Rethinking psychotherapy: It is perhaps the best and worst of times for mental health practitioners and scientists

Rethinking psychotherapy. Dan J. Stein*, Judith K. Bass†, Stefan G. Hofmann‡, Mark van Ommeren§. In Global Mental Health and Psychotherapy: Adapting Psychotherapy for Low- and Middle-Income Countries. 2019. https://www.sciencedirect.com/book/9780128149324/global-mental-health-and-psychotherapy

*SA Medical Research Council Unit on Risk & Resilience in Mental Disorders,Dept of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa,†Department of Mental Health, Johns Hopkins University Bloomberg School of PublicHealth, Baltimore, MD, United States,‡Dept of Psychological and Brain Sciences,Boston University, Boston, MA, United States,§Dept of Mental Health and SubstanceAbuse, World Health Organization, Geneva, Switzerland

It is perhaps the best and worst of times for mental health practitioners and scientists. Advances in psychiatric epidemiology not only have quantified the prevalence andburden of mental disorders but also have emphasized the significant treatment gap,particularly in low- and middle-income countries (LMIC) (Demyttenaere et al.,2004; Stein et al., 2015). Advances in neuroscience not only have led to a better under-standing of the psychobiology of mental disorders but also have underscored how farwe are away from a personalized psychiatry that targets specific brain circuitry inorder to achieve symptom remission in the clinic (Stein et al., 2015).In this context, psychotherapy remains a key intervention in the clinic and a keyfocus of research. Several decades of research have established the efficacy of specificpsychotherapies for particular conditions, and they are therefore recommended as first-line interventions in a broad range of evidence-based clinical guidelines. Furthermore,there have been gradual advances in our understanding of how psychotherapies effectpsychological change, raising the possibility that in the future, clinician-scientists willbe able to forge personalized psychotherapy plans that improve treatment outcomes.At the same time, further progress in psychotherapy requires important conceptualand empirical questions to be addressed. The diverse historical roots of psychother-apy, ranging from psychoanalytic to cognitive behavioral theories, raise the concep-tual questions of how best to explain the nature of psychopathology and how best toaccount for changes that may be seen during psychotherapy. The broad range of scholarship on psychotherapy, ranging from qualitative accounts to randomized controlledtrials, raises the empirical questions of what works best, for whom, and why.Within this context, the emerging discipline of global mental health has a key roleto play in reinvigorating the search for answers to these questions and so in advancingthe science and art of psychotherapy. First, global mental health has emphasized theenormity of the mental health treatment gap, particularly in LMIC, and has put for-ward the hypothesis that a range of nonspecialized mental health workers may be ableto undertake efficacious psychotherapy (Patel, 2012). Second, global mental healthhas emphasized the heterogeneous contexts in which psychotherapy must be deliv-ered, particularly in LMIC, and has put forward a range of ideas about how best to
adapt existing or forge new psychotherapeutic techniques and tools (Singlaet al., 2017).In this introductory chapter, we summarize ongoing contributions to psychotherapyfrom the emerging discipline of global mental health and outline the subsequent chap-ters of this volume, which provide more detailed accounts. We also emphasize theimportance of an integrative theoretical and research framework. While the noveltyof the intersection between global mental health and psychotherapy may well requirethat a broad range of ideas and activities are robustly explored, this intersection alsoarguably provides an opportunity for the field to move beyond past schisms and totackle future challenges in the field in a way that ensures that focused progress isin fact made.

1 Nature of psychotherapy

The complexity of current debates on the nature of psychopathology is exemplified inrecent controversies regarding the revision of theDiagnostic and Statistical Manual ofMental Disorders(DSM) and the International Classification of Diseases (ICD) andthe formulation of the Research Domain Criteria (RDoC) framework (Clark, Cuthbert,Lewis-Fernandez, Narrow, & Reed, 2017). Key questions that have been raisedinclude whether psychopathology is best described using categories or dimensions,the extent of the link between clinical symptoms and brain changes, and the extentto which syndromes and symptoms are context-bound.Psychotherapy has its own diverse historical roots and is influenced in an ongoingway by these debates on psychopathology. Psychoanalytic authors, for example, haveemphasized links between psychodynamic formulations and neuroscience discoveriesand have argued that empirical literature supports psychoanalytic interventions (Stein,Solms, & van Honk, 2006). Cognitive behavioral authors have similarly addressedthe biological basis of their theoretical formulations and have focused a great dealof effort on accumulating data in support of their psychotherapeutic interventions(Clark & Beck, 2010).Global mental health raises a range of additional conceptual questions for psycho-therapy. First, there are questions about who is best able to deliver psychotherapy; inChapter 1of this volume, Paul Bolton, who has undertaken seminal work on psycho-therapy in LMIC, makes the argument that task-shifting interventions are crucial inthis context. Second, there are questions about how best to formulate psychotherapiesin a resource-constrained environment; in Chapter 2 of the volume, Laura Murrayargues that transdiagnostic approaches are particularly relevant. Third, there are questions about how best to implement and scale up psychotherapy; inChapter 3, BrandonKohrt and colleagues discuss the importance of supervision, and inChapter 4, JudithBass and Usman Hamdani emphasize the role of implementation science in addressingthis issue.There are, however, surely deeper theoretical questions, which practical efforts toimprove psychotherapies in a global context must address. In particular, what psycho-biological structures and processes do psychotherapies target in which individuals, and how do they optimally do so? We might imagine that target structures and pro-cesses differ across mental disorders and across individual patients; how are these dif-ferences best articulated and assessed? While the RDoC effort has provided one recentconceptual framework for understanding psychopathology, is this the most suitableone for progressing efforts in psychotherapy?

2 Evidence of efficacy

Some might respond that no matter the conceptual foundations of psychotherapy, ithas shown good evidence of efficacy. However, despite a growing body of random-ized controlled trials demonstrating efficacy, the question of psychotherapy efficacy isfar from fully resolved. First, the quality of much of the evidence has been questioned,with critics emphasizing factors such as the weakness of methods that too often rely onwaiting-list controls and the avoidance of rigorous assessment of adverse events ofpsychotherapy. Second, the generalizability of the evidence has been questioned;the vast majority of psychotherapy research has focused on explanatory trials in aca-demic settings, with much less work undertaken in pragmatic or real-world contexts,including LMIC settings (van’t Hof, Cuijpers, Waheed, & Stein, 2011). Third, manyof the trials in global mental health are by authors who have an allegiance to the inter-vention, raising conflict of interest issues.The diverse historical roots of psychotherapy have arguably contributed to the het-erogeneity and weakness of the literature. Many schools of psychotherapy have takena predominantly qualitative approach to describing their concepts and outcomes. Evenwithin paradigms that emphasize the importance of quantitative research, there is asubstantial clinical research gap, with practitioners emphasizing, for example, thatthey are not able to rely on standardized research manuals that address narrowpopulations in a real-world setting (Pilecki & McKay, 2013; Teachman et al., 2012). Global mental health has, however, made an important qualitative and quantitativecontribution to the literature. In Chapter 5, Caroline Kuo not only emphasizes howcognitive behavioral therapy provides a useful framework for psychotherapy interven-tion around the world but also discussed how adaptations need to be made to ensuresuccess in diverse contexts. In Chapter 6, Maxine Spedding and Dixon Chibandadescribe a range of other psychotherapeutic interventions that may be useful in globalsettings; these include the World Health Organization’s Problem Management Plus(PM+), a transdiagnostic treatment for delivery by nonspecialist providers. In Chapter 7, Bradley Wagenaar and colleagues emphasize the data demonstrating thevalue of primary care collaborative interventions, as comprising a key platform fordelivery of psychotherapy.Global mental health research has also addressed a broad range of mental disorders. In Chapter 8, Pim Cuijpers and colleagues summarize the growing literature on inter-ventions for mood and anxiety disorders in LMIC. In Chapter 9, Kathleen Sikkemaand colleagues address the valuable interventions that have been developed to addresstrauma- and stressor-related disorders, such as post-traumatic stress disorder, acrossthe globe. In Chapter 10, Muhammad Irfan and colleagues cover psychotherapeuticRethinking psychotherapy3 interventions for schizophrenia and bipolar disorder in diverse settings. InChapter 11,Bronwyn Myers summarizes work on substance use disorders around the world. Taken together, this is a large and important contribution to psychotherapy research.Furthermore, global mental health research has also addressed a range of importantpopulations. InChapter 12, Jessica Magidson and colleagues tackle chronic physicaldisorders, including HIV/AIDS, complementing the earlier chapter on the importanceof collaborative care. InChapter 13, Shannon Dorsey and colleagues summarize workthat has been undertaken in child and adolescent populations in global settings. InChapter 14, Thandi Davies reviews research that has been undertaken on perinatalcommon mental disorders across the world. InChapter 15, Engelina Groenewaldfocuses on global mental health research that has been undertaken in the elderly.Finally, in Chapter 16, Derrick Silove focuses on research that has been undertakenon refugee and similar populations in the context of humanitarian crises.

3 Towards an integrative theoretical framework

In this brief section, we wish to argue that contemporary cognitive-affective neurosci-ence provides a useful and integrative framework for psychotherapy. Although psy-choanalytic theory provided some of the historical foundation for the development ofpsychotherapy, its conceptual basis is now outdated. This gap means that eventhoughtful efforts to integrate psychoanalysis with neuroscience typically do not findtheir way into contemporary neuroscientific journals (Ramus, 2013). Cognitivebehavioral therapy, on the other hand, has long attempted to integrate its underlyingtheory with neuroscientific findings. Advances in the psychobiology of emotion cantherefore be incorporated into its theories and approaches (Beck, 2008).Consider, for example, contemporary work on fear conditioning and extinction.A range of neuroscientific methods have been useful in delineating the relevant psy-chobiological structures and processes involved in these phenomena in the laboratory;we therefore have a growing understanding of the underlying neurocircuitry and of therole of different molecules that play a role (Stein, 2006). In the clinic, we are thereforewell placed to study how psychotherapy leads to alterations in this circuitry, asassessed by modern brain imaging techniques (Brooks & Stein, 2015). Furthermore,we can use this knowledge to target specific mechanisms; for example, it was hypoth-esized that the glutamatergic drug, D-cycloserine, would augment CBT in anxiety disorders by improving fear extinction (Mataix-Cols et al., 2017).Clearly, much further work is needed in order to consolidate this sort of conceptualframework. The psychobiological basis of anxiety and threat responses, where thereare good animal models, is perhaps easier to understand than that of the psychoses,where animal models are only partially useful. Clinical research tools are often rela-tively blunt compared with laboratory techniques; the fear circuitry of a rodent canliterally be dissected out, while current brain imaging methods have limited temporaland spatial resolution. The complexity of mental disorders and of the experiences ofindividuals who suffer from these conditions cannot be overestimated; simple modelsof dysfunction and of intervention will invariably fail to fully address this complexity.

Nevertheless, considerable progress has been made in recent years toward an inte-grative cognitive-affective neuroscience approach to the brain-mind and its patholo-gies. Although much further work needs to be done to fully delineate the relevantstructures and processes that underlie mental disorders and symptoms, importantadvances have been made in delineating key relevant phenomena, such as fear con-ditioning and extinction, emotional dysregulation and control, and reward processingand regulation. Such advances provide the framework for an integrative psychobiol-ogy of psychotherapy and for research on the neurocircuitry underlying particulartherapeutic interventions. Ultimately, therefore, there is scope for integrating globalmental health, neuroscience, and psychotherapy (Stein et al., 2015).

4 Towards a translational research framework

In this brief section, we wish to argue that global mental health has provided a uniqueopportunity for advancing psychotherapy. Psychotherapy practice and research havebeen constrained by being confined to a narrow set of contexts. While early efforts toexpand psychotherapy by inclusion of nurse practitioners and computerization shouldcertainly be acknowledged (Ginsberg, Marks, & Waters, 1984; Greist et al., 1998), theemergence of global mental health as a distinct discipline has ensured a focus on theextension of psychotherapy to a range of practitioners, to novel contexts, and to newdelivery platforms (Patel, 2012; Singla et al., 2017).Furthermore, a focus in global mental health research on moving from initial feasibility and acceptability studies, to efficacy research, and to larger implementationand scale-up has ensured that psychotherapy research is not merely an academic activ-ity, but rather is embedded within a real-world context. This framework allows trans-lation between initial hypotheses about what might be useful and the lived experienceof practitioners and patients as they try out psychotherapy techniques and tools. Thereis acknowledgment of key societal variables including the role of psychotherapysupervisors, the role of family members and peers, and other aspects of the contextin which psychotherapy occurs.Again, much further work is needed in order to consolidate this sort of researchframework. A range of approaches toward psychotherapy adaptation and implemen-tation are outlined in this volume; further elaboration and refinement of these modelsare likely to occur in future years. One key challenge is ensuring that mental disordersand psychotherapy are not stigmatized, and rather and that psychotherapies are viewedas potentially efficacious and cost-effective health interventions. A second key chal-lenge is establishing mechanisms that support psychotherapy research on efficacy andimplementation and that use lessons learned to further improve interventions.Considerable progress has been made toward establishing such a framework. Thedevelopment of an integrative conceptual foundation for psychotherapy is importantin overcoming past schisms and persuading funders and communities that this is animportant field. Developments such as rigorous syntheses of the literature (e.g., theCochrane Collaboration), the promotion of evidence-based guidelines, and otherefforts to address the practitioner-researcher gap have all been key in promotingRethinking psychotherapy the field of psychotherapy. WHO policies and products including theMental HealthAction Gap Action Programme(mhGAP) have been key in advancing support for psy-chotherapy (Keynejad, Dua, Barbui, & Thornicroft, 2018). The Sustainable Develop-ment Goals emphasize that mental health and sustainable development are intertwinedin important ways, and this will hopefully encourage further investment in this area(Votruba, Eaton, Prince, & Thornicroft, 2014).

5 Conclusion

Recent attempts to address the mental health treatment gap in LMIC by adaptingpsychotherapies for these contexts have drawn attention to key conceptual and empir-ical questions in the field. By so doing, we would suggest that they have reinvigoratedthe field. This introductory chapter has summarized ongoing contributions to psycho-therapy from the emerging discipline of global mental health; in succeeding chapters,these will be further expanded on. In the interim, we wish to emphasize the value ofintegrative theoretical and research frameworks for psychotherapy. Important pro-gress has been made in establishing such frameworks, but much further work isrequired to consolidate them. Our hope is that this volume contributes to such efforts.ReferencesBeck, A. T. (2008). The evolution of the cognitive model of depression and its neurobiologicalcorrelates.American Journal of Psychiatry,165(8), 969–977.Brooks, S. J., & Stein, D. J. (2015). A systematic review of the neural bases of psychotherapy foranxiety and related disorders.Dialogues in Clinical Neuroscience,17(3), 261–279.Clark, D. A., & Beck, A. T. (2010). Cognitive theory and therapy of anxiety and depression:Convergence with neurobiological findings.Trends in Cognitive Sciences,14(9),418–424.Clark, L. A., Cuthbert, B., Lewis-Fernandez, R., Narrow, W. E., & Reed, G. M. (2017). Threeapproaches to understanding and classifying mental disorder: ICD-11, DSM-5, and thenational institute of mental health’s research domain criteria (RDoC).Psychological Sci-ence in the Public Interest,18(2), 72–145.Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., Gasquet, I., Kovess, V., Lepine, J. P., et al.(2004). Prevalence, severity, and unmet need for treatment of mental disorders in theWorld Health Organization World Mental Health Surveys.JAMA: The Journal of theAmerican Medical Association,291(21), 2581–2590.Ginsberg, G., Marks, I., & Waters, H. (1984). Cost-benefit analysis of a controlled trial of nursetherapy for neuroses in primary care.Psychological Medicine,14(3), 683–690.Greist, J. H., Marks, I. M., Baer, L., Parkin, J. R., Manzo, P. A., Mantle, J. M., et al. (1998). Self-treatment for obsessive compulsive disorder using a manual and a computerized telephoneinterview: a U.S.-U.K. study.M.D. Computing,15(3), 149–157.Keynejad, R. C., Dua, T., Barbui, C., & Thornicroft, G. (2018). WHO mental health gap actionprogramme (mhGAP) intervention guide: A systematic review of evidence from low andmiddle-income countries.Evidence-Based Mental Health,21(1), 30–34.Mataix-Cols, D., Ferna ́ndez de la Cruz, L., Monzani, B., Rosenfield, D., Andersson, E., P erez-Vigil, A.,...R€uck, C. (2017).D-Cycloserine augmentation of exposure-based6Global Mental Health and Psychotherapy
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