Monday, May 31, 2010

Truth and Turf in the Psychotherapy Wars: Two Hands Clapping?

(This essay was originally published in the Winter, 2010, CAPPSTONE, the newsletter of the Chicago Assn. for Psychoanalytic Pychology, and subsequently in the Winter, 2010, PSYCHOLOGIST-PSYCHOANALYST, the newsletter of Division 39 of the American Psychological Assn., Psychoanalytic Psychology. Shedler's article was subsequently published in AMERICAN PSYCHOLOGIST)

The history of psychotherapy is, in part, the story of a long struggle among people and schools between searching for truth and staking out turf. Of course, that’s true of a lot of professions, but it might be more intense in psychotherapy, where the issues are about who owns the rights to understanding human nature and its treatment.

Jonathan Shedler, a psychologist at the University of Colorado-Denver, has written a monograph that advances accurate description of psychodynamic psychotherapy. “That Was Then, This is Now, Psychoanalytic Psychotherapy for the Rest of Us,” describes it in commonsense, non-jargon language that will be accessible to most readers. ( Shedler avoids the morass of claiming turf, in the name of theory pronounced as received wisdom, that is so characteristic in the history of psychoanalysis. The psychodynamic method, practiced well, is more important and more powerful than the ability of any theory to explain it. Psychodynamic psychotherapy is better explained as a method, with the minimum of theorizing, and better understood, as much as possible, through models of neuroactivity, as Allan Schore is developing. This brings us closer to the truth about psychotherapy.

A new attack in the therapeutic turf wars was launched from Psychological Science in the Public Interest, the journal of the Association for Psychological Science, in the form of an article by Timothy Baker, Richard McFall, and Varda Shoham (from the University of Wisconsin-Madison, Indiana University, and University of Arizona, respectively), entitled, “Current Status and Future Prospects of Clinical Psychology: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care.” ( ) This is the article which, reported as truth in Newsweek, prompted so much discussion; including a flurry of comments on the Illinois Psychological Association listserve, and a rebuttal by Katherine Nordal, APA’s director for professional practice, as quoted in the November/December The National Psychologist (“Psychology gets slap in the face”). Its authors, implicitly defining randomized clinical trials (RCT) as science in psychology, explicitly define evidenced-based treatments as those which have been validated by RCT studies, and consign all other methods of therapy to the garbage pail of superstition and uninformed personal preference.

There’s a lot at stake here, including how clinical psychologists should be trained, how graduate schools should be accredited, and how third party payers should select treatments to recognize, all of which Baker, McFall and Shoham assert should be reserved for RCT-based programs and methods. The stakes were highlighted when I spoke with a psychologist who is an executive at a managed care company. “It’s all about the evidence,” he said, adding that psychodynamic therapy might enrich people’s lives but lacks evidence of efficacy as a treatment.

Of course, that raises the question of what the evidence is. Shedler, in an article entitled “The Efficacy of Psychodynamic Psychotherapy,” which has been accepted by American Psychologist (a draft is posted on his website), reviews an impressive list of studies showing efficacy for psychodynamic psychotherapy. I don’t know how our managed care executive colleague would react, although I expect that he would find a way to disregard it. Perhaps there’s some selectivity here about what evidence to include.

But the argument about which evidence is real evidence obscures the larger issues. I often tell couples whom I see in therapy that each one is probably the world’s best expert on the other’s shortcomings, and something like that situation applies in the opposition between the radical empiricist and psychodynamic traditions. The radical empiricists are right in characterizing much of what psychoanalytic therapists have believed about human nature and its treatment over the years as utterly without factual support. Much psychoanalytic theory is based on the Authoritative Pronouncement of some alpha analyst or other, a tradition begun by Freud and still rife in psychoanalytic culture. There is nothing scientific about it, and the claim of scientific validity for theoretical pronouncements given without a shred of evidence (even liberally defined) to support them is justly characterized by radical empiricists as ludicrous.

On the other hand, reducing human nature in order to fit it into the scientific method available at the time has ever been the problem of behaviorism’s search for scientific respectability in psychology. While the radical empiricists are right in asserting that merely claiming that what one is doing is scientific doesn’t make it so, this applies to their own position of defining science as equal to RCT as well; that’s a philosophy of science, not science itself. In fact, most of what we know about human nature, and particularly brain structure and function, has come about through autopsy studies of people with brain injuries, by neuropsychological and imaging studies of brain-injured people, by animal studies, and by imaging studies of normal people; not by RCT studies, although of course they have made a contribution. I expect that the most valuable research in therapy in future will be neuroimaging studies, once the technology improves enough to measure changes in volume and interconnectivity of parts of the brain. I expect those studies to show improvements in frontal lobe density (especially right frontal lobe), frontal-limbic interconnection, and interhemispheric connectivity, as a result of longer-term, conversational, reflective, relational therapy, when it is successful.

The truth is that, “Life,” as Chicago therapist and teacher Harold Balikov used to say, “is not user friendly,” and emotional pain and behavioral problems in living are part of being human and living life. DSM diagnosis is not the same as physical diagnosis, and therapy is often more like education--in which there are lots of different schools and methods of teaching, and students may have to find the ones that work best for them--than medical treatment, which at least aims for an expert consensus of recognized best practice for any disorder. Truth in marketing mental health treatment would be something like: ”If you need mental health treatment, you may find that therapy, medication, or a combination, may work best for you, and you may have to learn about the mental health treatment choices available, and search for awhile, before you identify the practitioners and the methods which are right for your needs at this time.” Instead, the marketing that we see takes a bit of truth and spins it into deception: ”If you’re depressed, take our clinically proven pill;” to which the radical empiricists would add, “our clinically proven treatment!”

The truth is that different methods and treatment relationships may work better for different people, or for the same person at different times. Twenty sessions of cognitive-behavioral therapy will work better for some people, five years of analytic therapy for others; or maybe both will work better for the same person, at different times in his or her life.

And the truth is that both psychoanalysis and radical empiricism have their roots in traditions in which the dedicated search for some kinds of truth and the dedicated gathering of turf evolved side-by-side. Both traditions offer keen insights into human nature and its treatment, both obfuscate the truth about it as well; most especially by claiming that their method is better than the other, when in fact it is better for some people at some times when practiced by some practitioners.

If this leads to problems about how to authorize and pay for therapy, how to monitor it’s effectiveness and how to do second opinions, then those are issues that psychotherapy, like any mature profession, must develop effective solutions for.

Meanwhile, I’m reminded of the reflection of the poet and teacher Jalaluddin Rumi, that things that appear to be opposed may really be working together; as when the “opposition” of two hands produces a handclap. Perhaps the opposition of the psychodynamic and radical empiricist traditions will produce an effect that will lead many therapists (and maybe even reporters, if they take the trouble to study up on it) to a more inclusive and commonsense mainstream understanding of what therapy is and how it works. Shedler moves in this direction when he acknowledges the overlap between cognitive-behavioral and psychodynamic therapy while respecting their differences. Maybe, even, the opposition between truth-seeking and turf-gathering, even when done by the same people, can help the rest of us, through observation, to learn to sort out the one from the other; leading to a more inclusive perspective that we can ground our work in, train students in, and communicate to the public. Wouldn’t that be a step forward for psychotherapy!

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