth, however. No effective therapy gets done without those ingredients being present.
Dr. Dombeck takes issue with Dr. Engel's downplaying of the importance of technique in psychotherapy, pointing out that in the last twenty years or so psychotherapy research has become much more sophisticated and widespread, and that specific empirically validated (and highly technical) approaches to therapy for specific problems have been published which are demonstrably effective. Some of these therapies are "post-cognitive" in that they have successfully merged techniques drawn from very different sources to create targeted and effective hybrid therapies. Marsha Linehan's Dialectical Behavioral Therapy is offered as a prototypical example of a post-cognitive therapy, merging cognitive behavioral techniques with mindfulness techniques as an effective therapy for highly emotionally disturbed individuals including those with borderline personality disorder. In these cases, therapy techniques have been targeted to address specific concerns of specific populations of patients, and it is hard to argue that techniques don't matter. Dr. Engel agrees.
In Dr. Dombeck's view, the big specific recent innovation has been the marriage of mindfulness and acceptance techniques with cognitive behavioral techniques This marriage is present in DBT and as well in Steven C. Hayes' Acceptance and Commitment Therapy. Similar technical mergers have occurred in therapies like Jeffrey Young's Schema Therapy which marries psychodynamic concepts with cognitive behavioral techniques
Dr. Van Nuys asks how the changing economic landscape has influenced American psychotherapy. Dr. Engel relates how the peak of psychoanalytic activity overlapped a period in American health insurance history where major plans (including the government health care plans) would fund unlimited sessions. The withdrawal of the unlimited sessions benefit coincided with the rapid decline of psychoanalytic psychotherapy in American and the rise of short term forms of psychotherapy.
As the interview wraps up, Dr. Van Nuys asks Dr Engel to comment on the ways that various mental health professions have come into conflict with one another, and more specifically, to comment on whether psychologists should gain prescription privileges. Dr. Engel is all for doctoral psychologists who receive proper training being granted the right to prescribe appropriate psychiatric medications. He sees this as part of a larger issue and compares it to the fight that physician's assistants and nurse practitioners are having with the medical profession for similar prescription privileges.
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About Jonathan Engel, Ph.D.
Jonathan Engel holds a Ph.D. in the history of science and medicine from Yale, and has written extensively about the historical development of U.S. medicine and health policy. Most recently,he has authored the 2008 book, American Psychotherapy: The Rise of Psychotherapy in the United States. His previous books are Doctors and Reformers: Discussion and Debate of Health Policy 1925- 1950, Poor People's Medicine: American Charity Care Since 1965, and The Epidemic: A Global History of AIDS. He is a professor of health care policy and management at Baruch College in New York City.
Jonathan Engel conducts research in the historical evolution of U.S. health and social welfare policy. His books are Doctors and Reformers: Discussion and Debate on Health Policy, 1925-1950 (University of South Carolina Press, 2002); Poor People's Medicine: Medicaid and U.S. Charity Care Since 1965, (Duke University Press, 2006); The Epidemic: A History of AIDS, (Smithsonian Books, 2006); and American Therapy: The Rise of Psychotherapy in the United States, (Gotham Books of Penguin/Putnam, 2008). He is currently writing a history of the U.S. health system since 1970.
Dr. Engel started at the School of Public Affairs in 2008. Previously he was a professor of healthcare policy and management at Seton Hall University for 13 years, and taught courses in healthcare finance and policy at the Mailman School of Public Health at Columbia University and at the School of Public Health at the University of Massachusetts.
Dr. Engel received his B.A. from Harvard in the history of science in 1986, his MBA from the Yale School of Management in 1991, and his Ph.D. in the history of medicine from Yale Graduate School in 1994. He lives in Millburn, New Jersey, with his wife Rozlyn, an economics professor at West Point, and children Ezra, Ruth, Miriam, and Judah.
Carl Rogers, what's the story - Megan - Feb 25th 2009
I found it quite interesting that Dr. Engel was uncomfortable deciphering Carl Roger's approach. He made a comment about how Rogers had been a prolific writer, however when asked, he (CR) would not answer what the deal was with his approach (obviously my own words). One only needs to watch video of Carl Rogers' with a client to see how he worked therapeutically. He was genuine and consistent in a way that I can only hope to strive for. Rogers could seemingly establish rapport within 20 minutes. I am training to be a counselor, and I feel most counselors hope to establish that kind of relationship in weeks. It is hard to explain in "technical" cookbook terms how he worked...but he provided writing and examples that would inspire a whole new way to be a human, more-less therapist. Thank you so much for this podcast. I only recently started listening, but I am catching up with episodes of Wise Counsel & Shrink Rap on my Ipod. It rocks! and has totally expanded my horizons.