For much of my life I have been interested in the science of psychotherapy. I have tried to bring the best of both worlds to the table. However, in recent years I have begun to question whether we are anywhere close to that goal. Even more than that, I have begun to question whether it is a realistic goal at all. Perhaps there is a contradiction of ideas here that it is a true oxymoron, a logical imipossibility.
On the one hand, I firmly believe that counseling without some scientfic basis is dangerous or slipshod. Doing what comes intuitively and naturally to a counselor, that is just doing whatever comes to mind, can lead to meandering sessions that are a waste of time and money. Worse than that, such sessions can even be harmful to a patient. Even Primal Scream therapy must have seemed logical to somebody at some time, but is there a shred of evidence now that it works? (Primal Scream Therapy involved having the patient reenact the trauma of birth and doing so at a very high decibel level.)
Here is problem number one with the phrase "scientific psychotherapy." It is a practical issue. I have come to realize that some of our traditional research paradigms do not work. Here is one example of a traditional research model: For patients with characteristic A (e.g., depression) and stresses B (e.g., loss of a spouse) what effect does treatment C have compared to treatment D? It's an interesting question, but with a major flaw. Let's suppose that a patieint comes to me with symptoms of major depression. I then also note that there appears to be unresolved grief over the loss of a spouse. I decide to use a combination of cognitive behavioral therapy and grief therapy. However, after ten sessions or so, I begin to notice that the therapy is stalling. Something is not working. Finally, after the sixteenth session the patient reveals to me that they have a secret. They reveal to me that they have been involved in something illegal, and they are afraid of being caught and prosecuted. They are having nightmares of going to jail and feel terribly guilty. This issue was not even on my radar as a therapist. It was certainly not part of the treatment plan. I do not have a standard question on my intake form which asks if the patient is doing anything illegal. Furthermore--and this is important--if I did ask the question, it is doubtful that patients would be truthful at the outset. They do yet know me and have no reason to trust me. There are of course many other types of secrets which clients bring to counseling which are not disclosed at the outset of counseling..
I now realize that whatever I am working on with a patient for the first ten sessions may be merely the "anteroom" which may both hide and lead the way into the deeper issues. I have to first pass the test of being deemed by them to be understanding and trustworthy. If I am not viewed in that way, then the treatment can be a type of charade. The client may either thank me for their improvement and terminate therapy without telling me their secret, or they may simply disappear and drop out of treatment.
People often carry with them a great deal of shame with their secrets. Now consider the problem of how to build a scientific experimental model to deal with these hidden agendas. It might not be impossible; but neither would it be easy. In an experimental setting, the patient would have to be convinced of the trustworthiniess not only of the therapist but also of the entire research staff.
Psychotherapy at its best involves a human being interacting with another human being. In the situation above, it is conceivable that the therapist might share something out of his own life that was illegal or brought on a sense of shame. That would be particularly hard to do when the therapist would also have to decide on the trustworthiness of staff. Would such self disclosure by the therapist be helpful or unhelpful? It would probably depend on the timing--and many other factors.
Psychotherapy is one human being encountering another human being at the deepest levels. Fritz Perls, a psychiatrist, famously wrote:
I do my thing and you do yours.
I am not in this world to live up to your expectations,
And you are not in this world to live up to mine.
You are you, and I am I,
And if by chance we find each other, then it is beautiful.
If not, it can't be helped.”
This may be viewed as somewhat of an extreme form of laissez faire psychology. But it serves well to outline the question. Perhaps the most powerful way I can impact another person is also the least manipulative--just to be there for them.
This leads to problem number two, the problem of failure in therapy. It is a fundamental question. I very much value the rigorous scieintific training that I have received. I look with scepticism on some concepts, such as chakras and energy fields which some therapists believe can lead to "energy healing." My scepticism does not mean that I am right and they are wrong. I am quite willing to consider that they may be right and I may be wrong. But science is good at holding our feet to the fire and making sure that we do not arbitrarily make outrageous claims. So far so good.
But the problem is that science tends to assume that there is an answer for almost every problem. The idea is that if a solution does not exist, it is only because it hasn't been invented yet. If a particular type of personality disorder or substance abuse is resistant to treatment, the implicit idea is that there must be a way in which the patient can be "treated." Treatment failure in a research setting is implicitly understood as a step towards reformulation of theory and practical methodology. It is not accepted as being somewhat inevitable,at least in some cases.
Humanistic psychotherapy can be thought of as somewhat opposed to some types of scientific therapies. It allows theoretically for some degree of free will, and hence it is believed that the patient must choose to participate in their own recovery. They are not an object to be manipulated. If they do not make the choice to participate in their recovery then no amount of manipulation will cause them to become healthier.
I have not been able to resolve this conundrum. The scientific process has led to many breakthroughs and will continue to do so. However, the day that counseling treats a person only as an object to be medicated or manipulated, that is the day that I will no longer be interested in being a psychotherapist.
Here's another way of saying this: Science never takes "no" for an answer. If it hasn't found a way of curing depression for a certain type of patient, it goes back to the drawing board, looking for more theories and designing new experiments. In that way, the responsibility for curing the patient always remains on the scientist, sometimes called the "scientist-practicioner." The humanistic psychotherapist very likely regrets not being able to "cure" a patient but in the end accepts the right of the patient to resist treatment and to resist healthy behavior. There is the consolation that the patient is in the end a human being with free will. Science (such as behavior modification) sees no comfort in this idea because it does not believe in it..
All of this lands us in very deep philosophical territory indeed. Is there free will? This question has been pondered for millenia and will continue to be. But the slightly less intimidating question is whether the patienit shares responsibility for their own improvement. If they do, then failure will always be one possible outcome of psychotherapy. On the other hand, if patients do make choices and share in the responsiibility for their own recovery and health, then a positive outcome to therapy is not just a success, it is something which is to be celebrated. This is because the patient themselves has helped to bring it about.
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