Maybe it’s like the state of healthcare in the US, where corporate interests hove so overpowered the ranks of those who do the work that we have fallen into a state of passive demoralization. The field of psychotherapy is largely unaware that it is suffering the same fate. In our field, the passive demoralization is because so few realize that things could be better, so they accept the divisiveness that erodes fundamental aspects of our daily lives. Too many believe that our field has no choice but to remain locked in what Kuhn calls the “pre-paradigmatic” phase of its development where each therapy gives a different and incompatible explanation for its success, and no one theory is clearly better than another. The false belief is that we will never bridge the differences that separate the many brands competing for our discipleship. This pessimism is preventing our colleagues from taking in the fact that science has caught up and we are finally in a position to do much better. Not only that, but the transformation we are ready for isn’t even disruptive.
What makes me especially concerned is that this state of affairs has real consequences for us and for our disrupted world. Let’s start with the essential problem that self-referential theories, meaning explanations (those that rely on the very concepts they explain), can’t be reconciled. Psychodynamic therapy promises to “resolve intrapsychic conflicts,” such as those between the superego and the id. A behavioral therapist, will say, “Show me one of those” Behaviorally oriented therapies are no different. “Correcting irrational thoughts” is supposed to explain what makes people better, but how does telling someone they are wrong actually lead to change? Even within camps, the basic constructs are inventions, born out of genius intuition (I’m not being ironic) but, since they have no roots, their meaning is subject to endless debate and discussion with no independent benchmark to prove which is more valid. The student and practitioner are left to read a rich, but endless literature and decide, based on some arbitrary personal grounds, which explanation to adopt.
At least we have good research to prove that common factors correlate with therapeutic success, but to what benefit? Correlations give general conditions, but no specific guidance as to how we might foster changes to the unique problems our clients bring. They leave us in the dark as to how or why relationship, empathy, and intra-session emotion actually promote change.
Making training and practice unnecessarily difficult
We therapists are technicians tasked with repairing what has been called the most complex object in the universe. We need all the help we can get. Navigating the therapeutic space is infinitely harder when we don’t know specifically how our decisions are impacting the job we are hired to do. That is actually the definition of toxic stress, “feeling responsible for things we don’t have the knowledge, ability, or authority to accomplish.”
Consequences for therapists:
How is one to cope? Therapists are left with three choices:
1. Stay as close as possible to a specific therapy or manual, despite its limitations. Many of us take refuge in being a disciple of one therapy. This gives the illusion of certainty and provides the support of wise leaders and like-minded peers. And today, just about every therapy can point to clinical trials proving that it works. They do work, but the problem is rigidity and lack of fit with every client and every problem. Even when the dedicated therapist advertises allegiance to a certain brand, clients don’t come with the purity of clinical trial subjects. They bring multiple problems that often go beyond the limitations of a given protocol. Should the dedicated therapist refer out? That doesn’t sound like the right answer for the client, so the remaining option is for the therapist to “wing it.”
2. Perhaps the majority are those who are open to the vastness of what remains unclear and ready to accept the necessity of muddling through. The Society for the Exploration of Psychotherapy Integration has been wrestling with this reality since the eighties. Marvin Goldfried, one of the founders, continues to call for a core of knowledge that we can all agree on. There has been some success, but not yet a groundswell. The Society’s official journal, the Journal of Psychotherapy Integration, recognizes a five approaches. The most widely adopted are assimilative integration, where the therapist chooses one therapeutic orientation, but makes occasional use of others, and technical eclecticism, the thoughtful mixing of techniques from multiple sources. More recent additions are common factors, already discussed, and the unification movement, advocating for a larger framework, within which diverse components can fit. The latter is helpful for gaining a broad perspective on problems, but does not pretend to add precision on just how to bring about change. From early on, the gold standard of approaches was theoretical integration. Sadly, it has mostly been abandoned because “mushing” incompatible theories and constructs creates, at best, a new theory and, at worst, a mess. What is presented here is a novel form of theoretical integration that bypasses that problem.
3. A colleague recently summed up the third option for practitioners: Resorting to “How-ya-doing” therapy. He was referring to the easy way out, forgetting all the fancy theory and just being a good listener, while waiting for the client to find their way to health.
None of these is satisfactory. The choice is between doubt-ridden honesty and dishonest self-satisfaction, where both lead silently towards loss of faith in what we do. We have lived with it so long and are so hopeless about a way out that a majority no longer consider the situation toxic. But it is. And beyond individual passive demoralization, it has consequences for our profession and for the world.
The field of psychotherapy loses respect in a world where “normal science” (the step in Kuhn’s ladder that we haven’t reached), is the most trusted source of information. Our shortfall means less funding for research, less financial support for treatment, and further reinforcement for already dominant biological approaches, which, unfortunately, remain limited in their ability to resolve the problems psychotherapy aims to treat.
Furthermore, in the developing world, where the middle class population is expected to double from 2010 to 2030, the need to train new therapists is acute. Expecting adequate training using current methods is simply unrealistic. Outmoded models are too burdensome and inefficient. The likely outcome is seat-of-the-pants psychotherapy on a vast scale, for a world that we all agree is in trouble.
It’s nobody’s fault
All sciences have started out in the pre-paradigmatic phase, where there is not yet an agreed upon, foundational basis in science. Most of today’s sciences have long since found a basis independent of their own constructs. That’s what gives them the status of “normal science,” in which workers in the field set about elucidating the details. In contrast, inventors of schools of psychotherapy have been forced to rely on their genius and intuition, building theories around invented concepts that differ from “dark humors” and “phlogiston,” only in that they remain consistent with clinical reality. Lacking an independent core of science, that has been the best we could do.
In our field, the “science” has mostly focused on details within siloed brands and orientations. This parochial exploration can be useful for those within the same camp, but side-effects include increasing divisiveness, putting excessive emphasis on orthodoxy, and discouraging even beneficial mixing of techniques.
Everything has to be evidence-based. But what does that mean? For the purposes of research and publication, variables must be controlled to the point where conclusions are “beyond reasonable doubt.” But for clinicians, even if we follow an evidence-based protocol, we are applying something certain to a situation that is rarely identical to the controlled conditions on which the research is based. In doing so, we lose a degree of certainty and must settle for “the preponderance of the evidence” as our standard of clinical proof. The same standard applies when clinicians combine intuition, empathy, knowledge of literature, research findings, and experience to the complexities before them. In other words, for purposes of clinical practice, either way we must be content with basing our decisions on “the preponderance of the evidence.” Truly the best we can do is to assemble the many kinds of evidence available, including knowledge of our own biases. That is what professionalism means, even today.
The answer is easier than it appears
For clinical purposes, new science, available only since 2000, is pointing strongly towards a flexible framework in which:
- The problems targeted by psychotherapy have much in common, as they are products of the mind’s mammalian, automatic, and largely unconscious function of generating responses to appraised or predicted threats.
- Changes aimed for and achieved in clinical psychotherapy can be explained by three known and neurophysiologically elucidated mechanisms.
- The requirements for these three change processes can be boiled down to four essential clinical objectives, 1) limbic activation of the maladaptive pattern, 2) concomitant provision of disconfirming information, 3) shaping the disconfirming communications in forms that can be received and processed in the limbic system, and 4) new learning of skills, wisdom, vision, and values, encoded in memory via long term potentiation.
- The requirements known to neurophysiology converge with the actions of diverse therapies, confirming that existing techniques derived by intuition and experience turn out to map closely to and to be explained by the new neurophysiology.
- Additional nonspecific factors, starting with a positive therapeutic relationship and including supporting motivation, regulating arousal, and insuring safety are also important in the success of psychotherapy.
This basic organization of 3 + 4 + 4 elements provides a highly accessible and useful framework, compatible with any therapy. It is both simple and sophisticated in the sense that it focuses on what is universal but does not force individual variations into rigid molds. The purpose of such a framework is to give clinical guidance to therapists navigating the complexity of the human mind. This becomes possible when we view all therapies from the point of view of core science regarding mechanisms by which human response patterns can be changed. See further: "TIFT # 79: The Dark Horse Surges.”
Why this is not disruptive
The simple answer is that the new science of change confirms, rather than contradicting, existing therapies. It shows why and how current techniques make use of the same few processes, which explains why they all work and no one therapy has turned out better than the others. Furthermore, the new science fills in a gap in existing theories and explanations. It is adding new information, rather than proposing to change what has already been described. The only challenge is for existing therapies to assimilate the new knowledge of therapeutic action into existing concepts.
What’s in it for us?
The promise is relief from the uneasiness and stress of offering to help our clients without knowing how our methods work. With the new science we can navigate with the confidence of knowing precisely what needs to happen and what we must do to support the few change processes.
But that’s not all. We can actually improve technique. Knowing what is going on behind the scenes allows us to mix techniques with clarity about synergies as well as possible incompatibilities and how they might play out. That means better matching between the therapist’s toolbox and the needs and wishes of the client.
Even more important, “following process, not method” means attending to the details of known requirements for change processes, where we can focus on improving our skill, for example, at activating the old, maladaptive pattern while providing new, disconfirming information in forms, easily accessible to the logic of limbic structures. This level of precision is more attainable when we combine intuition with clarity about the change process being supported.
Finally, a better understanding of the structure and organization of nonconsciously generated coping improves our ability to formulate treatment strategies. When we understand how multiple pathologies (otherwise known as defenses, maladaptive patterns, irrationality, etc.) come about and relate to one another, then the question of what to do next becomes clear. The end result is to bring a new level of focus and clarity to our work, which ultimately equates to relief from passive demoralization.
Would you like to learn more? You are welcome at Howtherapyworks.com, where we have a new self-paced online course and learning community.
Jeffery Smith MD
Photo Credit: Matthew Henry, Unsplash
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