When I originally learnt psychotherapy, psychoanalysis was the dominant force and its arch foe was behaviourism. Freud had claimed to offer the first scientific psychology. The behaviourists came along with what they claimed was really scientific. Humanistic methods were also on the rise and were a reaction against both the established antagonists. Humanists such as Rogers, Maslow and Perls stressed human potential and personal growth. In reality all of these three movements added to human knowledge from the perspective of the outside view as well as offering actual therapy in which an inside view was essential to success.

Freud and Jung provided us with detailed accounts of actual therapy and built a model of the mind much of which has entered into the general culture - the unconscious, defense mechanisms, archetypes, complexes, association of ideas, interpretation, projection, transference, and so on. Behaviourism tried hard to adopt the language and attitude of hard science, but the success of particular behaviourist therapists owed a great deal to their individual genius and ability to tune in to the real needs of the particular client. Humanists rejected behaviourism and analysis, but, in fact, Rogers was one of the great pioneers of psychology research and his ideas grew out of his early exposure to the work of Otto Rank, a disciple of Freud.

Behaviourism’s attempt to deal only with inputs and outputs of the mind, taking the mind itself to be, as it were, an empty box, was never entirely convincing and led eventually to the addition of cognitivism as a scientifically flavoured way of thinking about what might actually be going on inside the box. I still have doubts whether this attempt to be “scientific” about subjectivity makes sense, but it has been bolstered in recent years by the slogan “evidence based”. This slogan was originally introduced as a way of giving cognitive therapy a political edge over other forms, especially over psychoanalysis and humanistic methods which were all then lumped together as not evidence based. This strategy worked in the sense that it convinced social administrators and insurance companies and thereby attracted funding to cognitive approaches, while causing a good deal of chagrin in other areas of the psychotherapy profession. Earning the epithet “evidence based” became the name of the game, though hardly any approaches to therapy do actually derive from evidence. Rather established methods attempt to achieve the “evidenced based” stamp of approval retrospectively.

There are psychotherapy courses to this day that do not teach the work of Freud or Rogers because they think it is not evidence based. Rogers, however, we should remember, was one of the great pioneers of psychological research. Rogerians have had to go to considerable lengths to revalidate their approach in terms of the new evidence based criteria. Evidence based now means that there exists a body of research of a certain kind that purports to show that the method in question is effective in treating specified psychological conditions. It is debatable whether the conditions in question actually exist as psychological entities, but this has become the fashion. Even behaviourism, as practised in the 1950s and 60s, would not qualify as evidence based in the modern sense, despite its pretensions to being strickly scientific, nor would it meet contemporary ethical criteria. None of this means, however, that it was not sometimes highly effective, just as other now supposedly non evidence based methods were effective in the sense of enabling people to live more creative and meaningful lives.

Rogerian method has now established some credibility as an evidence based approach, but the therapy being done by Rogerians is no different from that which they were doing when they were not considered so. Insofar as becoming accepted as evidence based has changed in any way the actual practice of Rogerian therapists, it is questionable whether such change will have been for the better. To do Rogerian therapy well, the therapist should not have her mind on research papers, she should have it on the client before her.

Much of the hoo-haa around whether an approach is evidence based or not is simply a political game, but it has distorted the field. The simpler the method, the easier it is to research and so the easier it is to produce the heap of research papers needed. This does tend to lead to a dumbing down. More sophisiticated methods do not lend themselves to being qualified as evidence based because they are more difficult to research and so less attractive to researchers. Thus, it has been easy for mindfulness to achieve some status as evidence based because it is extremely simple so is a favourite for PhD students. Thus large numbers of research papers came into existence very quickly. However, most of this research is of very poor quality.

The recent move to validation by evidence base has actually been accompanied by a shift in public attitude rather counter to what might have been expected. While insurance companies and hospital managements have moved toward favouring cognitive approaches, the forms of therapy that seem to be on the rise in terms of public popularity are existential therapy and hypnosis.

All this concern with supposedly scientific credentials has not changed the fact that the general impression from reviews of a great many large scale surveys is that all the main methods of therapy are of more or less of equal effectiveness. This suggests quite strongly that it is not the particular techniques or protocols employed by this or that school that really make the difference. Rather these are the games that therapists play with their clients while the actual therapy goes on on another dimension. Whether the therapist passes the time with the client doing dramatic reenactments, as in psychodrama, playing in the sand tray, as in Jungian projective therapy, teaching and learning desensitization procedures, as in behaviourism, interpreting dreams, as in analysis, or participating in encounter groups, as in some Rogerian work, is probably not the pivotal variable. If it were, much bigger differences in effectiveness would appear. If the research were done it might well be found that teaching people to play chess or going on sailing trip expeditions were just as effective in “curing depression”, say, as any of these other methodologies. In all probability, what really makes the difference, is something more subtle that goes on at a personal and interpersonal level. Identifying the real therapeutic element is probably beyond the reach of science as we know it and not likely to be detected by the kind of search for “evidence” that currently obsesses the profession.

This conclusion is in line with what we learn from a spiritual perspective. Zen masters and Tibetan gurus also have their pastimes in the form of rituals and temple routines. Shakyamuni Buddha had a massive impact upon the lives of many people and he too engaged them in certain activities, like watching corpses decay. The particular activity chosen certainly has some intrinsic features that teach the participant something, but the crucial, truly therapeutic (life changing) factor is surely something else. Indeed, it may well have a great deal more to do with that notion so totally remote from the evidence base, introduced by that bete noir of all the moderns, Sigmund Freud, namely transference, or, in Buddhist terms, transmission. As Ananda asked Kashyapa, “What was it that Shakyamuni transmitted to you other than the robe of gold brocade?”

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  • Interesting discussion. 

    Different methods and approaches each have a place and contribution to make.  The skills of a doctor might be (depending on circumstances) very different from those of a psychotherapist or psychologist.  Or maybe not?

    One sentence in David's piece resonated:  In all probability, what really makes the difference, is something more subtle that goes on at a personal and interpersonal level.  I agree. 

    Relationship is crucial.  How we relate, or are not able to relate is what makes the difference.  We meet others (clients, patients, family, partners, strangers).  Every meeting is a stepping onto sacred ground, unexplored territory.  What will happen is not clear.  An encounter takes place.  Sometimes both people are changed (for better or worse).  Sometimes they remain the same.  Sometimes something is transmitted which is hard to articulate.  One might feel different without really knowing exactly what is different?  What takes place in therapy can be analysed and reflected on.  Words and ideas can unfortunately not bring to life the experience of being in such an encounter and being changed by it. 

    A skilled therapist use many methods and is observing and learning all the time.  I have learnt from Medical and Buddhist practice that most methods have a function and limitations.  It might be the finger pointing to the moon but it is not the moon itself.  I have observed that the more experience, confidence and faith a practitioner/therapist has, the more willingness he/she has to be open and allow the natural unfolding of whatever presents in the encounter with the other.  There is a moving away from such a method for such a problem though methods can still be used.  Flexibility, open emptiness  and humbleness seem key.  No one of us knows or understands everything.  Life is a mystery.  Human beings are fools.  Sometimes the use of a specific method or question might be helpful.  Other times not.  Sometimes sitting in silence is enough.  Sometimes speaking has a place.  Being able to discern between the 2 is an art.

    Different psychological approaches and methods aim to understand and work with the fertile ground between people.  Relationships bring opportunity to learn about self, other, the world and the dance in between. 

    Therapy at best creates a space where the client (and therapist) can see, explore, learn and make meaning of life.  Maybe what is more important than different methods is whether the client/patient after encountering the other (therapist/clinician) is more able to face the reality of his/her life and willing to act and respond to what life is asking of him/her.

  • - CR bias nis ot surprising as I knew him personally

    - Freud himself did involve the families and he was certainly in favour of people becoming their own therapists. The fact that analysis has been hijacked by the well-to-do is not really his fault. Part of the problem arose when Jones translated Freud into English using a technical style of language intended only to be read by doctors, eg. ego and id in the English are simply "I" and "it" (ich, es) in the original German.

    - I agree that behaviourism is as much education as therapy. Education is generally a good thing and need not be in conflict with other therapeutic modalities. The hostility between schools of therapy is unfortunate. Buddhist psychology has behavioural, humanistic, cognitivist and analytical dimensions in a single system which seems more holistic.

    - The quote "Give me the child until he is 7 and I will give you the man" is Aristotle. "Give me the child and I will give you the man" is Spanish Jesuit Baltasar Gracian y Morales (1601-1658)

    - I don't quite get the evolutionist/creationist reference. I don't see a parallel with Freud/Behaviourism. Both are rather deterministic.

    - All the different major modalities have made pitches to be considered scientific one way or another but this is more to do with the fact that being labelled as scientific carries social kudos. We then get into endless debates about what being scientific really implies which, in the realm of human relations, is a very slippery area.

    - Thanks for the feedback.

  • An enjoyable read if slightly biased toward someone called Carl Rogers.  It seems like a comparison in part to the debate between Evolutionists and creationists.  Freud et al being on the 'Creationist' whilst behaviourism is on the side of Darwin who had some interesting observations regarding fearfulness response. Perhaps some of the reasons that Behavioural Therapies have risen in the way they have is due to demand for therapy. Much of the behavioural research has focussed on simplifying therapy in order to restore control and self help procedures, returning 'control' back to the client.  All Behavioural therapies when done correctly are also a teaching of sorts to be your own therapist when the need arises.  Its important not to confuse the idea of simplistic and 'dumbing' down of therapy with the efforts to provide evidence based method that can aid the client to feel empowered over whatever ails them. Behavioural work is an inclusive therapy and utilises where possible friends, family and loved ones as co-therapists.  I'm not sure Freud's couch would bear such a load.  Very often relatives and friends are as confused as to how to help as the patient is at dealing with the problems they have and consequently unwittingly reinforce (oop's I mentioned reinforce) the clients problems. It's a scary business trying to help your loved one. Behavioural work I suggest is more a 'peoples' therapy,  helping to create space fort hose who are in the middle and upper classes book private appointments with psychoanalysts and the rest to work out their Oedipus complexes.  I think it was Watson who coined the term 'Give me the boy and I will give you the man' (Tabula Rasa) and the black box you refer to has long been replaced by the 'I Phone' and Netflix.  Long live B.F. Skinner.

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