On Psychotherapy and Science
If psychotherapy were scientific we would have one word, like “photosynthesis,” to describe its process. There would be consensus on what is happening therapeutically and a common vocabulary to facilitate communication. Instead, we’ve got a variety of treatment models with so many differences they’re hard to compare, or basic commonalities hidden by jargon. One clinician might unknowingly christen an existing idea with a new name, while another might use a well-known term to signify something entirely different.
Within this field there are many schools of thought that war with each other, leaving no solid foundation upon which further discovery and knowledge might be built. I think Freud really tried and some of his followers were game (the ones he didn’t excommunicate…), but a century later people rename a therapy that has its roots in psychoanalysis as “psychodynamic psychotherapy,” and what happens to Anna Freud’s work on naming the defenses? Goodbye altruism, hello broken bird syndrome. Constant rebranding, that’s what happens. (I’m looking at you, IFS!)
I love the popular interest in mental health, but after spending time on the internet I sometimes hear myself saying, “I don’t think ‘object constancy’ means what you think it means…”.
Needless to say, these are confusing times.
I have an interest in history, and in particular, the history of the “mental sciences.” Psychology came about in the 19th century. It sounds like a science. So did phrenology, people. So. Did. Phrenology. What seems to abide from this time is a desire to pin things down and know. I get it. I totally do. I’m a seeker. I totally want to know how things work. But this desire to legitimate therapies by pairing them with science has been dogging us for a while. At this point when I hear the word “evidence-based” in the context of a therapy or therapy product, my first impulse is to run for the hills. That’s not entirely true, I might check it out, but I’m definitely skeptical.
I do like studies on what makes psychotherapies effective—including this one by Jonathan Shedler on psychoanalytic psychotherapy. (I’m using that study to present my own legitimacy—little bit sneaky, huh?—and that’s part of the problem.) When science is used to back something that is for sale, to create evidence and bolster consumer confidence, it becomes a vehicle for something other than knowledge. I don’t think determining the efficacy of psychotherapies in clinical studies is bad—in fact, we should all care deeply about what is most likely to help—but beyond the partnering with marketing efforts, the emphasis on quantifiable outcome can sometimes ignore factors associated with emotional wellbeing, such as our capacity for compassion, creativity, and connection.
In general, I get a little nervous where the human condition and science meet, as it has a huge bearing on what we are more likely to accept about ourselves and what we feel we need to change. Sometimes it seems that feelings themselves can be problematized and targeted for removal. But I appreciate medicine and its sometimes ruthless efficiency. Medicine is an actual science. Its history is rife with experimentation, which simply cannot be replicated for ethical reasons and because psychotherapy is highly subjective, with n=1 in every case. If you have a broken bone or a gallstone, a doctor is likely going to be able to fix what ails you. Remember syphilis? (Probably not…) Detection, diagnosis and treatment were key in bringing about changes that vastly improved people’s lives—literally saving them from mental anguish and death. I’m a huge fan of science and medicine, but as a therapist, it’s just not what I do.
One of the basic issues with a science that purports to study people—not their bodies but the whole gestalt—is that the ones doing the studying are also people. Isn’t objectivity supposed to be part of the deal? I imagine this imperative explains why professors were talking about rats in the Psych 101 course I almost took in college. What does rodent behavior have to do with people?! Well, we’re all animals. We’ve got that going, I suppose. I chose to study people through Religion and Art History instead, and later on Material Culture, and then Psychoanalysis. I have since come around to appreciate some of these behavioral experiments, and psychology in general, but attempting to understand ourselves by studying rodents still strikes me as odd. Yet looking towards another person to make sense of ourselves is…complicated.
Psychoanalysts think about this sort of complication a lot. We consider how we influence what comes up in the therapeutic situation all. the. time. while also leaving room for not knowing what is going on. (It’s not like we graduate into some mystical realm where the unconscious is an open book and we can check page 283 or something.) We are fallible humans who create theories to ground us, because this endeavor is a little harrowing sometimes, and then we examine them. The problem is when people reify theory as essentialist fact. Theory emerges from the social context in which it was created and it changes. For example, no one I know believes that the point of an analysis is to work through one’s Oedipus Complex. Though symbolically, we might work with some of the same themes, i.e. attachment, power, limits, shame, and sexuality. We use theory as a tool to construct meaning—and meaning often feels helpful to us people.
In my mind, psychotherapy isn’t a science. However, if we approach it as a true experiment, we might find that our attitude towards it becomes more open, playful, and curious. And this sort of treatment, in which people are treated as the complex and beautiful creatures they are, could be the best kind of medicine.
