Tuesday, June 26, 2012

Psychotherapy in Transition

Writing in The New Atlantis Ronald Dworkin provides an excellent overview of the history of American psychotherapy.

A practicing anesthesiologist with an additional doctorate in political philosophy Dworkin offers an outsider’s perspective on the field.

Dworkin emphasizes the role that managed care professionals and government policies have played in the field’s transformation. Since this aspect is often overlooked I for one welcome it.

I would be remiss if I did not point out that Dworkin ignores two of the most important and influential developments in psychotherapy.

Even though he discusses the role of Valium and other anxiolytics, he ignores the advent of Prozac and the SSRIs. I suspect that the new antidepressants greatly increased the status and prestige of psychiatrists. They have certainly influenced the movement away from long term talk therapy. This should have been mentioned.

Dworkin shows clearly how community mental health clinics and managed care led the field toward brief solution-focused treatment. Yet, he neglects to mention the most important recent intellectual development in psychotherapy: Aaron Beck’s invention on cognitive therapy, which gave short-term therapy more credibility and more substance.

Notwithstanding these flaws, Dworkin offers an interesting thesis:

Psychotherapy is no longer an intellectual movement today as it once was. But in the form of modern professional “caring,” it has assumed a new role, which is to provide a peculiar sort of substitute friendship — what we might call “artificial friendship” — for lonely people in a lonely age.

I am well-placed to appreciate the extent that psychotherapy used to be an intellectual movement with its own special priesthood. As the saying goes: Been there, done that. I have also spent a considerable amount of time and energy explaining to my former colleagues that the old days have up and gone.

Dworkin describes how it used to be:

In the old days, psychotherapists constructed vast philosophical fabrics out of the writings of visionaries. They dallied with ideas that bordered on philosophy and religion; their emotional natures were totally absorbed in the partisan passions of their analytic cliques; their subtle intellects concerned themselves with the dialectical splitting of dogmatic hairs. The words they used — id, ego, and superego, among many others — seemed like a transcendent manifestation of divine power, an example of humanity being vouchsafed glimpses of eternal truth flowing down through an elaborate and immense cascade of books, with individual therapists stretching back, through their pedigree of technique, to some godhead.

So far, so good.

Psychotherapy is in transition. It is still finding its way. It has not yet articulated and conceptualized what it is.

It makes sense for Dworkin to say that therapists today are more like caring professionals and artificial friends, but I detect a note of contempt in the description, a sense that it is not quite serious.

Dworkin attributes the change in therapy to the fact that the government and the managed care companies want to make it more widely available. This has caused therapy to take a turn toward the pragmatic, away from explaining problems to solving them.

In his words:

Short-term therapists tend to take a client’s self-described problem at face value; they believe using common sense and good humor to fix a client’s problem — in the fashion of a friend — is a legitimate goal of therapy. They think significant psychological change can occur in the experience of day-to-day living by simply behaving or thinking differently. Long-term therapists believe no real change can occur on this level.

He continues:

Clinical psychologists, counselors, and social workers who performed therapy worked together to promote a rival view, changing their image to that of the caring professional. They began to present themselves less as disinterested scientists and more as “caregivers” eager to talk to patients about their everyday problems — unlike doctors, who just wanted to drug them.

And also:

Indeed, the clinical psychologist today is not entirely different from the caricature painted by the profession’s academic critics: earnest, well-intentioned, subjective, and imprecise. Yet academic psychologists err in assuming that clinical psychology is still a branch of psychology, and therefore of science. It is not.

I have made the point before so I am pleased to second Dworkin’s idea that being a caring and empathetic listener or friend has nothing to do with scientific training.

And yet, cognitive therapy, which is currently on the ascent cannot be taxed with being unscientific fluff.

Dworkin’s larger problem is the way he conceptualizes the issues.

Caring about someone is not the same as helping him to solve a problem. Many therapists feel so deeply about their patients’ problems that they never get around to solving them.

Besides “caring” is a very tricky concept in itself. It does not necessarily coincide with friendship. True, you care about your friends but you also care about people who are not your friends. Some of us care deeply about celebrities; some of us care about what happens to fictional characters.

Dworkin is right to emphasize the fact that today’s therapists make a considerable effort to connect with their patients. Many therapists now believe, correctly, that the connection between patient and therapist is one of the most powerful healing tools.

If most people are suffering from feelings of disconnection, therapy cannot help them if it stays stuck in the old psychoanalytic model that proscribed human connection.
He is also correct to emphasize friendship, even though he seems to be disparaging it.  

In his words:

Once a consecrated priesthood, therapists today walk along the smooth road of ordinary duty. They help people with their everyday problems. They speak in a casual manner and even crack jokes. They are friendly. They smile. They differ neither outwardly nor inwardly from the clients they serve, for whom therapy has become a useful organization, a convenient and respectable appendage to existence, a sometimes necessary form of artificial friendship.

But, why is the friendship that develops between therapist and client artificial?

If it’s because clients pay their therapists, then one would note that you can be friends with your accountant or stock broker, both of whom you pay for their services.

If it’s because the relationship is so one-sided, well, so is your relationship with your accountant and your broker. Have you ever seen your accountant’s tax returns? Do you know what is in your broker’s portfolio?

Dworkin seems contemptuous of friendship, but I would recall that Aristotle considered friendship to be the basis for ethical behavior in human community.

If you behave badly toward members of your family they are still your relations. If you behave badly toward your friends you will soon find yourself friendless, lonely and isolated.

Also, friendship is freely entered into, thus it is a primary moral basis for freedom.

Finally, Aristotle points that friends see the best and bring out the best in their friends. So, the concept works as a perfect counterpoint with psychoanalysis.

Psychoanalysts have tended to see the worst in people, even when it is not there. They ignore what is best about people, even to the point of not accepting it as real.

Friends trust their friends; friends respect their friends; friends have confidence in their friends.

If your job is helping people to solve their problems it is good to show them that you trust them to do the right thing and that you have confidence in their good character.

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