Adam Blatner, M.D.
28, 2006: This is my commentary on an opinion piece written by Dr. Adam
Phillips in the 2/26/06 edition of the New York Times. (His original
piece follows this piece.)
Dr. Phillips writes about
an identity crisis in psychotherapy. I think that a significant reason
for this identity crisis is the possibility that the models or
categories used so far are somewhat lacking. I’m intrigued by the title
of this doctor’s new book–because what we are needing to reconsider is
the nature of psychotherapy. In my opinion, it may be more useful to
think of psychotherapy as a kind of a chimera, a word referring to an
animal that is composed of parts taken from several other animals, such
as a duck-billed platypus, or more often, an imaginary creature, such
as a gryphon, with the head of an eagle and the body of a lion.
Psychotherapy is itself neither science nor art, religion nor
education, but rather a mixture of elements of these and other
activities. Perhaps because I am a physician, I find that psychotherapy
partakes–or should partake--of the classical medical model in many
ways–especially regarding diagnosis. (Indeed, there are many real
medical conditions that cause psychiatric symptoms.) Both ancient and
modern medicine at times locates the causes of pathology beyond the
body of the individual: At one time it was the stars or weather. In the
18th century there were physicians writing about occupational diseases.
What we need, of course, is a multi-leveled assessment that includes
possible causative or exacerbating (making it worse) factors at every
level–nutrition, sunlight, exercise, toxins, chronic posture or
movement, morale, belief systems, social integration, state of
relationships, self-image, intensity of belief in various cultural or
sub-cultural norms and values, childhood experiences, recent trauma,
variety of interests, sources of joy, philosophy of life, skills,
capacity for self-reflection and personal change, sense of purpose,
wholesomeness of goals, and so forth.
Aside from the assessment, the treatment process is similarly
varied–that’s one reason I like the medical model, in some ways: Some
people need rest, others exercise–it depends on the specific diagnosis
and a variety of other factors, woven together in a particular case
formulation. One builds on strengths and also attempts to ameliorate
symptoms and address identified pathogenic dynamics.
Sometimes it is very useful to do some re-evaluation of the patient’s
childhood. I confess that I find psychoanalysis itself to be a
particularly cost-inefficient method–at least the classical technique.
I think it is possible to conduct a mixture of astute questioning and
listening so that the process can be speeded up. Sometimes a wide range
of other techniques can help promote insight and further
disclosure–techniques derived from drama (i.e. role playing), art,
music, poetry, keeping a journal, group therapy, and so forth.
Sometimes going back to childhood may not be that important–or at least
not at first–or second. In some cases, it’s enough to evaluate the
present situation and get some grasp on the nature of the problem. Many
people, if given some extra encouragement and a few skills, techniques,
or other small breakthroughs, then marshal their other strengths to
cope adequately with the problem.
I am wary about long-term or even moderately extended therapy–it is by
no means a benign procedure. The cost of travel and the fees for the
sessions adds another burden to the patient and family. Some people
don’t mind a bit, and even like the process, perhaps a bit too much.
Others are unreasonably unwilling even to spend just a session or two
re-evaluating their own lives.
I don’t assume that a person who says she’s been “in therapy” has
indeed given the process an adequate trial. The therapist may have
missed the point or perhaps not been that astute. Often the client or
patient has only attended once or a few times and hasn’t really engaged
in the process. (Such patients often have unrealistic expectations that
therapy is something done to them, rather than a mutual exploration.)
Often therapy takes several turns. One phase might involve just
reducing the sense of crisis and getting some idea of what is going on
and what will need to be done to deal with it. Sometimes a mixture of
medication or just a bit of counseling is needed, and often a bit of
work with the family, re-adjusting job or life stresses, and other
general care is what is indicated.
For some, that’s all that’s needed to re-stabilize. Some aren’t
interested in deepening their coping skills so they can be more
resilient in the future, some are. At this point the process shifts
more into a semi-educational model. Some instruction can happen, but
mostly it’s a matter of helping people to identify and build on their
own strengths, and identify and remedy their own misunderstandings. The
art involves something closer to a mixture of parenting and
Some therapeutic methods such as “cognitive therapy” have been found to
be effective according to rigorous scientific studies, but this therapy
mainly aims at the development of a group of skills that have to do
with individual clear thinking, becoming more logical, and, well, just
about everyone could do with improvement in this arena. Our educational
system only does a weak job of teaching critical thinking, even though
it gives lip service to this goal. Again, the challenge involves
individualizing the learning so that the patient’s various types of
intelligence, temperament, learning style, repertoire of blocks and
avoidances, and other variables can be taken into account. Again, the
inclusion of so many unique particulars is part of the art–and why the
process is simply to complex to be fully reduced to science.
(Hard science involves a process of establishing relatively controlled
variables, while only one or two are changed and the result then
assessed. When there are more than five or six operating, it becomes
almost impossibly difficult to really evaluate the results. There is
another type of research that is “softer,” involving reviewing the
stories, the case studies, in all their uniqueness. While it is harder
to draw “statistical” conclusions, certain patterns seem to emerge, and
the story becomes more understandable.)
So I roughly agree with the beginning part of the essay, and am more
reserved about the author’s final paragraphs, because he is supporting
a case for extended talk therapy. The scientific question may be to
compare this type of more expensive and longer-term therapy with other
somewhat similar forms that are shorter, more focused, with some
variables. My own approach is to reassess periodically: Some folks, as
I said, begin to get better after one or a few sessions; who is to say
that they “should” return for more? Some folks may be given permission
to return for a few sessions after a few months or years, and booster
sessions as needed. Might these be as effective as continued sessions?
So part of the problem involves asking the right kinds of questions. Is
psychotherapy effective? That’s assuming that the conditions are
relatively homogeneous. Is medicine effective? If we consider that the
mortality (longer term) is 100%, the answer is no. But that assumes
that our expectations are unrealistic–every 90 year-old should be
guaranteed another 90 years (at least) of health or vigor? Or should we
be able to say of everyone, “At least he died healthy”?
Some people in therapy are there because they’ve developed some
counter-productive attitudes and habits, and for a few, these are easy
to correct; for many, habit change and attitude change is more complex;
for another fair number, well as one elder therapist observed, many
people don’t really want to get “better,” they just want to be better
in the way they neurotically cope. In this case, better means really
shifting their goals from selfishness and short-term illusions to
longer term habits of thinking and behaving that are more socially
In summary, I think that the term psychotherapy is as broad a category
as medicine. It should not be thought of as a treatment method that is
even roughly the same for all patients. Its boundaries are fuzzy. A
physician may (or may not) do a bit of psychotherapy as part of helping
a patient address concerns about taking medicines. It can include more
than just talking, and address more than just intra-psychic conflicts.
More, I think diagnostic assessment is an important part of the
process, and then, based on the provisional formulation thus generated,
an individualized plan that makes use of a variety of modalities may be
discussed and, if agreed on with the client, the procedures may then be
implemented. Psychotherapy as a field and category may have as a
significant root form the Freudian method, but it has advanced far
beyond that approach in scope, theory, and technique, including also
many innovations that had little or nothing to do with psychoanalysis.
Still, the author of that opinion piece has some ideas that are worth
considering, lest psychotherapy be hampered by too-narrow sets of
criteria for evaluation. I would be interested in other inputs, and we
may build on my comments above.
p.s., here is the
original op-ed article by Dr. Phillips:
(The title of the piece is: A Mind Is
a Terrible Thing to Measure - New York Times Opinion
NYTimes.com News Published: February 26, 2006 (London Nick Dewar)
(Dr. Phillips is a psychoanalyst and recently the author of a book
titled, "Going Sane: Maps of Happiness.")
Psychotherapy is having yet another identity crisis. It has manifested
itself in two recent trends in the profession in America: the first
involves trying to make therapy into more of a "hard science" by
putting a new emphasis on measurable factors; the other is a growing
belief among therapists that the standard practice of using talk
therapy to discover traumas in a patient's past is not only unnecessary
but can be injurious.
That psychotherapists of various orientations find themselves
under pressure to prove to themselves and to society that they
are doing a hard-core science–which was a leading theme of the landmark
Evolution of Psychotherapy Conference in California in December — is
not really surprising. Given the prestige and trust the modern world
gives to scientific standards, psychotherapists, who always have to
measure themselves against the medical profession, are going to want to
demonstrate that they, too, deal in the predictable; that they, too,
can provide evidence for the value of what they do.
And, obviously, if psychotherapy is going to attain scientific
credibility, it won't do to involve such wishy-washy practices as
"going back to childhood" or "reconstructing the past" — terms that
when used with appropriate scorn can sound as though a person's past
was akin to the past lives New Agers like to talk about.
Since at least the middle of the 19th century, Western societies have
been divided between religious truth and scientific truth, but none of
the new psychotherapies are trying to prove they are genuine religions.
Nor is there much talk, outside of university literature departments,
of psychotherapy trying to inhabit the middle ground of arts, in which
truth and usefulness have
traditionally been allowed a certain latitude (nobody measures
Shakespeare or tries to prove his value).
It is, so to speak, symptomatic that psychotherapists are so keen to
legitimize themselves as scientists: they want to fit in rather than
create the taste by which they might be judged. One of the good things
psychotherapy can do, like the arts, is show us the limits of what
science can do for our welfare. The scientific method alone is never
going to be enough, especially when we are
working out how to live and who we can be.
In the so-called arts it has always been acknowledged that many of the
things we value most — the gods and God, love and sexuality, mourning
and amusement, character and inspiration, the past and the future — are
neither measurable or predictable. Indeed, this may be one of the
reasons they are so abidingly important to us. The things we value
most, just like the things we most fear, tend to be those we have least
This is not a reason to stop trying to control things–we should, for
example, be doing everything we can to control pain–but it is a reason
to work out in which areas of our lives control is both possible and
beneficial. Trying to predict the unpredictable, like trying to will
what cannot be willed, drives people crazy. Just as we cannot know
beforehand the effect on us of reading a book or of listening to music,
every psychotherapy treatment, indeed every session, is unpredictable.
Indeed, if it is not, it is a form of bullying, it is indoctrination.
It is not news that most symptoms of so-called mental illness are
efforts to control the environment, just like the science that claims
to study them.
It would clearly be naïve for psychotherapists to turn a blind eye
to science, or to be "against" scientific methodology. But the attempt
to present psychotherapy as a hard science is merely an attempt to make
it a convincing competitor in the marketplace. It is a sign, in other
words, of a misguided wish to make psychotherapy both respectable and
servile to the very consumerism it is supposed to help people deal
with. (Psychotherapy turns up historically at the point at which
traditional societies begin to break down and consumer capitalism
begins to take hold.) If psychotherapy has anything to offer–and this
should always be in question–it should be something aside from the
dominant trends in the culture. And this means now that its
practitioners should not be committed either to making money or to
trivializing the past or to finding a science of the soul.
If you have an eye test, if you buy a car, there are certain things you
are entitled to expect. Your money buys you some minimal guarantees,
some reliable results. The honest psychotherapist can provide no
comparable assurances. She can promise only an informed willingness to
listen, and the possibility of helpful comment.
By inviting the patient to talk, at length–and especially to talk about
what really troubles him– something is opened up, but neither patient
nor therapist can know beforehand what will be said by either of them,
nor can they know the consequences of what they will say. Just creating
a situation that has the potential to evoke previously repressed
memories and thoughts and feelings and desires is an opportunity of
immeasurable consequence, both good and bad. No amount of training and
research, of statistics-gathering and empathy, can offset that unique
uncertainty of the encounter.
As a treatment, psychotherapy is a risk, just as what actually happens
in anyone's childhood is always going to be obscure and indefinite, but
no less significant for being so. Psychotherapists are people whose
experience tells them that certain risks are often worth taking, but
more than this they cannot rightly say. There are always going to be
casualties of therapy. Psychotherapy makes use of a traditional wisdom
holding that the past matters and that, surprisingly, talking can make
people feel better — even if at first, for good reasons, they resist
it. There is an appetite to talk and to be listened to, and an appetite
to make time for doing those things.
Religion has historically been the language for people to talk about
the things that mattered most to them, aided and abetted by the arts.
Science has become the language that has helped people to know what
they wanted to know, and get what they wanted to get. Psychotherapy has
to occupy the difficult middle ground between them, but without taking
sides. Since it is narrow-mindedness that we most often suffer from, we
need our therapists to resist the allure of the fashionable
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