Early in his career, Sigmund Freud specialized in hypnosis. He would hypnotize patients in order to get them to open up about their symptoms, which would then presumably reduce their severity. He was quite new to it, and not very skilled, so he needed his patients to be as relaxed as possible – so he had them lie on a couch while he smoked his cigar and told them they were getting very sleepy.
Eventually, he discovered that simply having patients talk about their symptoms in a relaxed atmosphere might be even more effective. He ditched the hypnosis, but kept the couch (and the cigar). Other psychoanalysts who followed in Freud’s footsteps adopted the couch themselves – to the point where the Imperial Leather Furniture Company in New York City became a very wealthy corporation thanks to the sales of ‘analytic couches’ in the 1940s. The psychoanalyst with the cigar and the austere couch became a ‘meme’ of sorts more than seventy years ago. One that persists to this day.
Where would the New Yorker cartoons be without the psychologist couch? Bob Mankoff, himself a former experimental psychologist, is the cartoon editor of the New Yorker. He says the analysis couch in cartoons is a useful shorthand, one that immediately conveys a power dynamic. In The Sopranos, when Tony sees his therapist, he sits in a regular comfortable armchair – but the couch is there in the background, lest we forget what kind of office this is.
Of course, the field of psychoanalysis has progressed a great deal since the heyday of the Imperial Leather Furniture Company, and sitting behind a patient’s head while they talk on your couch is a thing of the past. But powerful images, engrained in popular culture, can hold a certain amount of sway long past their expiry date. As the image of the cigar-couch-psychologist fades, so too does the stigma around seeking help for one’s mental health.
Dr. Nicholas Carleton is a Professor of psychology at the University of Regina, a registered clinical psychologist in Saskatchewan, and is currently the scientific director of the Canadian Institute for Public Safety Research and Treatment. He is encouraged by the progress of the field in debunking and breaking down stigma in seeking help for mental health concerns.
“I think we’re watching stigma fall, and I think it’s largely because psychologists are increasingly out in the community. The notion that it will look like a Mad Men episode when you walk into a psychologist’s office, with a big old leather couch and someone smoking a cigar, all of which could feel very ominous, I imagine is pretty much gone from what actually happens. I also think we’ve started to diffuse that now mythical notion of what happens a little bit.”
Dr. Brigitte Sabourin is an Assistant Professor at the University of Manitoba in the clinical health psychology department, and a practicing clinical psychologist in Winnipeg. She is the Chair of the Clinical Psychology Section at the CPA, and says the field has come a long way but the core goals remain the same.
“We can define ourselves as a field of practice where we deal with human functioning. Clinical Psychology runs the gamut from identifying human problems and solutions to promoting general physical, social, and mental wellbeing. This involves assessment, treatment, consultation, program development, program evaluation, research, mentoring, teaching…”
Dr. Sabourin specializes in clinical health psychology, at the intersection between health psychology and clinical psychology. She does her work in a tertiary care clinic dealing with people who have chronic pain. This means looking at the biopsychosocial aspects of living with a chronic health condition, and applying clinical psychology skills and behavioural health principles to try to support them. Most clinical psychologists have a specialization like this, whether it’s in a hospital setting or in dealing with specific mood disorders. This is not the only way the field has changed over the past few decades. Says Dr. Sabourin,
“I think for one thing, the field has become more diverse. Historically it was dominated by white men, and that continues to change. Our commitment to evidence-based practice is continuing to evolve in bringing together all our knowledge in terms of what we know about anything from mental disorders to human flourishing. We’re now using that knowledge a lot more in terms of improving our services and being accountable to the people we serve. I think also the settings in which we practice have evolved. You see clinical psychologists in settings anywhere from primary care to very specialized services, which means the settings and the populations we deal with are much more diverse than they used to be. I also think the acknowledgement of how helpful it can be to access services has progressed. It’s not about there being something wrong with you, or that you’re crazy – that stigma has started to go away and people are realizing that we can help anyone from an elite athlete to someone who’s really having trouble with basic day-to-day tasks.”
Bringing together that knowledge and using it in clinical practice is something both Dr. Sabourin and Dr. Carleton know well. Both are researchers in addition to clinicians. Dr. Carleton sees, and treats, a lot of first responders in Regina – particularly RCMP, as the academy is there in the city. He also does a lot of research with the RCMP and other public safety personnel (PSP). Recently he and his team created an anonymous online tool where PSP could assess their own mental health and then reach out for support should they need it. He says,
“I think we’re seeing a better integration of science and practice. We’re doing a better job of connecting with one another, and having reflexive relationships between those psychologists who are doing research and those who are doing practice. We’re seeing how science informs practice and vice versa in a more dynamic way. For example, there have been significant changes when it comes to PTSD. Thanks to clinical practice interacting very closely with research, there are now four symptom clusters instead of only three. PTSD diagnoses can now happen without having a singular event, considering the aggregate of compounding events. Certainly for our first responders and other public safety personnel, those were two huge steps forward. Public safety personnel were having difficulty specifying which event was causing them the most trouble because they would have experienced hundreds or maybe thousands of them within a single calendar year. Previously, they would go to see a psychologist and say ‘I’m in trouble’, and the psychologist might have said ‘so am I because I’m struggling to diagnose you unless you pick one event’. We’ve fixed those things, and we’re making sequential improvements and important advancements.”
Another advancement, one with which we’re all familiar by now, is technological. I am conducting this interview with Dr. Sabourin and Dr. Carleton via Zoom, and there are dozens of other virtual platforms available for meetings – and even therapy sessions. Dr. Sabourin says,
“I think something else that’s really taken off, especially since the pandemic, is the role of technology and innovation in terms of accessing psychological services. The idea that you have to go into a psychologist’s office for even a fifteen-minute session somewhere in a forbidding building is no longer how we think about clinical psychology. Now we can access video conferencing platforms, phone apps, and so on. For example, we’re doing a lot of our group-based programming where participants can be in the comfort of their own home, and not have to drive to the hospital and pay for parking, and figure out where they’re going and all that. Decreasing the barriers to care and increasing the flexibility of how we do things is an exciting development. It has been moving that way for a while, but in the last two years with the pandemic has really taken off.”
Doing virtual therapy was a pretty fringe notion two years ago before the pandemic hit, but over the course of the last two years a lot has changed. Psychologists who were wary of holding sessions on virtual platforms have learned to do so effectively, and the prevalence of this kind of technology has eliminated some barriers to care, made more psychological help available, and gone a long way toward the continued erosion of the stigma surrounding the seeking of mental health support. Dr. Carleton says it has also helped in other ways.
“At the risk of speaking heresy, I actually think that being required to work remotely – while it may have stymied conferences – has actually increased collaboration in many ways. I can meet with someone in Australia at the end of my day and beginning of theirs, and for half an hour we can swap notes. We’re not locked into a mindset that requires one of us to fly somewhere for 16 hours.”
Dr. Sabourin agrees. Not only are collaborations easier, but getting more psychological care to more people is as well.
“We’re looking at how to increase resources and our reach. Part of this is adapting the ‘stepped care’ model that’s rolling across the country. It’s a little bit of psychology for a lot of people, and then as the needs increase and get more complex you get to a more intense model. We were reading an article in a research journal about this model in Ottawa, and the director of my clinic was saying ‘I wish we could just fly to Ottawa and sit down and talk to this person!’ And I said ‘I’ll set up a Zoom meeting for Tuesday’. It can just happen so fast and we’re so used to the platforms that it almost feels like we are face to face when we talk this way.”
I do this food order thing, where I get food delivered from local farms in my area. The food gets delivered by Miles [not his real name], a big burly man with a beard down to his belt buckle who drives the enormous freezer truck. A little while ago we were talking about this new job I had just started with the Canadian Psychological Association, and Miles told me about a co-worker he was worried about who was becoming more withdrawn. He was worried about his friend’s mental health. Should I reach out to him? Should I leave it alone? As a non-psychologist, I couldn’t give great advice about exactly what to do, but I thought that gently reaching out could never hurt. The next few times I saw Miles he would give me updates about how his friend was doing. One day last summer when I was working out of my garage, Miles and this co-worker were both in the truck and came in to sit for a few minutes. Now every time they make a delivery to my house, we sit for fifteen minutes or so to talk a little bit about our own mental health. How we’re holding up with this pandemic, what the struggles have been for ourselves and our families. Dr. Carleton says this kind of thing is happening more and more often.
“We’ve seen huge improvements in the discussion of mental health. Instead of it being something that’s kept in the dark, people are having frank conversations. The fact that we’re at a stage where we’re trying to mobilize knowledge about mental health to help transition toward substantial change – that’s a monumental shift even in the last two decades. We may not be exactly sure what we’re going to do next, but at least now we’re no longer denying that we have important opportunities for the population with mental health. I think a lot of that’s come about as a result of the advocacy of clinical psychologists and other mental health professionals.”
We’re not all the way there yet – some stigma remains and hangs on, like that image of the cigar and the couch. But mental health professionals continue to work at eradicating it, and clinical psychologists are no exception. Dr. Sabourin sums up the message very well.
“It’s okay if you’re struggling – you’re human. Being a human being on this planet is not easy! We’re all trying to live our life but we didn’t choose who our parents were, we didn’t choose our genes, we didn’t choose the fact that our brains are probably still programmed to help us survive 20,000 years ago and our environment has changed substantially since then. It’s about normalizing that it’s okay when there are times in your life that are harder than other times. We see these amazing human beings who have flourished – like Clara Hughes, the Olympic athlete who recognizes she’s had trouble. We have really famous actors and politicians who are becoming open with their difficulties and that something can be done about it. We’re recognizing as a society that it’s not the case that you’re either well or you’re sick. You can find tweaks. You can find ways of having a bit of an easier go, becoming more comfortable in your skin, being more present in engaging with your kids. Many of us struggle, and the fact that you’re seeing a clinical psychologist doesn’t mean there’s something wrong with you, we’re just all human beings trying to do the best that we can in this not-easy world.”