The truth about psychotherapy
Not so long ago, psychotherapy was a rare thing. Most people with mental distress did not get to see a psychotherapist. Sometimes people with anxiety states might be seen by a psychologist, for ‘behaviour therapy’, based on the animal learning principles discovered by Pavlov (classical conditioning – salivating dogs) or Skinner (operant conditioning – pigeons learning to peck levers that would generate a ‘reward’ or ‘reinforcement’ in the form of a pellet of food). There was also the psychoanalytic tradition, deriving from the discoveries of the unconscious mind and early personality development, in the work of Freud and many others – but relatively few underwent psychoanalytic therapy, particularly in Britain. In the USA, psychoanalysis became, for some decades, more prevalent with the arrival of analysts fleeing the Nazis in Europe at the outbreak of world war II. There was an attempt, by analysts such as Hartman, Kris, and Loewenstein (and others of the ‘ego psychologists’) to establish psychoanalysis as a general psychology, taught in universities and medical schools. For a time in the USA, psychoanalysis and psychiatry were somewhat synonymous – and clinical and other forms of psychology were strongly influenced by psychoanalysis. By contrast, in Britain, although Freud settled here, psychoanalysis never became pervasively established – and, perhaps for this reason, retained its radical and subversive nature, appealing to the less orthodox of clients and practitioners.
The third stream of psychotherapy (in addition to the behaviourists and the psychoanalysts) was the humanistic tradition, exemplified by the ‘person-centred counselling’ of Carl Rogers, based in the idea of essential human goodness and strivings for self-actualisation (to use Maslow’s term). A fourth stream emerged in the 1970s, in the form of cognitive therapy, developed in somewhat different ways by Albert Ellis and Aaron Beck. Ellis would use philosophical reasoning to counter the faulty thinking of his neurotic patients. Beck observed the ‘automatic thoughts’ that determine people moods and anxiety states – later focusing also on the deeper beliefs or ‘schemas’ that organise a person’s expectations of the interpersonal world, based on their early experiences within the family. During the 1980s, some psychologists began to combine the earlier ‘behavioural’ approaches with the new cognitive ways of working – and the hybrid ‘cognitive behaviour therapy’ evolved. Whilst the older behavioural tradition emphasised the importance of ‘exposure’ to stimuli that evoke unrealistic fear, so that ‘extinction’ of the fear response can take place (along the lines of Pavlov’s dogs), some of the cognitive therapists preferred to conceptualise ‘behavioural experiments’ whereby the patient would be encourage to face their fears, try out new behaviours, and discover that the fear would subside. However it is conceptualised, the CBT therapists began to explore, collaboratively with their patients, the details of their thoughts and feelings and behaviours, and would encourage them to try out different behaviours. Not surprisingly, this kind of approach was found to be quite effective with some patients – and definite, albeit modest, positive effects were demonstrated in well-designed research.
Of course, many psychologists and psychotherapists tended to draw upon a variety of approaches, trying to find what was most helpful for the particular patient or client – and, most clinicians, if they are not emotionally wedded to a favoured approach, will come to realise that no one approach has all the answers, and none are as effective all the time as we might wish. Even the best forms of therapy, and the best therapists, are only able to help a proportion of patients – particularly in the case of the more severe and complex kinds of distress and personality disturbance. Much depends on the motivation of the patient, as well as that of the therapist. Sometimes young and enthusiastic therapists may be more successful than those who have worked for longer and have become jaded.
A further trend in recent years has been an increased recognition of the ‘embodied’ (and 'embrained') nature of emotional states and the importance of focusing on the body. Emotions are obviously, in part, bodily as well as mental events – but, rather oddly, many psychotherapists used to function as if addressing an unembodied mind. A related development involved the understanding of psychological trauma and its imprints in the responses of brain and body. One of the first effective treatments for trauma was Eye Movement Desensitisation and Reprocessing (EMDR), involving the client engaging in bodily activities and stimulation, such as eye movements, or tapping on each side of the body, or listening to auditory stimuli alternating in each ear, or holding vibrating devices in each hand – all this whilst targeting a traumatic memory or other state of distress. Another component of EMDR is to ask the client where they notice the sensations in the body. Such activities engage body and brain, as well as mind. Increasingly, psychotherapists are recognising that in order to modify entrenched dysfunctional psychological patterns, it is necessary to modify the associated patterns of the brain. This can be done by [a] activating the problematic pattern, whilst [b] stimulating the brain (for example, with eye movements, tapping, or other physical activities providing sensory input) in order to disrupt the pattern. Of course, we do not have to call such work by the trademarked name 'EMDR' - and I prefer to refer to 'bilateral stimulation' since this alludes to certain therapeutic 'ingredients' rather than to a therapeutic brand.
A crucial difference between EMDR (and related approaches) and purely talk-based therapies is that much less depends on the input of the therapist, since the bilateral stimulation seems to facilitate the client’s own processing of their trauma and reappraisal of their beliefs and assumptions. When I first learned EMDR I was astonished to witness the spontaneous healing potential that human beings have when given just a little help of the right kind.
Although energy psychology developed independently (from the work of George Goodheart, John Diamond, and Roger Callahan, in the 1970s), many practitioners came to this approach via EMDR since the approaches have much in common. Both can involve tapping on the body, careful attention to thoughts and beliefs, and both are forms of exposure therapy. In the USA, some of the leading teachers of EMDR became leading teachers of energy psychology.
One of the inherently deceptive aspects of much of the current discourse about psychotherapy is the commercial ‘branding’ of different approaches. People make money out of [a] writing a manual for a ‘new’ form of therapy, [b] carrying out some research to demonstrate that it brings about some positive change in clients, [c] selling the ‘product’, in the form of the therapy itself, the training, and the supervision. Ever-increasing training and supervision requirements can be demanded, which may provide commercial benefits as well as those ostensive ones to do with quality.
The commercial pressures to create and protect a ‘brand’ of therapy means that purveyors of psychotherapies are inclined to emphasise what is different, unique, or special about their product – and to de-emphasise factors that it holds in common with other approaches. In order to carry out research on the therapeutic product, it is necessary to produce a manual for the therapy, to ensure that a relatively standardised product is being measured. When the therapy is found to be of some benefit to some people, the approach is ‘sold’ in the form outlined in the manual. The flaw in this is that we may not actually know what aspect of the manualised approach was helpful. Another manualised approach might be just as helpful. For example, one might write a manual for ‘rubber duck therapy’ – an approach wherein the therapist listens to the client’s concerns, explored his or her thoughts and feelings, offers hope and encouragement, and in addition asks the client to hold a rubber duck and imagine being a small child playing happily in the bath. Quite probably this approach would be found in a research trial to be somewhat effective, with some clients, in alleviating their mental distress and entrenched patterns of dysfunction. However, it would obviously not be reasonable to conclude that it was the rubber duck that was the crucial therapeutic ingredient.
In order to give the illusion that a particular approach is much more effective than others, a common device is to compare it with an essentially bogus ‘control condition’. For example, a form of behavioural exposure treatment for trauma was compared with a supportive psychotherapy condition – the manual for the latter included the instruction that if the client attempts to talk about their trauma, the therapist should direct him or her to more immediate aspects of daily life. Unsurprisingly, the behavioural exposure therapy was found to be more effective than the control condition. The problem with this conclusion is that the control condition was not a genuine therapy – it was not like anything that a psychotherapist would do in real clinical practice.
The truth is that whenever genuine psychotherapies are researched they are found to be effective to some extent. Moreover, whenever genuine psychotherapies are compared with one another, they are found to be more or less equally effective. This is the most consistent finding in decades of psychotherapy research. This ‘equivalence paradox’ is not a popular conclusion amongst those who favour a particular approach. Nevertheless, it is indeed the truth. For example, a very large study of the outcome data from practitioners of different psychotherapies within the British national health service found no difference in outcome between cognitive-behaviour therapy, person-centred counselling, and psychodynamic psychotherapy click – but this is simply in line with all such studies of genuine psychotherapies.
Where there are real differences is in the results achieved by different therapists (as opposed to therapies). Some psychotherapists are more effective than others – and some are outstandingly more effective. We know, from both common sense and research, that the following factors are important in successful psychotherapy: ·
Effective therapists naturally aim for these - regardless of the name given to their 'brand' of therapy.
Of course, these matters are neither simple nor clear cut, and different researchers and commentators will argue from different points of view. One proponent of the 'therapy X is best for condition Y' position is fond of countering the 'equivalence paradox' by pointing out that trauma-focused CBT is more effective for PTSD than more general CBT that is not trauma-focused. The problem with this argument is that it is basic clinical common sense that treatment for trauma would need to be trauma-focused. I would be inclined to hypothesize that a clinician who tried to treat psychological trauma without in some way addressing the traumatic memories and associated cognitions is probably ignorant of the nature of PTSD. As far as I can judge, there is no evidence that, when mainstream therapies are compared, and when these are delivered by competent therapists who are comfortable with the approach adopted and are free to work to the best of their ability, any one therapy is superior to another. What does seem to me very important is that the psychotherapeutic work, and the interpersonal style of work, must be adapted to the particular client, responding to the various forms of feedback provided by the client. A dogmatic stance by the therapist, or an undue assumption of therapeutic authority, can be unhelpful - and, in some instances, actually harmful.
For more details of relevant research and exploration of these issues, I particularly recommend the writings and website of Scott Miller: www.scottdmiller.com - and the work of Bruce Wampold, particularly his book The Great Psychotherapy Debateclick. Having been in clinical practice for 35 years, it seems to me that all the main schools of psychotherapy contain important aspects of knowledge and skill in how to help people. None of them contains all that we need. It is best to combine the relevant components of a variety of approaches. Even then, the results of psychotherapy are often (in my view) not adequate. We need to keep exploring and questioning in order to find better ways. Whilst personally I find the methods of energy psychology endlessly fascinating, and they provide an ease, depth, and rapidity of problem resolution that I have not found in other approaches, they are certainly not right for everyone and are not effective for everyone. I feel it is best for us all – in our diverse fields – to lower the hype about ‘psychological therapies’. They are all helpful to some extent with some clients – but none have all the answers. The most important skill of the therapist is to listen – to listen deeply and with his or her whole being. Whilst the client may not consciously know what needs to be addressed and in what way, if we listen carefully and patiently enough, some part of the client’s being does often know – and may, if we are lucky, convey this knowing to us in one form or another. To quote the title of my own analyst’s first book, it is a matter of ‘Learning from the Patient’ [Patrick Casement. Routledge. 1985]