Monday, October 14, 2019

Different Schools of Thought in Psychotherapy

At last count, there were over 200 different "schools" of psychotherapy, each with its own ideas about why people act in self-defeating ways or in ways which bring them emotional or even physical pain, and how to help them to stop. Of course psychotherapy is, despite having been around for a hundred years, a young science, but our field is more difficult to study “empirically” than any other. 

The problems we have are enormous because we cannot read minds, and people can choose to some extent how they react to any therapy intervention. Patients withhold information about their situations from therapists all the time due to protecting their families from negative judgments, guilt, shame, or a concern the therapist might not be interested in it.

In psychotherapy outcome studies, seemingly minor variations in therapist techniques that are in fact vitally important (such as body language and tone of voice) aren’t even measured. There are no good active control treatments, and, when two therapies are compared,  the therapy method favored by the first author of the study comes out ahead 85% of the time due to the authors’ biases (allegiance effects). 

We cannot do double blinding because that would mean the therapists wouldn’t know what they were doing, which would not be a good test of the treatment. And of course once again there can be a major lack of complete candor by subjects. Much of the study results are based on patient self report, a notoriously unreliable method of data collection. And there is no way to distinguish an act patients may be playing for their family of origin (a false self or personafrom their real beliefs and feelings, or performance from ability.

The ecological fallacy – thinking all patients with a particular disorder react exactly like an average patient - is rampant in the literature. If 20 % of clients with a particular problem respond to one intervention and 40% respond to a second one, this does not mean that the second one is better for everyone than the first. The 20% who responded to the first one could actually get worse with the second one.

There is also a huge and highly problematic groupthink problem in the psychotherapy field, with purveyors of various schools claiming a monopoly on truth. Often the need for ideological purity, the admiration for an academic leader within a hierarchy, or the profit motive causes science to take a back seat in favor of a group's other interests. 

Fallacious arguments ensue. One of the most common is that entire complex groups of theoretical constructs that characterize a given school are rejected in total by another school, as if, if one theoretical part of a school is wrong, the whole thing must be wrong. Psychoanalysis may have been wrong about penis envy, for example, but dismissing intrapsychic conflict entirely as a construct because of that is - in a word - stupid.

Another is that a phenomena that two schools are looking at but explain differently are just being called different names and are given different explanations, which are then accepted by a given school as gospel without even a thought to investigating other possible explanations. I recently wrote in a post about how both the cognitive-behaviorists' "irrational thoughts" and the psychoanalyst's "defense mechanisms" probably serve the same purpose, but that neither school explains that purpose with reference to group dynamics - IMO the key factor.

There is still hope. IMO we have to look for recurring patterns in our therapy patients (not in research subjects, because contact is minimal) as well as within their social milieu. At times, we have to meet with clients along with their significant others in order to get a more well-rounded picture. We have to do so in long-term psychotherapy, because it takes quite a while for the whole story to unfold. 

We should do this in order to figure out commonalities and in order to figure out what questions to ask. In particular, we should look for evidence of motivated reasoning in what our clients report – logical fallacies, inconsistencies and contradictions (sometimes voiced months apart – the importance of extensive therapy notes cannot be overestimated), and defensive reactions. If handled well, this will help us unearth what clients may be trying to hide from us. 

Doing so also suggests questions we may have not thought to ask, or pay attention to environmental variables we were not even aware of that turn out to be major contributing factors to psychopathology that demand attention.