psychotherapy

Psychology Tomorrow

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Psychology more than any other science has had its pseudo-scientific no less than its scientific period. — James Baldwin

As I sit here reading a paperback copy of Psychology Gone Wrong: The Dark Sides of Science and Therapy by Tomasz Witkowski and Maciej Zatonski (not the accordion duo), I can’t help but notice myself agreeing with many aspects of this polemic work. However, as a practicing psychotherapist who has always accepted the empirical limitations of psychology, it doesn’t obliterate my appreciation for what I “feel” are the philosophically vital and essential elements (unshakeable bulwarks) of psychotherapy. For the sake of analogy, all partial differential equations in physics are deterministic, but their measurements are subject to stochasticism (randomness), and the randomness of how the human mind operates is primarily why I find psychology interesting. No special pleading should be necessary to historically demonstrate that cognition and behavior can be altered effectively through psychotherapy. Nevertheless, an analysis of long-term treatment methods in various forms of therapy is often confounded by the subjective experiences of clients combined with biased reasoning or questionable motivations by therapists—factors that significantly complicate the investigation of proposed treatment mechanisms. To be fair, subjective experience is partly why studying human consciousness has been referred to as “the hard problem,” but subjectivity in therapeutic treatment settings can undoubtedly be diluted by suggestibility and gullibility.

Most clinically approved and evidence-based forms of psychotherapy used today (i.e., Cognitive Behavior Therapy and Dialectical Behavior Therapy) allow clients to engage in discursive reasoning while providing theoretically-based guidance and emotional support to assist “processing” with the goal of behavioral modification. Finding solutions for optimizing functioning, resolving emotional dilemmas, and establishing well-being often requires an open dialogue (e.g., brainstorming) for sifting through useful or logically cohesive information while examining thought processes and behaviors that are counterproductive. I also believe that philosophical thought experiments can be constructive for abstract problem solving—albeit for higher-functioning clients. However, a trap door in psychotherapy begins to open if the practitioner ignores the role of non-specific effects (the therapeutic interaction, setting, and suggestive narratives) during the application of various treatment methodologies while overestimating, or conveniently fabricating, the specific effects (any proposed mechanism of treatment that is falsifiable). In addition, clinical transparency becomes problematic if pseudoscientific modalities and deliberate cases of fraud are not weeded out through a peer-reviewed framework of empirical restraints. As it currently stands, non-specific effects, self-report, and positive correlations are endemic in psychotherapy-based research. Furthermore, biased interpretations of clinical outcomes with a propensity to rely on anecdotal evidence automatically degrades discussions about the actual mechanisms of psychotherapy interventions. Given these factors, mental health therapy constitutes a wide range of clinically informed, but not always accurate or predictive, efforts to elicit shifts in cognition and behavior. After all, “soft” science should be expected to be malleable—especially when the margin of error is much greater than in other scientific fields such as molecular biology. However, what remains the subject of scrutiny, criticism, and debate are exaggerated claims regarding treatment efficacy that seem conveniently disproportional to the available evidence, such as research with reproducibility problems, uniformed clinicians, and unambiguous cases of deception, fraud, or abuse.

Another important consideration is that “evidence-based” practice in the field of psychology or psychotherapy is not the same as evidence-based practice in chemistry or internal medicine (e.g., the plausibility of certain concepts and applications would be more readily dismissed in modern chemistry than in modern psychology). Although it’s true that “different things work for different people,” an unwillingness to concede the influence of placebo effects or non-specific effects appears to be more common since the advent of New Age marketing, and there is certainly no deficit of “alternative” therapies promoting self-help via “cutting edge” psychology at the hands of “enlightened” life coaches. Given this unfortunate trend, it’s easy to see how clients can be exploited and taken advantage of by practitioners—even if the intention of treatment is not spurious. Consequently, any effective psychotherapy is dependent on client receptivity, and there is no empirical way (that I know of) to calibrate levels of sincere receptivity (lie detector devices are not reliable and certainly not admissible). In fact, it’s much easier to negate criticism of interventions by asserting client resistance when modalities prove less than effective. However, it’s true that client participation is crucial regarding treatment outcomes during all therapeutic interactions. More importantly, a distinction between uniformed practitioners and unethical practitioners is also beneficial in these critiques. For example, uniformed practitioners may believe that a bogus intervention is valid, whereas unethical practitioners may “know better” but aren’t discerning when it comes to achieving their primary motivation (profit).

Many mental health topics that formerly belonged to the domains of psychology and psychiatry are now being imbricated with advances in neuroscience for the potential remediation of unverifiable propositions. To paraphrase director Thomas Insel of the National Institute of Mental Health (NIMH), the future of psychiatry is moving towards clinical neuroscience, and clusters of symptoms will be soon be usurped by clusters of data. Additional interventions such as optogenetics and neoteric studies involving brain mapping are attempting to fine-tune or abrogate the armchair deductions (and inductions) that dictated so much of twentieth-century psychiatric research. There is a long line of academic disciplines waiting impatiently outside the patent office for a wax seal of scientific validity.

As the zeitgeist shifts on the clinical landscape, a natural selection process will invariably occur to “trim the fat” on the principles and practices of tomorrow’s psychology. The caveat emptor is not to abandon mental health treatment or the insights available from studying human psychology, but to abandon the unconstrained credulity that can emerge from both sides of the couch.

Provoking the Muse

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Art is creative for the sake of realization, not for amusement … for transfiguration, not for the sake of play. — Max Beckmann

From a psychoanalytic perspective, the therapist’s role is to provide a comfortable, safe, and non-judgmental environment for free association to take place while allowing the client to experience multifarious epiphanies. The assumption is that solutions will follow naturally from any emergent realizations. Another way to conceptualize this process is something I call the expectorant effect (i.e., guaifenesin). Eliciting information via psychoanalysis should “loosen” repressed or suppressed feelings by “thinning the mucus” of resistance. However, once the dislodging of psychological constipation has commenced, psychoanalysis often outsources long-term problem solving by assuming the client has adequate internal resources for eventual self-correction.

With more invasive forms of therapeutic interaction (e.g., Cognitive Behavior Therapy, systematic desensitization), the therapist should act as a strategic interventionist while incorporating salutogenic priming to stimulate, without falsely influencing, cognitive processing. Associative learning implies associative memory; likewise, maladaptive ways of thinking can be unlearned by establishing new associations. As with the sequential domino effect, one conceptual understanding can innervate a chain reaction that results in a surge of awareness on many levels (cascading luminescence). Information and memories that are dysfunctionally internalized may require extensive exposure to critical thinking skills for promoting adaptive reflectiveness, evidence-based confidence, and future resilience. Furthermore, this is why I believe proficient psychotherapists must also be competent philosophers and teachers. It’s not what you think but how you think that matters for the manifestation of operative change to occur. Teaching someone how to reason more clearly is a vital component for preventing maladaptive emotional and behavioral relapse.

I would submit that effective psychotherapy should be imbued with creativity, but not in a namby-pamby, platitudinous, non-empirical, let’s-break-out-the-crayons-and-have-some-wholesome-fun sense. Being inventive requires the therapist to draw from a large reservoir of therapeutic techniques and educational material to supply the client with sufficient “weapons” for encountering future psychosocial skirmishes. The goal of psychotherapy shouldn’t be to simply make the client feel better; rather, it should provide a user-friendly methodology that allows the client to become their own adjudicator when navigating the perils of circumstance via self-regulation. How this is achieved is less significant than how it is assimilated and actively reproduced. The mechanisms of therapy matter, but effective mechanisms can become ephemeral pacifiers if a platform of persisting continuity cannot be established. What makes sense during a clinical session should also work well in other contexts without the oversight of a clinician. Any epistemic proposition or treatment intervention should be robust enough to withstand peer-reviewed field testing and reliable results over extended periods of time. Subsequently, the creativity of the client is personified as they eventually customize therapeutic information for optimum utilization and self-assured independence. Nevertheless, the internal spectrum of ingenuity sometimes requires a supportive source of inspiration.