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Saving Talk Therapy: How Health Insurers, Big Pharma, and Slanted Science are Ruining Good Mental Health Care
A hard-hitting critique of how managed care and the selective use of science to privilege quick-fix therapies have undermined in-depth psychotherapy--to the detriment of patients and practitioners
In recent decades there has been a decline in the quality and availability of psychotherapy in America that has gone largely unnoticed--even though rates of anxiety, depression, and suicide are on the rise. In Saving Talk Therapy, master therapist Dr. Enrico Gnaulati presents powerful case studies from his practice to remind patients and therapists alike how and why traditional talk therapy works and, using cutting-edge research findings, unpacks the problematic incentives in our health-care system and in academic psychology that explain its decline.
Beginning with a discussion of the historical development of talk therapy, Dr. Gnaulati goes on to dissect the factors that have undermined it. Psychotropic drugs, if no longer thought of as a magical cure, are still over-prescribed and shunt health-care dollars to drug corporations. Managed-care companies and mental health "carve outs" send health-care dollars to administrators, drive many practitioners away, and over-burden those who remain. And drawing back the curtains on CBT (cognitive behavior therapy), Dr. Gnaulati shows that while it might be effective in the research lab, its findings are of limited use for the people's complex, real-world emotional problems.
Saving Talk Therapy is a passionate and deeply researched case for in-depth, personally transformative psychotherapy that incorporates the benefits of an evidence-based approach and psychotropic drugs without over-relying on them.
In recent decades there has been a decline in the quality and availability of psychotherapy in America that has gone largely unnoticed--even though rates of anxiety, depression, and suicide are on the rise. In Saving Talk Therapy, master therapist Dr. Enrico Gnaulati presents powerful case studies from his practice to remind patients and therapists alike how and why traditional talk therapy works and, using cutting-edge research findings, unpacks the problematic incentives in our health-care system and in academic psychology that explain its decline.
Beginning with a discussion of the historical development of talk therapy, Dr. Gnaulati goes on to dissect the factors that have undermined it. Psychotropic drugs, if no longer thought of as a magical cure, are still over-prescribed and shunt health-care dollars to drug corporations. Managed-care companies and mental health "carve outs" send health-care dollars to administrators, drive many practitioners away, and over-burden those who remain. And drawing back the curtains on CBT (cognitive behavior therapy), Dr. Gnaulati shows that while it might be effective in the research lab, its findings are of limited use for the people's complex, real-world emotional problems.
Saving Talk Therapy is a passionate and deeply researched case for in-depth, personally transformative psychotherapy that incorporates the benefits of an evidence-based approach and psychotropic drugs without over-relying on them.
264 pages, Hardcover
Published January 9, 2018
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Displaying 1 - 15 of 15 reviews
April 5, 2018
This book highlights the rise and fall of traditional talk therapy. The first two chapters go over the beginnings of psychotherapy, starting with Sigmund Freud and moving through the various therapists after him and their contributions to the field. These chapters, I thought, were very interesting, as they show how dynamic the field is and how many changes were made throughout its history, steadily getting more effective in its methods.
The next two chapters, three and four, go over the rise of the first anti-depressants, the most famous being Prozac starting in the 1980's, and the introduction of more scientifically measurable treatment methods like cognitive behavioral therapy (C.B.T.). The author describes how the first anti-depressants like Prozac and Xanax exploded onto the scene, apparently curing depression in people left and right, and making quite a lot of money in the process. This leads up to the current situation in America, with most people with depression, or depressive-like symptoms, on some sort of medication. On top of this, more scientifically built therapies that cut down on the more personal face-to-face interactions, like cognitive behavioral therapy (C.B.T.) or acceptance and commitment therapy (A.C.T.), are introduced to quickly and efficiently reduce therapy visits and cure the patient.
The fifth chapter goes over how new therapists are being trained within the new realm of therapies that include the methods mentioned above, and how the traditional trust-building of therapist and patient is being played-down. While the last three chapters explain the importance of real talk therapy, with examples from the author's own experiences, along with small explanations and the importance on building a rapport with their patient(s) to help the healing process, the growth of the therapist's expertise and wisdom, and the importance of natural human connections.
Overall, I did like this book. The author certainly makes his case for making connections with patients through a long, healing dialogue. To get people to speak about their innermost thoughts, feeling, ideas, and so on, to really examine what is bothering them and why. As someone who has went through therapy, I can attest to this method. To be able to talk to someone with a non-judgmental and open point-of-view who can help you re-frame your experiences, is very important for the sorting-out of your mind and life.
I did have a few issues with some of the content, though, which by themselves aren't too bad except that I'm seeing them as all as a string of problems connected as one big one. So here goes...
The author likes to point out how good of a therapist he is, which in itself is not totally a bad thing, except that he did it enough times for me to take real notice. This was also coupled with the amount of times he brings up the subject of money and how much the therapist should be paid.
A therapist is engaging in a very difficult procedure and should be paid for it, I totally get that, no question, and he brings this up at the end of the book. It's just that he is also seems very much against the "scientifically measurable" therapies like C.B.T., for example. He says that they are there to get the patient fixed asap and has statistical significance so that those methods can be perfected and the therapist trained accordingly. All this leading to less human connection and less billable time for the therapist. I do agree with the genuine human connection, that connection with my therapist helped immeasurably and I see his point, what I don't agree with is his apparent anti-science stance he makes from time to time. One therapy he brought up is M.B.S.R., or mindfulness based stress reduction, which is a highly successful (and scientifically measurable) therapy started in 1979 by Dr. Jon Kabat-Zinn. Though I haven't personally engaged in this therapy, if you read enough books on the psychology of stress and/or trauma you will come across this method, and it is a very highly recommended method which has helped many people. My therapist had me work with acceptance and commitment therapy (ACT), along with talking, and the ACT methods helped me quite a lot. I'm not quite sure why these "quick fix" therapies are so bad, they're just (in my opinion) different perspectives which, depending on the patient, help them get to the core of their problem. Sure, one person should use ACT and not CBT, or CBT and not MBSR, and so on, but they are there to help the patient sort out their issues. Granted, he does mention how some therapists do use the science-based methods along with talk therapy, mixing them in and not just using them exclusively, and that's great. But the author treats them as if they are just another form of medication.
Maybe it's just me, but in his tone of writing in this string of issues I noticed, they connect together to produce a profile of a guy who is self-promoting himself a bit too much and who wants to get paid a lot and frequently. Less pills, less "scientifically based" methods, and more billable in-the-chair time with him. I could be COMPLETELY off the mark here, but these things rose up as I was reading and I thought I would voice them out and see if anyone saw this too.
OKAY, THAT BEING SAID...
Would I recommend this book? If you are interested in mental health care, YES, I would definitely recommend this. Yes, I wrote a rather long rant about that narrative I saw running through the book, and I apologize for the length, but ignoring all that, the book is really interesting. I do agree with most of what Dr. Gnaulati talks about: we are a very social, collective species that needs that natural, living connection between our fellow human beings, and talking is a major part of that connection. We in Western culture have become more and more fragmented from each other, and having trusting, fulfilling relationships helps balance ourselves out. Therapy should not be made up of pills and forms to fill out, it needs to be a honest, open, and trusting dialogue.
Thanks.
The next two chapters, three and four, go over the rise of the first anti-depressants, the most famous being Prozac starting in the 1980's, and the introduction of more scientifically measurable treatment methods like cognitive behavioral therapy (C.B.T.). The author describes how the first anti-depressants like Prozac and Xanax exploded onto the scene, apparently curing depression in people left and right, and making quite a lot of money in the process. This leads up to the current situation in America, with most people with depression, or depressive-like symptoms, on some sort of medication. On top of this, more scientifically built therapies that cut down on the more personal face-to-face interactions, like cognitive behavioral therapy (C.B.T.) or acceptance and commitment therapy (A.C.T.), are introduced to quickly and efficiently reduce therapy visits and cure the patient.
The fifth chapter goes over how new therapists are being trained within the new realm of therapies that include the methods mentioned above, and how the traditional trust-building of therapist and patient is being played-down. While the last three chapters explain the importance of real talk therapy, with examples from the author's own experiences, along with small explanations and the importance on building a rapport with their patient(s) to help the healing process, the growth of the therapist's expertise and wisdom, and the importance of natural human connections.
Overall, I did like this book. The author certainly makes his case for making connections with patients through a long, healing dialogue. To get people to speak about their innermost thoughts, feeling, ideas, and so on, to really examine what is bothering them and why. As someone who has went through therapy, I can attest to this method. To be able to talk to someone with a non-judgmental and open point-of-view who can help you re-frame your experiences, is very important for the sorting-out of your mind and life.
I did have a few issues with some of the content, though, which by themselves aren't too bad except that I'm seeing them as all as a string of problems connected as one big one. So here goes...
The author likes to point out how good of a therapist he is, which in itself is not totally a bad thing, except that he did it enough times for me to take real notice. This was also coupled with the amount of times he brings up the subject of money and how much the therapist should be paid.
A therapist is engaging in a very difficult procedure and should be paid for it, I totally get that, no question, and he brings this up at the end of the book. It's just that he is also seems very much against the "scientifically measurable" therapies like C.B.T., for example. He says that they are there to get the patient fixed asap and has statistical significance so that those methods can be perfected and the therapist trained accordingly. All this leading to less human connection and less billable time for the therapist. I do agree with the genuine human connection, that connection with my therapist helped immeasurably and I see his point, what I don't agree with is his apparent anti-science stance he makes from time to time. One therapy he brought up is M.B.S.R., or mindfulness based stress reduction, which is a highly successful (and scientifically measurable) therapy started in 1979 by Dr. Jon Kabat-Zinn. Though I haven't personally engaged in this therapy, if you read enough books on the psychology of stress and/or trauma you will come across this method, and it is a very highly recommended method which has helped many people. My therapist had me work with acceptance and commitment therapy (ACT), along with talking, and the ACT methods helped me quite a lot. I'm not quite sure why these "quick fix" therapies are so bad, they're just (in my opinion) different perspectives which, depending on the patient, help them get to the core of their problem. Sure, one person should use ACT and not CBT, or CBT and not MBSR, and so on, but they are there to help the patient sort out their issues. Granted, he does mention how some therapists do use the science-based methods along with talk therapy, mixing them in and not just using them exclusively, and that's great. But the author treats them as if they are just another form of medication.
Maybe it's just me, but in his tone of writing in this string of issues I noticed, they connect together to produce a profile of a guy who is self-promoting himself a bit too much and who wants to get paid a lot and frequently. Less pills, less "scientifically based" methods, and more billable in-the-chair time with him. I could be COMPLETELY off the mark here, but these things rose up as I was reading and I thought I would voice them out and see if anyone saw this too.
OKAY, THAT BEING SAID...
Would I recommend this book? If you are interested in mental health care, YES, I would definitely recommend this. Yes, I wrote a rather long rant about that narrative I saw running through the book, and I apologize for the length, but ignoring all that, the book is really interesting. I do agree with most of what Dr. Gnaulati talks about: we are a very social, collective species that needs that natural, living connection between our fellow human beings, and talking is a major part of that connection. We in Western culture have become more and more fragmented from each other, and having trusting, fulfilling relationships helps balance ourselves out. Therapy should not be made up of pills and forms to fill out, it needs to be a honest, open, and trusting dialogue.
Thanks.
April 11, 2020
I wish that every young graduate who has only been taught short-term interventions, and who believes that CBT and its derivatives are the only types of treatment approaches that "work," would read this book. It really might be a mind-blowing experience for them.
Dr. Gnaulati is an advocate for psychoanalytic and humanistic therapies, which require the emotional investment of the clinician. I absolutely adored his point that the workbooks and homework assignments that are at the core of CBT practice are a way for therapists to avoid dealing with their counter transference. Of course, the CBT community thinks transferences are to be avoided, rather than a tool to be used in treatment.
I'm not sure it's a great strategy for those of us who are advocates for long term work to come out arguing against psychotropic medications, as it puts us in danger of being on the wrong side of history. Gnaulati isn't completely opposed to meds, but feels they often do more harm than good.
I would have liked to see Gnaulati acknowledge some of the mistakes that the psychoanalytic community has made, such as remaining quite insular in large metropolitan areas, and being slow to outreach to a less affluent clientele. In addition, even with mental health parity, going to therapy for many years is costly, and it would be nice for therapists to acknowledge this. Despite the science being questionable, short-term therapy is extremely appealing to many folks, and this reality needs to be confronted.
While there have been similar books published, Saving Talk Therapy does a good job of advocating for a type of treatment that is frequently under attack, and misunderstood.
Dr. Gnaulati is an advocate for psychoanalytic and humanistic therapies, which require the emotional investment of the clinician. I absolutely adored his point that the workbooks and homework assignments that are at the core of CBT practice are a way for therapists to avoid dealing with their counter transference. Of course, the CBT community thinks transferences are to be avoided, rather than a tool to be used in treatment.
I'm not sure it's a great strategy for those of us who are advocates for long term work to come out arguing against psychotropic medications, as it puts us in danger of being on the wrong side of history. Gnaulati isn't completely opposed to meds, but feels they often do more harm than good.
I would have liked to see Gnaulati acknowledge some of the mistakes that the psychoanalytic community has made, such as remaining quite insular in large metropolitan areas, and being slow to outreach to a less affluent clientele. In addition, even with mental health parity, going to therapy for many years is costly, and it would be nice for therapists to acknowledge this. Despite the science being questionable, short-term therapy is extremely appealing to many folks, and this reality needs to be confronted.
While there have been similar books published, Saving Talk Therapy does a good job of advocating for a type of treatment that is frequently under attack, and misunderstood.
May 17, 2018
Saving Talk Therapy advocates what Freud established as psychotherapy. The author is a fan of Freud which anyone in the psychology profession might be. But he fails to mention the disservice Freud my have done to psychologically healthy women who were experiencing physical symptoms of hysteria.
In my opinion as a patient, talk therapy is a very legitimate treatment method. However I have participated in both talk therapy and evidence based practices and I have benefited from both. Discounting anything other than talk therapy to the psychiatric practice is doing a disservice to many people who may respond to other methods.
In the second part of the book he gives great advice to those who may be new or contemplating the psychiatric practice. Empathy and the therapist/client relationship is important. However I also found the author arrogant in these topics as well.
In my opinion as a patient, talk therapy is a very legitimate treatment method. However I have participated in both talk therapy and evidence based practices and I have benefited from both. Discounting anything other than talk therapy to the psychiatric practice is doing a disservice to many people who may respond to other methods.
In the second part of the book he gives great advice to those who may be new or contemplating the psychiatric practice. Empathy and the therapist/client relationship is important. However I also found the author arrogant in these topics as well.
July 17, 2022
Some interesting history of psychotherapy and insights about the value of things that cannot be measured in the therapeutic dynamic that help shift our clients into more meaning, intention, aliveness. It just seems like the version of the CBT therapist Gnaulati is critiquing is a bit of a straw man. Definitely good cautionary commentary about the dangers of handing therapy over to managed care/insurance companies who know little about the craft of psychotherapy and over rely on research of CBT that does not reflect how most therapists actually apply and incorporate it.
April 23, 2019
As a therapist, I found this book so validating. It was great to read someone else experiencing the same struggles with the mental health system as well as giving some history as to how we got here. I would definitely recommend this book for anyone, but I would especially recommend it for therapists.
January 19, 2023
This is a dense book that’s tough to get through, but I agree entirely with all the concepts. We’ve been sold a bill of goods that pills will solve everything (they won’t) and that if we do go into therapy we need CBT or other “evidence-based” treatments, when actually those treatments are just easier to measure than the empathetic relationship that is what actually heals.
April 28, 2025
This is a good read for a counselor or therapist in training. For those who are more experienced would recommend the final chapters. The beginning chapters are more for beginners or those new to the world of mental health.
November 5, 2025
honestly wasn't a bad book i think the author kinda had too strong of some opinions but it's interesting given the fact that im about to go into regular therapy rn lol finding it weird that i can point out some of the certain things that my therapist does
February 24, 2018
Interesting look at our mental health care system.
March 12, 2018
This was a very interesting look at mental health care.
April 7, 2018
I first heard gnaulati on npr's "On Point." I felt that his defense of traditional insight – oriented psychotherapy was spot on. I also thought that his critique of the state of affairs in cognitive behavioral therapy was spot on. In this text, he continues this argument against vapid and quite limited psychotherapy practices.
As a private practitioner who struggles to keep his doors open given the practices outlined in this book, the author does highlight holes and misinformed practices that are governed by insurance companies, many of whom do not possess the expertise to truly understand the impact and manifestation of mental illness. Although some might claim that his critique is pejorative or anecdotal, for those of us in practice, he very much speaks to the struggles inherent in giving patients quality care while also being able to earn a living. He also highlights how the trending towards "Mc treatment" and a movement toward larger systems with less focus on individual care, is a current plague to quality healthcare. I do think that his promotion of therapeutic technique toward the end of the text is rather remedial, but I don't think this is aimed at a necessarily academic audience. Good piece of work.
As a private practitioner who struggles to keep his doors open given the practices outlined in this book, the author does highlight holes and misinformed practices that are governed by insurance companies, many of whom do not possess the expertise to truly understand the impact and manifestation of mental illness. Although some might claim that his critique is pejorative or anecdotal, for those of us in practice, he very much speaks to the struggles inherent in giving patients quality care while also being able to earn a living. He also highlights how the trending towards "Mc treatment" and a movement toward larger systems with less focus on individual care, is a current plague to quality healthcare. I do think that his promotion of therapeutic technique toward the end of the text is rather remedial, but I don't think this is aimed at a necessarily academic audience. Good piece of work.
March 3, 2019
Fascinating talk on the current mental health system and how we got here.
June 10, 2019
Great read. I have listened to it. Very well researched and beautifully written. Will definitely buy it in print now. :)
Thank you.
Thank you.
August 25, 2020
Great book that provides a wise, sophisticated, scientifically informed, and impassioned defense of traditional talk therapy!
June 10, 2019
Well researched and argued. At first I was defensive about his attacks on CBT, which has benefitted me, but as he described how CBT has been reduced to mere impersonal steps and worksheets in many cases like the Kaiser and VA models, I understood his critique. My therapists were talk therapists who subtly wove in CBT techniques; they let me talk and work through my issues.
Having lost my wonderful health insurance, I’m now in a plan with limited and rushed mental health services; they just want to give everyone a pill. Evidence from this book can help me argue for the care I need.
Having lost my wonderful health insurance, I’m now in a plan with limited and rushed mental health services; they just want to give everyone a pill. Evidence from this book can help me argue for the care I need.
Displaying 1 - 15 of 15 reviews