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Something has gone wrong with psychotherapy ~ Dharmavidya

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    • #2516

      Dharmavidya writes:

      I am currently at the Evolution of Psychotherapy Conference in Anaheim, California. This conference is organised by the Milton Erickson association, though there seem to be few people here who really practice as Milton Erickson did. It has been interesting for me to see a sample of contemporary psychotherapy practice, though I feel rather disappointed with what I have seen.

      The dominant methods showcased here are ones that follow a philosophy of ‘the therapist knows best’. This is a product of the pressure on psychotherapy to present itself as ‘scientific’ and ‘evidence based’. There are, for instance, a range of methods that approach the problem by conducting the kind of research that looks for ‘the five, seven (or whatever number you like) things characteristically done by successful people, couples or therapists’, isolating and defining these ‘elements’, and then either imitating them or teaching them to clients. If we think we know what successful people do, then surely we can make people be successful by getting them to do these things – isn’t that scientific? Well, no, actually it is nonsense.

      Let me give you an example. A very well known pair of couple therapists presented their work. They began by telling us that outcome research suggests that therapy in their field gets very poor or insignificant results and they believe that the solution is to make the field more scientific. I was skeptical, thinking that they are probably ineffective because they are already trying too hard to seem scientific. Science, after all, thrives on the study of inanimate, measurable, consistently replicable entities and human beings do not fall into this category. So, the presentation went on to give us a list of the things that successful (i.e. enduring) couples do. On this list was included “kissing passionately”. This is obviously an important discovery and we can take it that it must be true because after much careful study science has discovered it – successful couples practice kissing. Who would have guessed? Isn’t science wonderful!

      Well, now we know what successful couples do we can teach these things to couples who are failing and make them better, can’t we? They obviously have not heard of this important scientific finding. There must be any number of dysfunctional couples out there who have never heard about kissing who are just waiting for a knowledgeable expert armed with science to come and enlighten them. Isn’t this totally ridiculous? The failing couples all already know perfectly well about kissing. They do not need to be taught. They are not doing it for a reason. However, these approaches do not ask “Why?” they only ask “How?” However, if you take two strangers and induce them to kiss, it is rather unlikely that they will fall in love as a result. Even more unlikely is it that a warring couple can be remedied in such a way.

      Other items on the list include various communication skills. It might seem that teaching these might have a slightly greater chance of doing some good, but it is subject to the same logic – or illogicality. Successful, happy couples communicate in ‘positive’ language five times as often as in negative language. Well, for sure. But this does not work the other way round. Rephrasing what you say to somebody you hate may enable you to escape with your skin, but it will not bring the enmity to an end. Social skills approaches are really relevant to social (i.e. non-intimate) encounters. Thus assertiveness training, for example. The danger in applying them in deeply personal situations is that those relationships are then rendered wooden or mechanical – do it by numbers – and, further, by introducing a large number of rules about how the people should communicate they provide a stack of criteria upon which they can pass judgement on each other or themselves for not getting it perfectly right all the time. The very methods taught easily become ammunition.

      These approaches are not psychotherapy. At best they are forms of social skills training, but generally clients who come to therapy are not ignorant of social skills, they have the skills but they are not using them for what seem to them to be good reasons. Therapy needs to penetrate those reasons and understand the motivations behind them, not simply teach people to comply with the ideas of the therapist who always knows best. In fact, therapists do not know best, and when they try to impose such a stereotyped model upon clients they do them a disservice.

      I watched several demonstrations by therapists who, although from supposedly different schools, all adhered to this kind of philosophy. I found them all excruciatingly awful to watch. Of the three, one was, in my view, somewhat better than the other two because she did show some empathy for the clients. However, even this one talked about three times as much as the two clients combined as she strove to get the clients to conform to her diagnosis and talk to each other in the way she thought that they should. At one point in the interview, after she had talked non-stop for an extended period she said, “I’m going to stop you now while I explain something,” and then went on talking for another inappropriately lengthy period. This is not psychotherapy as I understand the term.

      An emergent theme or question that is being asked at the conference is whether psychotherapy has progressed beyond Carl Rogers. As I am the author of the book called Beyond Carl Rogers, I find it particularly interesting that leading people at the conference are asking this. The general view seems to be that the answer is negative. There is “not a scintilla of evidence” that any of the elements isolated by the ‘scientific’ approaches make the slightest different to outcomes. All psychotherapy modalities get pretty much the same level of good and bad outcomes. Outcome research does not suggest that any technique or protocol is superior.

      What outcome research does suggest is that (a) the use of protocols reduces effectiveness, (b) some therapists do get consistently better results than others but this has nothing to do with what school of psychology they belong to, ( c) that about half of therapists actually get worse results than clients who use self-help books, (d) that therapists who get good results are those who manifest precisely the characteristics that Rogers identified – empathy, positive regard and genuineness.

      My own impression is that psychotherapy has rather gone backwards since Rogers. A variety of attempts have been made to turn Rogers into a do-it-by-numbers replicable system, all of which fail. Other approaches, mostly related to cognitive behaviourism, adopt the therapist-knows-best philosophy and also fail.The demand for methods that are easy to teach and easy to research seems to have lead to a general dumbing down of practice.

      Psychotherapy is not like medical treatment. It is an art and it is deeply personal. It is not a matter of rolling out standardised treatments for identified syndromes. It is not a situation where the therapist can know in advance what is right and best for the client. It should certainly not create situation like those in the demonstrations I have been watching where the client can hardly get a word in edgewise and is supposed just to comply.

      These people all mean well and believe they are doing the best they can for clients, but something has gone badly wrong. Therapy is suffering from an overdose of rationalism. The spirit does not thrive in this atmosphere. If the project to make it more scientific were sound, then contemporary therapists should be getting noticeably better results than therapists thirty years ago. They are not and it is not.

      It is, therefore, not so surprising that here in America the number of people going to therapists is declining and that a significant number seem to have transferred their allegiance and now prefer to go and see a psychic healer. Healers often show greater empathy and seem to get better results. It is all rather disappointing and I think that much of the blame for this decline has to be laid at the feet of the craze for ‘scientific validation’ and an ‘evidence base’.

      I am not opposed to real science. Carl Rogers himself based his work on extensive detailed research. But a great distortion has been introduced and much of the supposed ‘science’ lacks rigour, is biassed, is not independent, and often, as illustrated above, is wrongly conceived.

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    • #2526

      I enjoyed reading this very much. Very informative and good to read an alternative view to the evidence-based dominant one. At OCD conferences I have noticed that following this evidence-based road has proved very effective for some people but that there are also people whose OCD has proved reluctant to play ball. From an exclusive focus on CBT, now mindfulness and EMDR are being tried. I found EMDR very effective but this was also because I had a very empathetic, warm and calm therapist.

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