Adam Blatner, M.D

February 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 individualized education.

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 integrated.

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 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 control over.

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 certainties.

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