I recently read the description of a presentation by Scott Miller "Over the last 40 years, thousands of research studies and how-to books on psychotherapy have been published. Presently, hundreds of treatment approaches exist, each claiming to contain ingredients essential to therapeutic success. Despite the steady parade of the 'new and improved,' the overall effectiveness of psychotherapy has not changed a single percentage point. Not one point—no improvement in effectiveness, whatsoever. Meanwhile, practitioners are facing an economic environment never before seen in history. The cost of training is up, incomes are down, and fewer people are seeking psychotherapy as a remedy to their problems. What’s more, the majority of people who could benefit, choose never set foot in a therapist’s office. How did this happen? How did psychotherapy lose its ability to attract and enchant? More importantly, what can therapists do to get it back? In this workshop, therapists will be pushed to move beyond the narrow narratives characterizing modern clinical practice, reconnecting psychotherapy with practical strategies from its deepest roots in magic, healing, and religion."
I think that the questions raised here are well worthy of extensive debate. We seem to have reached a point in our culture at which nothing is deemed acceptable unless it has the imprimatur of science upon it. This means that the label "scientific" and the use of scientific sounding terminology is now extensively used as a form of advertising, however shaky the supposedly scientific validation might actually be. However, this trend according to which science tries to conquer every aspect of life is not good for science itself nor for the things that then have to pretend to be scientific in order to be acceptable. It can introduce substantial bias and distortion. This is true in the field of psychotherapy where nowadays therapies increasingly rewrite their principles so as to make them seem scientific, often, in the process, betraying the heart and soul that are their actual raison-d'etre. The fact that a therapy is associated with a large number of "scientific studies" does not actually prove anything about its superiority. If psychotherapy were amenable to scientific study then we should have made great progress by leaps and bounds, but it simply does not happen.
My hunch is that basically psychotherapy is a process of influence and how good it is turns on how good is the person who influences you far more than upon any technique or protocol. The idea that the effective agent lies in a replicable procedure is false. However, without replicable procedures you cannot count as scientific. So we establish things that don't work, simply because they are easier to research. The remarkable thing is not that psychotherapy effectiveness has not inched forward - the really remarkable thing is that it has not slipped back.
Also, psychotherapy is a community held together by values and to enter that community one has to be socialised into those values, yet by no means all psychotherapy values are obviously virtuous. Not all the directions that popular psychotherapy is likely to influence one towards are self-evidently good or beneficial. Psychotherapy can make a person more self-obsessed and even more selfish. It can lead to building up rationales for dysfunctional behaviours. It can instil a philosophy of life that is stronger on rationalisation than on character. It can also inculcate stereotypes and suffer from a subtle judgementalism. Mostly the people who spread these influences are completely unaware of the bias and often have never considered the possibility that their value system is open to question.
Over the years I have moved in various circles within the psychotherapy world and in all of them one finds some excellent people. One feels that they would be great healers even if they had never read a psychology book, but that whatever therapy theory they associate with serves them as a language and a structure. They use it rather than being used by it. But then one also meet people who have passed the exams, got the piece of paper, who one has serious doubts about. This is not an issue about tighter regulation - some of the worst abuse cases have been at the hands of the most qualified and validated people. It is not about needing higher academic standards - there is no (or possibly even an inverse) relationship between knowing how to pass therapy theory exams and ability to be a good therapist.
I am not arguing that all research should be abandoned, just that we should have a much more modest estimate of what it is capable of finding out, but I am arguing that the present fetish for awarding status to therapy methods on the basis of supposed scientificness is damaging and misleading nonsense. And going back to Scott Miller's original observations, I think it will be very difficult for the real effectiveness of psychotherapy to increase while the current culture and ethos of the profession, coupled to its associated education and validation systems persists. However, the days of the great pioneers are over. Freud, Moreno, Rogers - how would they fare today?
I'm not opposed to proper science - love it in fact, but both sicence and good practice are corrupted by what is happening in the therapy world...
Being seen as scientific confers status.
To be seen as scientific a method needs plenty of “scientific studies” so that it can say “Innumerable scientific studies have shown that...”
To get many studies a method needs to be easily researchable.
To be easily researchable it needs to be relatively standardised, mechanical and replicable.
“Standardised, mechanical and replicable” more or less defines bad psychotherapy.
Thus we confer highest status on the worst.
The supposed “science” that “validates” some therapy methods is mostly based on correlations of self-reported results with standardised inputs and symptom reduction.
However, self-report is not a good basis for finding the truth as it has large elements of wishful thinking included,
standardised inputs are barely really psychotherapy at all, and
symptom reduction is not necessarily a good indicator of real progress.
This type of methodology is not really science at all, it is simply a well-established PR procedure for establishing a fashion.
To have something at least approximating to real science one needs objective observers who have no vested interest in outcomes applying general criteria of wellbeing unconnected with particular symptoms.
To give an example from physical medicine, if the rate of incidence of a particular disease reduces after the administration of a particular drug, this is indicative of something, but it is not clear exactly what. It may sometimes be the case that people thus “cured” go on to live shorter lives. Thus large regular doses of vitamin C seem to reduce the risk of catching a cold, but, as is now thought, seriously increase the risk of getting cancer. Longevity is a fairly good “general criteria of wellbeing unconnected with particular symptoms” but it is not much use for the kind of short term studies that practitioners crave to “validate” their favoured remedy. There is a parallel in psychotherapy research: a client may complain of a symptom and a quick fix therapy may get rid of it, but at what cost? Nobody knows. A more profound personal encounter may not necessarily have a direct impact upon the presenting symptom, but may change the direction of a person's life, yet whether this is for the better can only really be judged in the long run.
Thus the fashion for “evidence based approaches” and “scientific psychotherapy” tends to undermine the best while encouraging the trivial. It also encourages methodologies that are reductionist and so fail to do justice to the human condition.
This is all rather unfortunate.
Thank you Dharmavidya for making an important point on what is missing from current approaches in psychotherapy. This modern phenomena is widespread in professional circles and just as true for medical doctors and allied healthcare professionals. The rise of the church of Science and focus on EBM (Evidence Based Medicine) means professionalism and other more subtle but important issues at play in our work have been neglected and overlooked. The result is not been good for anyone, patients or healthcare professionals. I recently gave a talk to trainee doctors in our department on VBM (Value Based Medicine) - an attempt to add one of the missing ingredients! We are too clever for ourselves. We tend to oversimplify what is ultimately a very complex and mysterious thing called life and in the process miss what it is all about. Made me think of Einstein who wisely observed: Not everything that counts can be counted, and not everything that can be counted counts. The NHS for one is obsessed with counting (a bit like researchers) but I agree this does not always help us move forward, on the contrary, my diagnosis of the system is that it is stuck and unwilling to explore new ways of looking and being with what is, mostly because it thinks it already has the answer. A growing realisation of the state of affairs has made me consider carefully where I will direct my energy in future. I feel like a little stream finding its way from the head to the heart of matters in a slightly crazy world. May Amida continue to be my light on this foolish journey.
Interesting article on how what is "proven by science" can change radically from decade to decade. Also says a lot of interesting things about dreaming and the brain.
Very interesting read. Thank you Dharmavidya.