The McDonaldization of psychotherapy: Processed foods,processed therapies,and economic class

The death of theoretical systems (and rise of empirical validation)

Three years ago I was supervising several doctoral students in a clinical trial that applied a psychoanalytically informed approach to the treatment of individuals struggling with bulimia nervosa. One afternoon, a supervisee came into the consultation room clearly distressed. Hesitantly, she told me that she had just had a rough interaction with several faculty members in her department. She narrated how her professors asked if she was conflicted about providing an “unethical” treatment to patients. She further explained to me that they did not understand why a treatment was being administered that did not fit the “golden standard” of empirical validation. Particular forms of cognitive-behavioral therapy were the treatments of choice for this set of symptoms and psychoanalytically informed treatments were without this type of scientific backing. As such, it was unethical to provide this treatment that did not fit in the “best practices” category.

Several months before, at an American Psychological Association (APA) annual convention, Dr. David Barlow gave a distinguished address wherein he proclaimed that the era of different theoretical approaches to therapy was over. He indicated that we are now in a time when treatments and their components and processes are either shown to be effective or not. In an impressively sophisticated manner, therapies now receive their identity, legitimization, and “branding” based on where they can be located on an evaluative axis of effectiveness.

Somewhere in the progression of the psychological “sciences,” a specific and particular epistemological “monopoly” (Slife, Wiggins, & Graham, 2005) has obfuscated the fundamental recognition that therapeutic orientations do not merely live on a commensurate axis related to symptom-reduction and/or increased well-being. Technicism and instrumentalism have become a new type of common sense with an unacknowledged history (Richardson & Manglos, 2012). Its “disguised ideology” reaches into clinical training programs and textbooks with no space for alternatives.

Different therapeutic orientations are, actually, different languages that human beings have for understanding their suffering, meaning, identity, and healing. They represent a rich and kaleidoscopically diverse set of traditions and interpretative possibilities for experience. Therapeutic orientations are hermeneutical language systems through which patients and therapists make sense of experience. They have different frames of reference, metaphors, developmental assumptions, metaphysical underpinnings, epistemologies, and value systems that are, in many ways, incommensurable (Kuhn, 1996). Albert Ellis’ Rational-Emotive Behavioral Therapy (REBT) and Melanie Klein’s Object-Relations Therapy conceptualize and language experience out of utterly different paradigms and ideologies. Locating them on an effectiveness axis is an alien epistemology to their respective traditions of meaning and is a clear statement that an alternate epistemology—foreign to both—is arbitrating their worth according to its own value standards.

Slife and Gantt (1999) maintain that for a field that touts itself as being pluralistic in perspective and open to divergent and diverse voices, it is surprising to see the degree of epistemological narrowness that exists in the research methods used in psychotherapy research in particular. The implications of this are more significant than we often recognize. Building upon the work of those who have argued for a methodological and perspectival pluralism in psychotherapy research and outcome studies (Kirmayer, 2012; Slife, Wiggins, & Graham, 2005), I hope to extend their arguments and recommendations beyond methodology and philosophies of science and more fully into the realms of language and how specific treatment orientations position persons in relationship to their suffering and potential. Selecting a therapeutic orientation is a selection of language for one’s experience and suffering.

Language as mediator

What is the importance of understanding psychotherapeutic approaches as languages? In the 20th century, across the many divides in philosophy, a linguistic turn ushered in a radical recognition of the ways that language mediates, constitutes, and positions one in experience. Whether in critical theory, semiotics, continental philosophy, or analytic thought, the power of language to close and open one to experience, shape experiential possibilities, and establish hierarchies and values that reflect “normative unconscious processes” within society (Layton, 2009) has significantly impacted the trajectories and core considerations in many philosophical systems (cf. Wittgenstein, Austin, Lacan, Kristeva, Derrida, Levinas, Bakhtin, Cavell). This is not completely foreign to the psychological discipline. Feminist, multicultural, and narrative psychologists (to name only a few) are acutely attuned to this phenomenon and its implications within therapeutic contexts. They have been advocates for watching how language reifies particular problematic social realities.

However, before moving too quickly to the issue of how use of particular language may collude with and perpetuate oppressive conditions, we need to more broadly reflect on the more basic condition: language mediates and positions us in relationship to our experience. And, furthermore, language is brokered within the psychotherapeutic hour. As an example of how language is lived out in a live therapy session, I point to an illustrative moment in a psychotherapy instructional video used in some clinical training programs. The segment is from a five-part Cognitive Behavior Therapy for Depression Video Series titled Structure of the Therapy Session (American Psychological Association, 2007). At the start, the patient (an actor) describes his experience of depression. As the young man begins to speak it becomes clear to the viewer that he is speaking in a style—using metaphor and other descriptive words—that are quite different from the psychoeducational language previously explained to him by the therapist. The therapist, who is also one of the co-instructors of the video, interrupts the patient and explains that she is going to stop him to remind him that he is confusing his thoughts from his feelings and interchanging them as he speaks. She then takes one of the metaphoric sentences he used and corrects it, re-articulating and re-aligning it with a causal description of the relationship between his automatic thoughts and depressive feelings. The actor/patient nods as he learns a new language, logic, and metaphor for understanding his experience.

The therapist, in this segment, is not applying a technique that links up with universal truths about human functioning and healing. She is working from within a particular psychological theoretical perspective that derives from a specific set of assumptions about how persons change, how thoughts and emotions relate, the nature of causality, etc. All therapy approaches have such assumptions—necessarily—as they are human systems situated in particular values and visions of reality (Christopher, 1996; Cushman & Gilford, 2000). Treatments—Foucault and other critical theorists and psychologists remind us—are technologies of healing that relate to technologies of self; always built around complex interplays of social, political, economic, geographical, cultural, historical, and philosophical components (Cushman, 1995). As psychotherapists, it is imperative that we understand we are brokers of particular languages for and philosophies of identity and healing.

Treatment practices and their respective languages carve out the horizons of possible experience. In psychotherapy, the language tradition spoken about my experience shapes, orients, and ultimately mediates my self-experience. Sharing about my experience during the week with a therapist and then learning how to engage in “cognitive restructuring” might teach me fundamental assumptions about what it means to be a thinking subject, and highlight the implications of discrete thoughts upon my emotions and actions so that I can replace older ways of thinking with new ones that lead to more desirable emotions and actions. In a different consulting room, while sharing about some of my thoughts with a therapist and being responded to with a transference interpretation, I may learn to see how my past repeats in new ways, recognize some of the core affective registers involved, and gain reflective capacity to better integrate the disavowed needs that keep playing out outside of my awareness, so on and so forth. Each of these languages is a heuristic and becomes a way of being in the world. The theory’s “gaze” creates the optics, clearing, and possibilities for identity. It also, as with all theories and languages, both opens up and reflects realities and closes down and deflects realities.

Said another way, each theoretical approach is a linguistic metaphor for understanding human experience. Recently, five experiments were conducted that explored the ways that metaphor profoundly and uniquely influences how we reason about complex issues (see Thibodeau & Boroditsky, 2011). The results demonstrated how theoretical and abstract ideas are ultimately “suffused with metaphor” and that when we seek information or data we frequently do so in order to validate and bolster the implicit values from the chosen and influencing metaphor. The researchers explain how even a single word (serving as a metaphor) influences how people form an opinion and respond to an issue. The example used in the article relates to how crime is understood. For instance, using the word “virus” contributed to a wholly different response and set of prescriptive actions than using the word “beast.” When considering the nature and resolution of criminal activity in society, the metaphor used shaped the type of intervention, approach, and social arrangements suggested by the participant. The metaphor employed changes how we understand the subject. The researchers further add that “[i]nterestingly, the influence of the metaphorical framing is covert: people do not recognize metaphors as an influential aspect in their decisions” (2011, p. 10).

As a further example, Ethan Watters (2010), in his book Crazy Like Us: The Globalization of the American Psyche, writes a haunting exposé about how GlaxoSmithKline (the pharmaceutical giant) studied the language for depression in Japan so that they could “market” a reformulation of this term—a reloading of its meaning that would medicalize it and reduce its “severe” connotation—in order to create a consumer marketplace for Paxil. More specifically, depression was described as a type of “cold of the soul” that, if left untreated, may lead to suicide (p. 225). By using such language, an implicit origin story is introduced regarding the nature, course, and appropriate intervention for depressive experience. A disease metaphor engenders the necessity of a medical solution (along with a type of experiential set related to being the bearer of a medical syndrome). The need for psychopharmacological intervention is thus cultivated and the very quality of experience of depression altered. Laurence Kirmayer, a prominent cultural psychiatrist speaking about this particular situation, explains:

What I was witnessing was a multinational pharmaceutical corporation working hard to redefine narratives about mental health … These changes have far-reaching effects, informing the cultural conceptions of personhood and how people conduct their everyday lives. These companies are upending long-held cultural beliefs about the meaning of illness and healing. (as cited in Watters, 2010, p. 198)

Perhaps less explicitly and quickly, but no less effectively, a homogenizing wave of language has altered the ideological and experiential fabric of American societies. In a sociopolitical and economic context that has historically defined itself—its meanings, truths, methods, and narratives—through a positivist version of scientific inquiry (see M. Freeman, 2000; Slife, Reber, & Richardson, 2005; Taylor, 1989, 2007; Toulmin, 1990), the Euro-American psyche is well-irrigated for the “medicalization” of its identity and experience, along with being quite receptive to respective languages of ESTs and therapeutic approaches (Conrad, 2007). In the present climate, we have empirically validated syndromes, empirically validated selves, and empirically validated treatments that all match up. And, we have “brand-names” for them as well (Ablon et al., 2006; Rosen & Davison, 2003; Wachtel, 2010; Westen, Novotny, & Thompson-Brenner, 2004). Many have acronyms. This form of medicalization contributes to a type of forgetting about the metaphoric base and philosophical plurality of our psychotherapeutic languages. It tends to create an illusion of a homogeneity of experience and language.

Therapy has become a valued commodity in a capitalist society and this commodification language finds its way into the technical models, manualized approaches, and scientifically arbitrated ideologies that shape therapists’ and patients’ understandings of the process and of themselves as persons. Many have already written on this and there is no need to rehash this argument (Cushman, 1995; Cushman & Gilford, 2000; Richardson, Fowers, & Guignon, 1999). We will return to this in the final section of this article. For now, I hope to call attention to its specific implications for those with fewer resources and demonstrate how this substantial inequality forms the foundation of a broader ontological winnowing for psychotherapy and limiting of care across class contexts.

Processed foods and processed psychotherapies

Here we arrive at the most fundamental purpose and importance in making this argument. In the present realities of managed care, community mental health, and service provision, as a patient, I face a basic reality. If I am “covered” by a State-subsidized plan, run-of-the-mill Health Management Organization (HMO), or don’t have insurance at all, the type of psychotherapy that I am likely to receive is fairly circumscribed. Statistically speaking, I am most likely to sit with a graduate student-in-training and receive a short-term, symptom-focused treatment (Hollingshead & Redlich, 2007). Often, due to time limitations, the rise of particular clinical training models, and paperwork and quality review processes that are oriented around a particular language tradition, the therapist works as a “psychotechnician” who is a “dispenser of a predetermined set of technical maneuvers” (Cushman & Gilford, 2000, p. 989; see also Huett & Goodman, 2012).

In contrast, if I have a Preferred Provider Organization (PPO) plan or am able to pay out of pocket, the picture is quite different. I now have the option of selecting a type of therapeutic language (existential, psychoanalytic, phenomenological, multi-modal, cognitive-behavioral, acceptance-commitment therapy, gestalt, etc.). As a patient with financial resources, I can select a therapeutic approach that matches the particulars of my way of understanding change, persons, suffering, and relationship. Or, at the very least, I can select a therapeutic approach that intentionally calls into question my particular ways of understanding these things. Either way, I am able to struggle into the most meaningful language tradition for my suffering and healing. It is not pre-decided and circumscribed in the same way that it would be if I had minimal financial resources.

In short, class disparity translates into a significant disparity in availability and access to particular languages for self-experience (the importance of which was articulated above). And, I feel the need here to clarify: I am speaking about poverty saturated areas, not middle-class or lower-middle class contexts. That is another conversation (albeit with some potentially similar themes to be discussed in the final section). The APA Health Disparities Initiative reports (APA, 2014) and the Primer on the U.S. Mental Health Delivery System (Sundararaman, 2009) provide pictures of counseling options in low-income contexts as woefully insufficient to meet the demands. Murali and Oyebode (2004) report that “The World Health Organization has described poverty as the greatest cause of suffering on earth” and recognizes the “effects of relative poverty on the development of emotional, behavioural and psychiatric problems, in the context of the growing inequality between rich and poor” (p. 216). The Department of Health (2001) in the United States estimates that children “in the poorest households are three times more likely to have a mental illness than children in the best-off households” (p. 220). Alongside these findings is significant evidence that there is clear “differential availability and use of treatment modes and facilities by different social classes” (p. 217).

I hope to draw a parallel. It is a well-documented trend in contemporary culture that processed foods are consumed in much larger quantities in lower income communities (Beaulac, Kristjansson, & Cummins, 2009). Frequently referred to as “food deserts” in the literature, low-income neighborhoods are typically characterized not only by the absence of grocery stores that carry fresh food but also by the placement and presence of multiple fast food outlets and convenience stores, which purvey primarily processed foods with long shelf lives (Beaulac et al., 2009; Walker, Keane, & Burke, 2010). Kwate (2008) reminds us that in a food desert, “it is easier to get fried chicken than a fresh apple” (p. 34). The very fact that a variety of food choices are often not available in lower income contexts (Drewnowski, 2009; Drewnowski & Darmon, 2005; A. Freeman, 2007; Morland & Evenson, 2009) and that McDonalds chain restaurants (to name only one example) are “densely” present in these neighborhoods (Kwate, 2008; see also Drewnowski & Darmon, 2005) is quite telling of some of the ways that this plays out. Processed foods are much cheaper and thus accessible. The foods that are available are nutrient-poor, having only a fraction of the nutritional value of unprocessed and fresh foods. They are also apt to be the least healthful choice—if not downright harmful. The increased consumption of low-nutrition foods in low-income families correlates strongly with poor health, including high obesity and Type II diabetes rates (Casey, Szeto, Lensing, Bogle, & Weber, 2001; Drewnowski & Darmon, 2005; Morland & Evenson, 2009). The disparity between prevalence rates of obesity, heart disease, and diabetes in food deserts and middle- and upper-class regions is frightening. Andrea Freeman (2007) argues that through the distribution of food resources there is an “oppression through poor nutrition” that is transpiring in the United States and its implications for health are a social, political, and economic issue (Drewnowski & Darmon, 2005).

The issue here is one of choice and resource for choices. Food choice is dictated by SES (Drewnowski, 2009). In low-income neighborhoods, processed foods dominate (Bauer et al., 2012; Walker & Kawachi, 2012). And, in the absence of resources, new tolerances and even preferences (e.g., tastes) form around what is available (Bourdieu, 1984; see also Layton, 2009). One’s consciousness does not hold out for higher quality possibilities. Rather, what is available in one’s community becomes what is eaten for dinner, what ultimately informs family recipes (think here of intergenerational transmission of language), and what is craved and becomes a part of tradition. Appetites adapt. Tastes develop. Spam, Fritos, Doritos, Kraft Dinner, and Coke are staples of diets.

Hunger does not have the face that it used to. In the United States, there is enough food to distribute. The issue is the types of food available and for whom, along with the manner with which nutrition is defined. Obesity can be one of the new faces of malnutrition and poverty (Albritton, 2013). Bodies can be hungry even while the psychological registry of hunger has been tricked into satiation. For instance, in a recent book The Noodle Narratives, three anthropologists, Errington, Fujikura, and Gewertz (2013), describe the international rise of instant ramen and its “brilliant career” over the last decades. Costing only several cents a package, there were over 100 billion servings of ramen sold in 2012. The consumption of ramen far outpaces McDonalds and many other processed foods. Instead of sounding an alarm about what this means for human health (see Michael Pollan, 2008 for such an alarm), these authors explain how “Instant noodles do good by alleviating the hunger of millions of people around the world. These supercheap, superpalatable noodles … help the low-wage workers in rich and poor countries alike hang on when the going gets tough” (Errington et al. as cited in Barclay, 2013). They are described as a “proletariat hunger-killer” (Mintz, 2013). Because people become hungry much faster after eating mere wheat flour, palm oil, which is 49% saturated fat, is used to fry the noodles. This, along with the water in the soup, helps to prolong the length of time that the consumer experiences satiety. “And that helps explain why ramen have become a staple part of the world’s undernourished and part of some humanitarian food aid packages” (Barclay, 2013). In response to criticism regarding this trend, these authors indicate that ramen are a

“virtually unstoppable” phenomenon. And they foresee a world of 9 billion people “in which the affluent will be presented with too many food choices and [will be] called upon to use their survival skills to choose wisely, and in which the poor will have to use their survival skills to get by on cheap food” like ramen. (Barclay, 2013)

Let’s tie this back into the mental health delivery system: last year, an article titled “Therapy Deficit” was published in the journal Nature. Addressing the concern about access to mental health care, the article extols a program—“Improving Access to Psychological Therapies”—in the United Kingdom wherein this “massive, enlightened initiative in psychotherapeutic capacity-building has increased the number of practising cognitive behavioural therapists by several thousand, providing more than 600,000 people with access to these services, particularly patients with depression and anxiety disorders” (Editorial, 2012). The article is written as a laudatory piece—psychotherapy is now being provided to those who didn’t have it previously. Implicit within the tone and content is the sense that we are to read it as though psychotherapy is a simple word, like “food.” Though, as we just discussed, “food” isn’t a simple word either. Distributing larger amounts of “food” to more segments of the population does not actually reduce starvation. Depending on what it is, it may merely collude with the changing of hunger’s manifestation, masking starvation further. Ramen is not a food that we should be distributing to the hungry, not unless one believes that the eradication of hunger pains is synonymous with being nourished. Spaggheti-Os should not be the food that we supply to food pantries for the impoverished in the inner cities.

In like kind, we cannot believe it is enough to provide more psychotherapy to people who didn’t have access to it. Psychotherapy is not such a simple “word.” And, the words “Evidence-Based Practice” (EBP) or “Empirically Supported Treatments” (ESTs) don’t change that, no matter how much they create a sense of scientific backing and consumer protection (Cushman & Gilford, 2000). Psychotherapy, as argued above, is multifarious and radically interlaced with economic class. More access does not translate to better health or the issue being addressed. It may actually serve to gloss over present circumstances—perhaps a greater danger. What if our reliance on medicalization practices and languages inadvertently contributes to missing the profound variation in human experience and resilience? What if our calculus neglects hunger in its complexity?

Curtailing availability of a variety of psychotherapeutic orientations could result in the creation of “therapy deserts” comparable to “food deserts.” If “food deserts” involve the circumscription of options to processed foods, then a “therapy desert” might be understood as a situation wherein individuals are normatively given access to mostly processed versions of psychotherapy. In processed psychotherapies, the language variations available to individuals are rather miniscule. Templated languages are somewhat pre-packaged renditions of therapy. This is an increasingly present trend in mental health delivery with “tool-kit” models of intervention that assume a type of interchangeability of the subject (Rotheram-Borus, Swendeman, & Chorpita, 2012). Paul Wachtel (2010) already warns about the “brands” of treatment that create a “Walmart approach to mental health care” (p. 264). He argues that these are incentivized by their cheapness and ability to be “disseminated” without the need for expensive training and education (p. 264). Without financial resources, a suffering individual is relegated to a particular language tradition of this sort, with little possibility of choosing or accessing alternative options.

Many recommendations have come out in recent years that call for more equal access to health care and treatment services (Department of Health, 2001). These developments are laudable, though another dimension needs to be added to these conversations. There have been many positive trends, of course, including the passing of particular laws that have—as part of their goals—the reduction of social inequality with regard to types of services offered, coverage, and accessibility (Sundararaman, 2009). However, there may be a manner by which the emphasis on evidence-based practices for mental health providers, rather indirectly, has the greatest impact on economically disadvantaged communities by limiting the therapeutic options available to them and inadvertently disguising the ongoing disparity in choice. We turn to this issue now.

McDonaldizing science: The creation of a medicalized subject

At issue here is how psychology and its service delivery and marketing apparatuses affect the very “taste” predilections that exist at the level of class and treatment preference (Bourdieu, 1984). How do we influence the very languages that are sought and the particular forms of treatment that become normative and even expected in contexts where economic resources are minimal? The marketing of evidence-based epistemologies through the cultural allure and capital of “science” (Cushman & Gilford, 2000), often understood to be a safe and value-free arbiter (i.e., lingua franca) for therapeutic decision making (Dueck & Reimer, 2009), creates an overly simple answer to the reason why there are clear segregations and hierarchies that exist in the therapeutic approaches available at different class designations. Shorter-term and symptom-reduction models of psychotherapy dominate in lower-income contexts and this receives little scrutiny because the interventions distributed are “justified” with the label of empirical validation.

There are plural philosophical, theological, and psychological traditions present in any local context. We are—particularly in the United States—a multicultural, multi-lingual, and multi-truthed society. Despite the fact that there is no singular model or set of models that defines psychological disorder and treatment—none that comprehensively captures the manifold discourses of the many psychologies with their complex and varied ways of understanding the person and methods for conceiving change, healing, and “the good life”—the EST movement and medicalization of psychological practices often contributes to a type of “false consciousness” (to use Engels’ term) wherein consumers of mental health practices may come to believe that there is a rather definitive and “best” model for understanding human psychology. The inclusion of psychological care in the medical system—making psychotherapy a “medical” practice (with its own procedural codes, STEM status, and so forth)—has had the unfortunate effect of reflecting (and further creating) a forgetfulness of the important and rich philosophical, ideological, and linguistic differences that exist in different orientations and approaches. Persons become “plug and play representations” of psychological styles, traits, and attributes, with particular disorders and their respective sets of symptoms (Goodman, 2012). In this “medical world,” much like having a broken arm, one can have depressogenic automatic thoughts. Some mindfulness, thought stopping, and behavioral activation achieve a high rate of responsiveness for such persons. Evidence backs this up. But, one can clearly see the language transpiring in this equation. A language of cognitive mechanisms, measurable patterns, and documented types of resiliency forms the foundation of this way of understanding human experience and treatment; necessarily, an ontological conversion by the client is required, through adopting this language, for engagement in therapy to even take place. It is a particular language with particular assumptions. However, by using the terms EST and “medical” to certify this language and these interventions as preferable, primary, or most “effective,” there is a universalizing legitimization that is quite alluring. In this situation, language quickly forgets itself. It forgets that it has become a monopoly language whose primacy excludes the possibilities of plural ways of being, ways of experiencing, and ways of healing (Kirmayer, 2012). The terms “effectiveness” and “evidence” erase the theoretical and linguistic starting points that have particular values and qualities. Furthermore, in speaking about “symptom-reduction” or “medical” intervention, the metaphorical base is lost to a form of certification/legitimization procedure.

The valorization of ESTs contributes to fundamental and frequently unspoken assumptions regarding which languages are immediately in the fold and which are now excluded. Symptom reduction is frequently assumed as a gate-keeping, primary value. And, this becomes commonsensical particularly in a context where various social institutions, economic forces, and consumer pressures lead to increased “medical jurisdiction” over larger segments of human experience (Conrad, 2007, p. 4; see also Rosenberg, 2007). ² In this process, a type of “scientific validation” contortionist act contributes to a web of practices that are ultimately not good science. It does not take seriously its own epistemological limitations and the potential for violence that exists in such overextension of itself (Gadamer, 1996; Hoffman, 2009; Teo, 2010).

“Best practice” models, out of which the EST movement in psychology emerged, cannot mean the same thing in psychotherapy as they do in the medical establishment. And, they cannot mean the same thing because the meaning-making quality of psychotherapy obstructs the possibility of a sufficient, singular language. In his landmark essay, “Doublethinking Our Way to ‘Scientific’ Legitimacy: The Desiccation of Human Experience,” Irwin Hoffman (2009) implores us to recognize how the “privileged status” of empirical psychotherapy process and outcome research is “unwarranted” and “flawed” epistemologically (pp. 1044–1045). Though there may not be consequential difference in language about body injury, illness, and treatment, psychological suffering and identity involves a “consequential uniqueness” (p. 1049) with reference to the individual and his or her particular constellation of experience, which creates a radically and qualitatively different situation for healing. This is part of the reason why diverse and varied theoretical and language systems are so important. As Slife and Gantt argue (1999), methodological pluralism actually advances understanding in social inquiry.

We cannot merely hope to say that particular therapeutic approaches clearly “work” (see Kazdin, 2006; Wachtel, 2010; Westen et al., 2004). That is part of what is so misleading about instrumentalism and its corollaries (Richardson & Manglos, 2012). Therapeutic approaches “work” based on a positioning of the subject in the complex matrix of meaning-making, narrative, economy, and political constitution (to list only a few). For example, self-help books “work” in a post-industrial, neoliberal, expressive individualistic, and pragmatic terrain (Binkley, 2011). A great deal is implicated in the question of which psychotherapy treatments are “effective.” It does not point to some universal, biologically “natural,” ahistorical truth about human functioning. It actually speaks more fundamentally to the moral vision and core values of a culture and its configuration of the self (Christopher, 1996; Cushman, 1995). We are taught how to desire—its parameters and locales. Similarly, we are taught how to understand the vicissitudes of our identity, experience, suffering, and potential. There is nothing benign in language acquisition. It is marketed to us.

Understandably, proponents of ESTs argue that empirical validation actually empowers patients in a way that was not taking place previously. That is, patients are able to have voice in describing whether treatment is helping them or not. An advocate for ESTs would likely even take this article to be supportive of the EST movement because of the ways that Evidence-Based Practice works to ensure that quality treatment is being provided rather than harmful or ineffective models. ESTs are intended to provide accountability and a form of consumer protection. This as an important point and it represents much of the good intention present in the EST movement. I do not have nostalgia for the days when ESTs were not here. I do not think we had it right before this movement came along. Patients need to be empowered and quality controls are of paramount importance. But, I am concerned that this sensibility misses something on how this bears out in practice.

One problem is that patients—in this neoliberal, capitalistic marketplace of ours—have already had their desire and self-understanding shaped to such a degree that the deck is loaded (Binkley, 2011; Brown, 2015). Subjectivity is already oriented and positioned for symptom-oriented and symptom-reduction based languages. Marketing has been effective and—as always—links well with the economic needs of an existing system. So, when a patient comes into the room and says, “I want ‘Cognitive Behavioral’ treatment,” we must imagine where they learned this and how it jibes with a particular approach to product acquisition. Many of our patients come into the room letting us know that their primary care physician (PCP) recommended that they receive CBT—as though they are speaking about Tide or Snuggles as preferred products for laundering clothes. Something of desire has already been sold. A medicalized subject.

As an example of how mainstream and assumed this paradigm has become, I point to a recent article in the American Psychologist titled “Disruptive Innovations for Designing and Diffusing Evidence-Based Interventions” (Rotheram-Borus et al., 2012). In this piece, the authors argue that in order for Evidenced-Based Practice to reach its full potential and be widely used and accessed, the mental health delivery system (or “Evidence- Based Therapeutic and Preventative Programs” or “EBI” Science) needs to undergo a similar “disruptive innovation” as banking and minute clinics embedded in retail chain drug stores (among other examples) have witnessed. Banking has been revolutionized by ATMs. Two dollar generic eyeglasses are now accessible at pharmacies. And, most pertinent to the topic at hand, CVS Pharmacy has minute clinics for brief medical interventions. These types of accesses have altered the fabric of these services and their use. The authors state that a “disruptive innovation provides a simpler and less expensive alternative that meets most of the same needs for the majority of consumers. The new service is more accessible, scalable, replicable, and sustainable” (2012, p. 467).

Rotheram-Borus et al. (2012) make a few additional statements that are worth noting here as they capture something of the sensibility frequently resident in this type of conversation:

Our focus now needs to shift from solely demonstrating that EBIs can work to interjecting what works into user-friendly and scalable tools, products, and experiences. This article suggests ways to redeploy what we have learned from our EBI science in novel ways to extend our impact, create consumer demand, and permeate the daily lives of children, families, and communities. (2012, p. 463)

Psychological interventions need a brand (or brands) as broadly diffused and as accepted as the Good Housekeeping Seal of Approval once was. (p. 471)

We are armed with science but do not know what, when, and how to deliver the science broadly at low cost and with high impact. (p. 471)

Our EBI science needs to shape families’ daily lives as much as McDonald’s or Facebook shapes Americans’ daily routines. (p. 464)

We would be well served to think of the scale-up of EBI programs as involving challenges in distribution systems, similar to distributing products and services at Walmart. (p. 472)

Overlooking (for the moment) the enormous assumptions regarding the fundamental applicability and empirical purity of EBIs and their transformative potential, the employment of psychotherapy as a “product” that is distributable in the fashion of “Walmart” goods is questionable. This approach links up with the type of rationality that Ritzer describes in his book The McDonaldization of Society (2011). Ritzer contends that our desires and decision-making are increasingly orienting around the values and tenants of predictability, control, calculability, and efficiency. He points to how this bears out as true in terms of education, healthcare, prefab suburban developments, and even the types of vacations we take. When people go to Walmart or McDonalds, they know exactly what products and brand names they are likely to find. Homogenization and standardization, not pluralism and diversity. In terms of psychotherapy: specific intervention types, worksheets, homework assignments, tried-and-true interpretation. Processed psychotherapy. Ritzer develops his social critique from Max Weber’s analysis of bureaucracy and Weber’s concern that rationality can become an “iron cage”—creating a type of irrational rationality that dehumanizes its subject.

It is important to note that EST researchers and practitioners are not being accused here of intentionally and malignantly marketing an epistemology and monopolizing language. As indicated earlier, this epistemology and language has already been marketed to them and makes sense in the cultural clearing that values particular characteristics, meaning of symptoms, change mechanisms, etc. The very methods and types of data are already cultural artifacts of our commodifying system (Cushman, 1995). They are valued because they jibe with our values: expediency, rationalism, adaptation, individualism, and so forth (see Cushman & Gilford, 2000; Ritzer, 2011). This is, however, a form of rationality and logic that needs to be called into question; it cannot stand as our primary currency of reason.

What once may have been an effort to distribute affordable mental health care may contribute to the creation of therapy deserts. Patients and their care have become a consumer body to be seized and capitalized upon through the propagation of sparse languages and the unequal distribution of quality services. And the psychotherapy desert is growing. In fact, it has grown into the middle class and beyond. This has narrowed what psychotherapy is and can do in people’s lives. Current claims of scientific superiority, greater empirical validation, and effectiveness may serve to reframe and cloak this socioeconomic disparity and its overall impact on contemporary subjectivity across class lines. Arthur Frank (2004) captures some of the sensibilities represented here when he writes:

The risk is that reforms will be determined by rationales of economic efficiency uninformed by underlying values … Do we want to be providers and consumers or to be hosts and guests? In an age when efficiency most often means lowest unit cost, honorable attempts to bring better care to more people may inadvertently increase what Heidegger identified as subordination to orderability. Reform can increase medical demoralization rather than create conditions that facilitate generosity. (p. 28)

Here, I concur with Cushman and Gilford’s (2000; see also Cushman, 2002) argument that, in our present cultural clearing, the languages and techniques used in psychotherapy may contribute to a general flattening and eroding of personhood:

For the late-20th-century Western society in general, the intersection of mainstream psychology and market values reflects several deeply held cultural beliefs, such as the importance of efficiency, pragmatism, and objective reasoning. This vision is especially appealing to psychologists, representing as it does the allure of science and the promise of an ongoing march of rational, technical progress that have both been central to psychology’s historical self-understanding. It captures in particular one of psychology’s most profound commitments and hopes: the achievement of an effective practice attained through unimpeachable scientific procedures. (p. 986)

Science is culturally enticing and much has been written on why this is the case in modern Euro-American history. Discourses pertaining to “evidence-based practice” frequently represent treatment approaches as “medical” and, in so doing, place a premium on a version of science capable of vouching for approaches that are efficient, predictable, controlled, and calculable—the tenets that so enamor our McDonaldized and expedient psyches (Ritzer, 2011). No one loses out more in this than the already impoverished.

Some might counter argue by saying that “science” and ESTs are universally “marketed” and have not been focused on persons with fewer resources. That is, it is not some class-based conspiracy to keep the underprivileged in particular societal positions. However, we know how insidious and complicated interpellation is. We are often blind to how science actually ambulates within, shapes, and reflects the social order. We are blind to how particular epistemologies and ideologies produce the subject proper and become commonsensical. Our subjectivities are not mere representational systems, but also extensions of socioeconomic, political, and historical values (Cushman, 1995; Kirschner & Martin, 2010, Layton, 2009). McDonalds is marketed across classes, but it is consumed in significantly larger quantities in lower income communities.

Conclusion

A recent article in the APA Monitor (Weir, 2013) addressed the significant health gaps that exist between nations. There was an interesting finding: in nations with socioeconomic inequalities, it is not only those at the lowest income levels who suffer. Research by the National Academics has shown that “even Americans who are insured, college-educated, with higher incomes and healthy behaviors are worse off than similar groups in other countries” (Weir, 2013, p. 39). Richard Wilkinson has quite a simple yet groundbreaking explanation for these findings: inequality itself perpetuates illness. His research has found that “People in more egalitarian societies live longer, experience less violence, have lower rates of obesity and teen pregnancy, are less likely to use illicit drugs and enjoy better mental health” (as cited in Weir, 2013, p. 39) than countries with more inequality present. What might this teach us as we work toward more robust, pluralistic, and inclusive service delivery models?

Psychotherapy is a preternatural space where one learns language that mediates self-experience—both opening up and avoiding/excluding experiential possibilities. It has been argued that mainstream psychological conversations need to more sufficiently recognize the plurality of languages for human experience and that the “best” is not locatable on an empirical and evaluative axis (Slife & Gantt, 1999). As stated earlier, it seems as though we forget that the selection of a therapeutic orientation is a selection of language for one’s experience and suffering. In the epistemological battles being fought regarding “empirical validation” of treatment approaches, questions about the implications of how language, experience, and class intersect are essential.

The language options available at various class designations cannot be ignored. We need to remain cognizant to the ways that this language arrangement ultimately “introduces unrecognized and invisible prejudices” (Gadamer, 2004, p. 169). A shift in the types of conversations that transpire around psychotherapeutic research and practice is needed. Questions pertaining to what approach is the most meaningful, sophisticated, experience-near, and phenomenologically adequate language for a particular patient becomes primary rather than abstract and aggregate models that live on an evaluative axis. How might we form a more humane, generous, and attuned discipline that does not merely mirror the current economic stratifications that plague both the present social order and individual subjectivities alike?