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There’s been a lot of noise lately about how awful the new version of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association is going to be. Virtually none of this drive-by criticism appears to be the least bit informed as to the goals of the DSM-V, much less the process by which it has been developed.

A recent critical article: Why Many Mental Health Professionals Are Ditching the DSM-V ‘Bible’. There are SO many problems with this article, yet most will completely elude detection by readers.

1. The title asserts that “many” MHPs (Mental Health Professionals) are abandoning the DSM-V. Absolutely NO evidence is given for this assertion. A cheap shot, nothing more.

2. The title refers to the DSM as a “Bible”, which it is not. The Bible is considered to be a revelatory document (by believers) or a historical document (by non-believer scholars). The DSM is neither. It’s a data driven, clinically validated, periodically updated classification scheme, and nothing more. That’s all it’s designed to be.

3. “major players in the mental health community say the book needs more research”. Who are these “major players”? The NIMH is mentioned, but that’s now old news, and not immediately relevant, anyway (see #4 below). Unnamed academics from Columbia and Rutgers are also referenced – complaining about the DMS’s lack of epidemiological perspective, and insufficient consideration of ancillary causal factors. As usual, these non-clinician critics want the DSM to be the kind of research review it never was intended to be. It’s for working clinicians, not researchers. It USES research, in several ways, but is NOT a research report, review, or even summary. Once again we see non-clinicians simply failing to understand what we in clinical mental health are actually doing in our work.

4. NIMH director Thomas Insel is paraphrased (correctly, I think) as saying the DSM lacks validity because it classifies disorders solely by their symptoms. Pray tell, what is the alternative? The DSM, in recent iterations, derived from a desire to diagnose not according to theory (for which, by definition, there was little or no formal research support) but according to actual clinical presentation – yes, symptoms. WHAT ELSE DO WE HAVE? This isn’t a mistake, it’s a NECESSITY. We’re playing the only game we actually CAN play, at this point in the evolution of our knowledge of mental illness.

Insel’s project is a research strategy, for an agency with a very strong commitment to basic (i.e., physical science and medical) research. But don’t expect it to answer all questions; it simply can’t

There is a vast amount of research – from studies of morphology in biology to the famed “Minnesota twin studies” in psychology – which supports the idea that what one sees in the real world is about 50% derived from genetic factors and 50% derived from environmental factors. The conceit that any study of genetics+environment will allow us to account for the spectrum of depressive disorders, anxiety disorders, and most particularly trauma disorders is either phenomenally ill-informed or gratuitously over-optimistic. The further notion that the results of such a effort will properly be considered “medical” presupposes that psychology can be reduced to physiology, at the least. Yeah, and while you’re at it, let’s reduce computer programming to mere electronics. This is sort of “reductionist” logical error one is cautioned about as an undergraduate. Such decomposition of a higher order field to one or more lower order fields has never, to my best knowledge, happened – outside of the realm of theory, not is it ever going to.

For how many decades has the search been unfolding for a “gene for alcoholism”? And the results: still looking…

“Further evidence and an approximate estimate of heritability – crudely speaking how genetic a condition is – can be derived from twin studies that yield figures of 50% for males and 25% for females…” (Ball, D. (2004). “Genetic approaches to alcohol dependence”, The British Journal of Psychiatry
185: 449-451 doi: 10.1192/bjp.185.6.449)

What this should make clear is that “medical” approaches to such things will ever only get us part of the way to our goal. The rest of what it will take has to do with behavior, learning, and a causal model that will contain a number of non-physical factors. And alcoholism is EASY, compared to anxiety, depression, or trauma disorders.

It is fundamentally misguided to think that psychology can be reduced to physiology or medicine. Yet, if awareness of this thinking error is not much in the minds of the general public, it is also significantly lacking in the minds of too many mental health professionals. Insufficient awareness of this error is at the heart of much criticism of professional clinical psychology by non-clinicians outside of the field. They just don’t get it. Clinical work is NOT research any more than research is theory. Different areas of thoughtful activity – different goals – different processes – different rules – different outcomes. So shall it always be.

I appreciate that several rather subtle considerations are touched upon in my remarks above, of necessity. This is ALL about explanatory and prediction strategies, and THAT topic isn’t seriously taken up by most students until graduate school. If this were an easy topic, it’d be covered in high school.

Biology is still actively arguing about species delineation and classification (a fascinating topic, by the way). It’s hardly surprising that we are doing the same in the nosology of mental illness. It’s part of the process by which science improves itself. We’re NOT in trouble; we’re just doing our job.

[based on a 2013.05.14 post to the G+ Trauma and dissociation: education and advocacy community]

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(continued, from previous post | part 1 | part 2 | part 3 )

WHY I (AND YOU AS WELL) SHOULD CARE

We’re part of a critical historical time – and science is at the center of it. I can easily predict that 2000 years from now our times will be noteworthy by virtue of three things, the first being the most important, because it’s the cause of the other two:

  • the emergence and cultural dominance of scientific method, as a way of validating and creating knowledge;
  • our managing not (yet) to blow ourselves up with weapons which were capable, for the first time ever, of removing most life from the planet; and…
  • whatever it is we do about the approaching global climate change and resource exhaustion crises.

So, I urge that the first thing we need to do is have respect for our place in history – all of us living at this time in human history, as educated, thoughtful people.

Psychotherapy is a part of the culture of science. That’s why we study it only at the graduate level, after getting a general education which includes non-trivial introductions to mathematics, physical science, biological science, and social science. Without science, we are reduced to the nonsense of prior ages – to things like ether, and phlogiston, and to the notion of evil spirits as a cause of plagues. With science, we have fought back magnificently against these erroneous idea and perplexing problems, and others as well such as Ptolemeic astronomy, infectious disease, and instability in large scale economic systems. We are even beginning to fight successfully against genetic disease, a truly astounding achievement.

We have erected a vast and well-oiled machinery for validating critical propositions, such as:

  • Does every cancerous breast really have to be surgically excised? (It was thought necessary, before the matter was empirically investigated.)
  • Is an extract of cocaine a good ingredient for a popular soft drink (Coco-Cola)? (Once science understood a little about cocaine and the brain, this seemed like a not-so-good idea; the practice was discontinued, but not the name.)
  • Is schizophrenia best treated with restraints and cold water baths? (Well, not any more. We actually can do some helpful things now, and science brought them about.)
  • Does vitamin C in large doses prevent the common cold? (Science found that it didn’t, sadly, but large doses ARE a dandy way to mess up certain parts of your body and biochemistry.)

You get the idea, I hope. Taking psychotherapy away from the science of psychology is unthinkable, howsoever much the science at its core must be tempered by, and enlivened with, the art of human relationship and the intermittent irrationality of existential optimism.

Professional psychotherapy is part of the democratization of knowing. Psychology, and its rowdy child, psychotherapy, is a part of a much larger historical movement. For many reasons, in western European culture there slowly developed a concern for the kind of knowing which allows for reliable prediction. This turns out to be best developed when what is “known” can be experienced by more than one person. Prediction came to be based on process accessible to all, rather than on the dogma of person or tradition. If this change of value hadn’t gotten real results, it would merely have been another dogma, and thus not very important at all.

That didn’t happen. Instead, what slowly emerged was the notion that the basis for our best knowing had to be accessible to our senses. Not MY senses, or YOUR senses, but OUR senses. Knowledge and the making of knowledge took on a decidedly democratic flavor. It could no longer be private, dispensed by the knowing to the unknowing. This criterion rules out what cannot be seen, heard, touched, etc. Use of instrumentation, as sense extenders, is allowed, of course. Astronomers and microbiologists, among others, do it daily.

Our own profession, psychology/counseling/psychotherapy, clearly developed under this umbrella. The critical distinction that sets all domains in this group is that between dogma and science. Dogma is validated by the authority of person or tradition. Science is validated by anyone who is informed enough to set up the conditions of observation. If you know how to operate the Hubble telescope – or access its photographs, you too can observe the Cat’s Eye nebula (and I hope you get to – it’s extraordinary). But, I have no way of observing a past life, or the archangel Michael – at least not in a way that can be reliably replicated by other people. The culture of science insists that we draw a firm line, placing that which can be known reliably by all on one side, and all else on the other. So: general principles of psychotherapy go on one side, angels and space aliens on the other.

Ersatz reality – it does nothing for us. When we take something that is a concept and act as if it is a validated reality, we commit the logical fallacy of reification. I have seen too much of that in my profession. I don’t mind creative thinking and unusual concepts – far from it. I do mind blurring the distinction between (a) a mere idea and (b) reality as it may be known by any adult of sound mind.

There is a large class of concepts which may be used to account for observable phenomenon in psychotherapy: among the ones I don’t think we can use are evil (or good, or ancestral, or whatever) spirits, space aliens, past life re-experiencing, the archangel Michael, and so on (see note 1, below). Some of my clients freely use such ideas (as do some of my Texas relatives!). Therapists I know have had clients who speak of alien abductions. I even had one once (such a client – not an abduction!). I see no need to contest such concepts with our clients. But, we must not, in our own thinking, glibly take them at face value, either, for several reasons:

  1. We usually don’t have enough information to validate much beyond what we can observe in our consulting room. We tend to forget this, and at that point we commit the sin of reification. Bad dog! Heel!
  2. Our job is to validate a client’s feelings, not their thinking. People have a need to explain, and particularly so when they are experiencing painful feelings. People are also inherently creative – we are all natural storytellers. Just because I can concoct some colorful or compelling explanation for something does NOT mean that I understand it, or that my explanation is valid. We must not forget that people make explanations (or borrow them from others) for many reasons. In trying to make sense of what’s happening to them, psychotherapy clients sometimes get it right, and sometimes it’s just a desperate grab. Any port in a storm. This is not a problem as long as we ourselves stay on track concerning what our job is and is not.
  3. Our OWN thinking does need to be as valid as we can possibly make it. Someone may think that their heart pain is due to messages from their dead mother, but their cardiologist had better not pursue this line of thinking. Better that she/he consider that anxiety or fear or some other stress may be related to the pain, as that sort of linkage does have an empirical basis and may thus lead to a useful intervention. In fact, what a competent cardiologist will likely do is look first for organic explanations. As psychotherapists, we have exactly the same objectives and priorities. Again, let me urge: when science is available, don’t use art. Culture (including religious beliefs and their many relatives) supplies art. Hard thought and work supplies science. (Ever wonder why they call it “hard” science?)
  4. Effective therapy is focused on client feeling. A client’s thinking is of primary interest only when it fairly directly connects to this. This principle is the basis of cognitive therapy, and of good case management. We can leave our clients free to do their own cognitive investigations, as long as their affect (feeling) dynamics please them (in which case we have no work to do). We need to focus on the causes of their affective distress, using the best information available to locate those causes. To look to spirits (or whatever) when relevant personal history is at hand, or evidence of mal-formed thought about self, or any other ordinary psychological explanation, is simply irresponsible. It is incompetent. I regret to say that I see my peers do this far too often. (see note 2, below)
  5. Strong feelings never validate; data validates. When client thinking matters, and it often doesn’t, it gets validated by reference to other thinking, and ultimately by reference to data – the stuff we can see, hear, touch, etc. Feelings are great – they give life meaning. They do not, however, validate anything. If you’re up on your neuropsychology, you’ll know that the function of feelings in the brain is to cause a temporary unity of otherwise relatively dissociated brain parts, in order to bring about some act or additional thought (see note 4, below). For that reason, feelings are utterly essential to life itself…but not to scientific method – at least not a means to validation of any hypothesis.

We should care because history demands it. Rarely do we return to a former mode of thought in order to improve our effectiveness. I see no reason to retreat from that which may be verified (even if it hasn’t yet been, as is the case with much in psychotherapy) and embrace that which we have for good reason abandoned: thought which merely is coherent, or which merely appeals to us for some reason, or which “feels” right. All those things may well lead us to a good place, and are often our starting point in the search for new knowledge, but we must not go there if we have better places to go.

The thrust of our history is that science is what we are about, whenever possible. In science, we strive mightily to stay on the ground, to get our fingers dirty. It’s often not glorious work, and it’s not for the lazy, the ill-trained, or those lacking in long range vision. It is, however, for those who have some grasp of human history. It’s clear which direction history is headed, and it certainly isn’t toward the use of astrology or past lives in psychotherapy!

An age is called Dark not because the light fails to shine, but because people refuse to see it. ~ James Michener

I am unable to account for how it is that, in a time when we are literally peering into the brain as human personality expresses itself in real time, some of us are retreating to Chinese folk medicine and the like (see note 3, below). For that you need a graduate degree, and years of supervised internship? Someone, at some point, has taken leave of their senses.

THE FIX FOR PRESUMPTUOUSNESS

Honesty, and a degree of humility, will do the trick. The last thing in the world I want to do is discourage innovative thinking in the best field of work I’ve ever known. That is not to say, however, that anything goes. We do have standards, and they have been both hard won (remember Galileo’s run-in with the Roman Catholic dogmatists?) and well tested (it wasn’t Chinese folk medicine, or astrology, which produced a vaccine for polio, or a treatment for HIV AIDS).

In professional psychotherapy, we are obliged to do our best. We are obliged to learn about both belief and knowledge, and respect both in their proper place. We are obliged to be transparent, and not to appear to have knowledge when we have something less than that. We are obliged to be honest – with ourselves, between ourselves, and with our clients. There is much that we do not know, and some that we do. Let’s be clear about which is which, and not seek to fly where we can only crawl. Let’s simply get it right, because this is not a game for children, or for the mind of a child.

WHAT PSYCHOTHERAPY IS NOT – AND IS – ABOUT

Aside from issue- and context-appropriate psycho-education, as part of our case management of a client, psychotherapy is not about validating a client’s thinking. It is not about uncritical acceptance of a client’s way of thinking about themselves, or anything else – or uncritical rejection, either. It is not about being distracted by the inherent creativity of human cultures and human minds.

It IS about compassionate relationship – after all, we’re all trying to solve the same problem, albeit with differing tools, and different skills. It IS about embracing the core of meaning: our feelings about what has been and is happening to us, and about doing what we can to change the essential nature of that core for the better.

So – they report being abducted by aliens? You know what to do: Screen for the many flavors of psychosis, then get on with helping your client make their peace with their universe, howsoever they see it. Don’t get distracted by the exotica. Stay focused on the dance, and the music driving it. The costume may or may not interest you, but unless attending to it helps you to make a happier dancer, don’t go there.

Lion and tigers and bears…oh my! And angels and aliens and reincarnation…oh my, for sure! But…we really do need some kind of “parental block” device for errant concepts in psychotherapy models. Until that device arrives, it’ll be up to us to keep things in order. We must not let our clients, ourselves, or our historical destiny down.

Little children, when asked to run, sprint full out, then collapse. We must run as adults, knowing our capability and conserving our resources. This approach has taken us far, and the journey is not over.

NOTES

1. I can just hear the howls from certain quarters, so allow me throw a little cold water: I fully realize that all human thought rides on wheels of pure assumption, including physics. Especially physics – witness the miasma of modern pre-empirical (theoretical) physics – things are orderly enough until one looks beneath the hood, as it were, then out come the strings and the quarks and the quacks and the klinks (OK, I made up those last two, but who really noticed – come on , be honest…)

However, the realization that all certainty is built on a foundation of uncertainty does not give one license blythly to be presumptive. One legitimately presumes only when these is no other option. Filling that pot for supper is always a priority. Elegant theology is a lovely thing, but doing something about birth defects is a whole different order of concern. They simply cannot be put on the same level by sane people. At some point, the ability to actually DO science really matters. Wait until you get cancer, then you’ll understand, if you don’t already. Until then, you have the luxury of denial, if that’s the best you can do.

2. I’m sick of hearing about “energy” in psychotherapy discussions when what is clearly being talked about is “feeling”. We can observe the latter in brain scans (indirectly, of course, but rather convincingly). But what in blazes is “energy” – as in “energy psychology”? I can make no sense of this, nor I suspect can anyone else, yet there are a number of books about it. I do have some comprehension of energy – physics was my favorite hard science, in high school and college. But “energy psychology”? Well, my best guess is that someone’s battery was a bit drained one night, and they continued to think past the point of reason, and out came “energy psychology”. I recommend a conceptual recharge.

Seriously, though, while there do exist coherent expositions of energy psychology, there also exist coherent expositions of the politics of heaven, as conceived of by Scholastic Catholic philosophers. The problem should be obvious: these ideas aren’t falsifiable. They don’t belong in science OR psychotherapy, for that reason.

3. Chinese folk medicine, I will remind you, has been busy for years supporting a trade in bear gall bladders, tiger penises, rhino horn, and other assorted animal parts, for their purported healing properties. I can predict that these aspects of Chinese folk medicine will soon be no more, as various animal populations it preys upon depart our planet forever due to breeding stock decimation. What does that do for your chi? If only we could sneak a little real science in the back door here we might save a few of our precious animals.

4. Siegel, D. J. (2004). The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. New York: Guilford.

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(continued, from previous post | part 1 | part 2 | part 3 )

ARE THERE ANGELS AMONG US? CAN WE PUT THEM TO WORK?

It depends upon who you ask. I’m using “angels” here as a surrogate for a wide range of concepts – the reality of which appears to be in substantial dispute. In addition to space aliens, angels, energy fields, psychic work, and past lives, we might well add God, Allah (etc., etc.), the devil (or devils in general), ghosts, Krishna (or Jesus, or whoever) as an avatar (personal form) of a supreme being, the idea of reincarnation, and so on. Most, if not all, of these are unfalsifiable, and thus not usable in psychotherapy models. Some of my peers seem not to have notice this, or worse yet, just don’t grasp the importance of the discrimination.

Call that dog to heel, not to heal. (But please see note, below.) As I said, people differ. In the course of life, many questions, and hopefully some answers, come to mind. Sometimes they shouldn’t – not unless well leashed, as it were. It’s all a matter of context.

Great Danes are wonderful dogs – but probably more wonderful outdoors than in the house. So it is with unfalsifiable concepts, when allowed to be a part of one’s psychotherapy model – they’re fun to play with, not so fun to live with. I’m afraid neither Krisna nor the ghost of your dear grandmother can do much to improve the accuracy of your diagnoses – at least not in any way that we can track or validate. I wish it were so, but I do not think any of us should pretend that it is when in fact it isn’t.

PROFESSIONAL PRESUMPTUOUSNESS

Pretending is for children. In their professional discussions some of my peers talk as if angels really exist, or as if people’s mothers really can speak to them from beyond the grave, etc. I think this is presumptive – in the sense that something appears to be presumed when in fact it should be examined, and carefully at that. (I have exactly the same reaction to some of the statements I have heard from a few of my relatives who are deeply involved in charismatic Christianity.) The problem is just this: belief is not knowledge. Belief is assumption, and nothing more. Confusing the two is not helpful. It is, in fact, a sin – the sin of reification, which is a very bad thing, but I’m getting ahead of myself (as well as being a bit playful with my language).

Please understand that I have no problem with angels, or mother-ghosts, or charismatic Christianity (I prefer it to the other kind, in fact), or any other concept or system of thought involving or dominated by unfalsifiable concepts – until such unfalsifiable concepts take up residence in one’s therapy model. At that point, a line is crossed, and I get concerned.

If some psychotherapists think and speak with a bit of confusion, or worse yet – inappropriate certainty, so what? Why do I care? Why should I care? Those last two questions are not the same, so I’ll take them up individually.

WHY I DO CARE (AND YOU SHOULD, TOO)

Psychotherapy is hard – we can’t be careless about how we do it. We are all children of our history. First, our parents give us genes, selected from genes they were themselves were given. As we are created at conception, these genes get mixed up a bit, and thus we are not exact copies of anyone at all, not even our parents. Then, our parents affect us by how they interact with us, and therein lies a very important tale…for another time. Then, the rest of the world gets a crack at us. If we’re lucky, at some point we get to reflect on all this, and ponder the possibility of making some changes. A new wardrobe? Not hard. A personality adjustment? Ummm…

But matters akin that last request are what we take up in psychotherapy. If such were easily achieved, you could get it done by the same person who checks your groceries. “Could I have some stamps, uh, and a better sense of humor, and a little less anger about pushy people, please?”

Art? Science? The choice is clear. In matters of real difficulty, knowledge is generally useful, if it may be had. Otherwise, roll the dice and it won’t matter what happens. But in psychotherapy we cannot do that. The plain fact is that psychotherapy, while to a significant degree an art, is at least as much a science. Art is craft, personal skill, and mystery, and engages processes of the brain outside the conscious and the verbal. Science is about what is obvious, to a careful observer, and it seeks to reduce or eliminate mystery. The two are complementary, and each benefits the other.

In psychotherapy, both art and science are needed and used, and I strongly suspect it will ever be so. Yet, sometimes we have a choice between the two – we can take the route either of art or of science, relative to a particular matter. At that point one might consider the notion that to do art when science is available is plain stupid. Choosing to do the former, in such a situation, suggests a fundamental failure to understand what is at stake. Such irrationality doesn’t occur when people accurately understand consequences.

An example…filling the pot. First, let’s set up a non-trivial situation, because psychotherapy is not a trivial undertaking. People’s lives do hang in the balance.

So…let’s imagine that we are far out in some wilderness and must hunt for our supper. We haven’t eaten for three days, and we’re rather interested in having something in the pot tonight beyond grass and rocks. This is a thought experiment, and that is the situation I give you.

I will also give you two options for bringing home supper.

  1. An exquisite English longbow – the kind that decimated armies in Europe when it was first taken across the English channel. It packs a punch. I will give also you a highly skilled bowman to go with it.
  2. A modern compound bow, with a sighting device and a string release trigger attached. Again, I give you also an experienced bowman to go with it.

Both are powerful, and can shoot accurately. The first is essentially wholly dependent upon the art of the bowman, while the second has some technical tricks which allow both more shots to be released before the bowman tires AND more accuracy with each shot. Less art, more science. Also, more productivity, if you’re a hunter.

So, which option do you prefer? How hungry you are will likely influence your decision. Remember that I have set this experiment up you really do want to eat tonight.

I will predict that most readers will take the second option. It is more likely to fill the pot. Less art, more science. Better results, we may reasonably predict. With an empty belly, I can easily make my case: “to do art when science is available is plain stupid.”

I do care because I want to hedge my bets. When doing psychotherapy I do want to fill the pot – to get results. Don’t you? Optimal results require our best tools, actual and conceptual. I want science in place of art, whenever I can get it. If I have to do something stupid, I want it to be involuntary rather than voluntary!

(continued, next post)

NOTE

OK, I’m probably wrong about dogs! (But give me a break – it’s only a metaphor, folks!) While I know of no research to back up the notion, I have reliable report of dogs being used as psychotherapy adjuncts – “therapy dogs”. I’m so attracted to the notion, in fact, that I’ve consider acquiring one myself. The idea enchants. The proposition that dogs can facilitate healing is falsifiable, so it may be allowed into one’s model, and certainly is to be found off in a corner of mine. However, the status of the idea should be transparent: good research on this intervention has yet (to my knowledge) to be done. Woof!

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( part 1 | part 2 | part 3 )

This entry is was stimulated by a post to an Internet discussion list in which I participate (see note 4, below). It will be in three parts, due to its length. I encourage you to read the whole piece.

INTRODUCTION

This is addressed to my professional peers. I realize that non-professionals may also read this, so some things are explained at levels which aren’t necessary for professionals.

Basically, I make a plea here for us think about our work with more care and awareness of consequences. Too many psychotherapists appear to have entered into unnecessarily confused thinking, through a failure to grasp the historical and intellectual context of psychotherapy as a discipline and a profession. Our profession has both liberal and conservative aspects, and for good reason. We are a diverse lot, but do not and cannot allow indescriminant thought.

What we do as psychotherapists matters – to us, to our clients. As you consider what I write here, I ask that you recognize that my concern is always ideas, and not the individuals who express them. People who personalize can’t have adult conversations about serious topics. Let’s have an adult conversation.

If, when reading what I have written here, you believe I have strayed into error, offer your constructive comments below. Talking among ourselves is important – that’s why I wrote this.

Anyone who is easily confused about authority should be advised: I live in a rural area, and our utilities are not as good as in other parts of the world. My direct line to God has yet to be set up, so I can offer here only my own thinking (see note 1, below). I speak freely here. You can too, in your comments.

PSYCHOTHERAPY – WHAT IT IS

It’s distinct from counseling. Let us begin by distinguishing counseling from psychotherapy. “Counseling” has a fairly indefinite connotation. People buying stock can obtain counseling prior to purchase (and may need it afterwards as well!). Lawyers, in the USA, are sometimes addressed as “Counselor….”. And, yes, there is also psychological counseling – and some individuals who do that also do psychotherapy.

At the risk of being overly simplistic, counseling is advice-giving. If the advice is from someone with considerable knowledge and experience, it may well be worth a great deal. But…it’s not psychotherapy.

Psychotherapy is about healing mind, employing principles which may be validated. Strictly speaking, psychotherapy is about healing (therapy) for the self (psyche). But there is a further connotation, which separates psychotherapy from all other sorts of good, healing counsel: it is the practice of healing the “self” of a person, utilizing the best knowledge we have of such things. It’s a “profession”. It practitioners received formal education, training, and certification, after which what they have to offer to others may legally be described with a vocabulary which may not be used by any other individuals. The purpose of all this control is to protect the consumer of services, and to protect the investment an individual has made in becoming such a professional.

Making psychotherapy a profession means that some things are NOT psychotherapy. For example, these are not: shamanism, conjuring, messages from some alleged “other” world, angelic intervention, spirit involvement, and a great many things. Oh, such things – if they are real – may indeed facilitate psychotherapeutic healing. I don’t take that up here. They just aren’t properly a formal part of psychotherapy, for reasons I hope I make clear, below.

What moves me to write at this moment is that all this apparently is not obvious to all my professional peers, and I think it should be (see note 2, below).

HEALING PRINCIPLES IN PSYCHOTHERAPY ARE SPECIAL

The practice of healing a person’s mind using the best principles of psychology – the science of the person, of the Self, of the mind, of the brain – science as in physics, chemistry, astronomy, geology, etc., shares a distinguishing feature with these other fields: its key assertions are arrived at in a specific and formally describable way.

It may help if, for a moment, we think of psychotherapy as a kind of product. There are laws in my country (USA), and many others, describing what may and may not be called “chocolate”, “cheese”, “wine”, and a great many other things. There are laws which also describe who may describe themselves to others as a “medical doctor”, or a “realtor”, etc. Again, these controls protect both consumer and producer or practitioner.

Psychotherapy’s product is its practices and principles. Psychotherapy is properly based on knowledge derived from the application of inductive reasoning (see note 3, below) – the production of generalizations from a set of premises (data) which invariably is a sample from a larger population of interest. While in practice this ideal not always achieved, it nevertheless the standard. Therefore, it is simply bad form to represent a principle or practice as known or validated when it is only supposed or assumed to be effective.

Knowing, potential knowing, and all else. I think we should make careful distinctions between what we know, what we could know, and what we can’t know. For example…

  • We can know that when a creature with a non-trivial brain experiences something pleasant after a particular course of action, the chances of that action’s being repeated will generally increase. Ample empirical study has validated this concept.
  • We could know that some new way of conducting an intake assessment leads to subsequent greater, or lessor client compliance with treatment – IF someone were to examine the matter in a careful empirical study.
  • We can’t know whether the presence of angels in our consulting room facilitates psychotherapeutic healing. Angels cannot reliably be introduced into any experiment or study, and appear unlikely ever to be.

If you can’t disprove it, you can’t prove it. Karl Popper formalized this idea in his proposition that some ideas are fasifiable and some are not, and that only the former belong to the realm of science. It’s a crucial notion. It proposes that if you cannot get an idea “grounded” in a research proposal, you cannot take it for a flight.

Angels-as-therapeutic-adjuncts appears not to be a falsifiable hypothesis – we cannot realistically propose how we might show that this idea is wrong. We therefore must not bring angels and their ilk into our formal psychotherapeutic models, at least not so long as “angels” are taken as supposedly real entities. (I don’t have anything against angels – they’re just a convenient surrogate for all manner of hypothesized yet unreachable entities, influences, factors, etc. Besides, they are reputed to have feathers, and I like things with feathers.)

Having a license doesn’t give one license. I am troubled when psychotherapists allow into their formal toolkit various concepts, hypotheses, and assumptions which are not knowledge – and which aren’t even knowable – but which come to be treated as such. Worse than that, too often some of my peers seem to prefer such weak notions to others which are far stronger, are available for use, and yet somehow are mysteriously passed over. This just doesn’t make sense, and as professionals we do not have justification for doing this. Belief is never to be preferred to knowledge.

VARIABILITY – DEVIANCE – IS A GOOD AND NECESSARY THING

If you are at all informed about the known dynamics of both (a) sexual reproduction, in all plant and animal populations which reproduce in this way, and (b) its larger manifestation – organic evolution, you know that variability is an essential part of long term survival. Populations whose individuals do not differ from each other die out eventually – it’s that simple. Tomorrow’s successes are often recruited from today’s deviants.

We are all the children of non-conformists – biologically and culturally, because the same system dynamics which drive biological evolution and persistence drive cultural evolution and persistence. (I have to trust you understand this to some degree, as I haven’t the space to explain it here.)

Biologically, much deviance is useless, and even fatal. I would assert that the same is true of cultural deviance. In the real world, progress often has a high price. The lesson seems clear: deviant things are necessary, and most of them are worthless. But not all.

My concern is about deviant – read unusual or non-status-quo – thinking in psychotherapy which is not discarded – but which should be, because it makes no useful contribution, and in fact degrades the quality of our reputation and product.

LIONS AND TIGERS AND BEARS…AND ANGELS? – TWO QUESTIONS

A tale for our times. Suppose Client X comes to a psychotherapist for help, and with multiple complaints (they tend to do that). This client is engaging, interesting, thoughtful, and humanly appealing. A good alliance is established between client and therapist, and it is soon discovered that this client’s issues are not simple. As the client tells his tale, a variety of references are made to such things as angels, energy fields, psychic work, and past lives.

The therapist, in recounting this in a peer consultation group, appears to take the client’s story at face value, essentially as it was reported, and just as if the client had been talking about a lack of motivation, a thyroid condition, an alcoholic father, and a recent change of medication. I have seen just this sort of report, from a number of my peers, and it sets off all kinds of alarms in my mind.

Clients do present us with non-mainstream ideas we ourselves don’t possess. Alternatively, we may find ourselves serving a population who generally accepted beliefs deviate considerably from our own. That’s diversity in the flesh, and we see more of it now than a generation ago. As my colleague Natalie Zigel says,

The “new age” generation of self help has opened many doors to people searching for answers, and that’s good. Personally it’s been positive for me, particularly in dark times, to explore myself in a larger context than just my ego self. But it also provides exits and flights into deeper pathology for others…no matter how intelligent or organized…

Inquiring minds want to know. It appears to me that at least two questions arise from these sorts of situations:

  1. What do we, as therapists, do with such references to concepts and entities, whether or not we accept them as valid?
  2. How do such references relate to the psychotherapy process, if at all?

[ continued, next post ]

NOTES

1. I say this because too many people have, in the past, become threatened by the confidence with which I sometimes speak. They say goofy things like, “Well, you know, that’s only your opinion.” I’m sometimes grateful to receive such clarifications – about them, not me. When I’m dealing with an easily confused person, I appreciate some indication of this, and such mindless, unsolicited clarifications give me just the indication I need!

2. A little personal disclosure: I do not come to this topic without bias. My first graduate degree was in cultural anthropology, the study of which brings one into contact with people who believe all sorts of things. In addition, there certainly are a broad range of beliefs about many things, and considerable dissent about these beliefs, in my own culture, to wit:

  • God exists / God is delusion
  • the universe was created / the universe evolved
  • the US government is concealing evidence of alien visits to our planet / yeah, sure (!)
  • we had good reason to go to Iraq and bash Saddham / …if we are Republican!
  • …and so on.

I certainly don’t necessarily reject beliefs not personally endorsed by me. BUT, I don’t like points of view entering into my own professional field which appear to violate the core assertions of its professional culture. More than once, in recent discussions with my professional peers, I have seen this happen. I have been largely silent about the matter, until now.

In addressing this topic, I am concerned not to cause shame or distress to anyone. I cannot help it if you find it difficult to encounter someone who disputes your beliefs, but I do hope to lay out MY dispute in a reasonably gentle and fair manner. I do believe that adults can (and should) disagree about important things. This process engenders the diversity which confers upon us adaptive potential.

One more personal disclosure: Very early in my adult life I developed a love of philosophy, and especially for that branch of it concerned with the problem of knowing – epistemology. In our own time, this concern had focused on the problem of induction – of producing a state of knowing when one doesn’t have all the information needed to be certain. Since the age of 17, I have read, studied, written, and done research ever mindful of my deep fascination for this topic. What I have to say here reflects this. I make no apologies, but give warning simply because in my experience not many in my profession have much background in epistemology or induction or even formal research theory and methods. We all take a few required courses (and some of us take much more), but many seem then to run far, far away. I didn’t. I love this stuff. Sometimes I feel a little lonely, though.

3. Let’s be precise: Only in deductive reasoning can we be sure of the outcome – IF our premises are in order, AND we employ correct logical method. Essentially all interesting real-world generalizations involve inductive reasoning, however. With induction, conclusions are NOT certain, but probabilistic, stochastic, and heuristic. Great words all, but the point is that inductive reasoning is not about certainty, but about the best we can do for now. It’s all about practical life in the real world.

The core of the problem is simply this: we don’t have all the data. In inductive reasoning about real world matters, data take the place of the premises one sees in deductive reasoning. Because the questions we seek to answer are about domains which we never can examine exhaustively, we must settle for a sample of the domain. Settling for that, we give up any hope of being certain of the outcome. In most cases, however, our likelihood of erroneous conclusions can be calculated.

Inductive generalizations are not guesses, but are calculated likelihoods. This makes some people edgy, but one just has to get used to this reality. It’s just the way things are, and it’s the reason why science continues to advance.

4. This is not a response to the discussion list post, in any way. The post merely got me to thinking, and that lead to this statement.

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