Psychotherapy as a “Craft Tradition”

One from the archives:

What will contribute to the growth of psychotherapy as a discipline?

Is psychotherapy a science? If it’s not a science then is it reliable? Psychotherapy is not a science, though some approach it from this perspective. They cite efficacy studies that suggest a specific treatment is more effective for a particular disorder. What gets lost in this equation is that these results are the product of quite artificial constraints and their conclusions are based on generalities. Many individuals do not fit within the generalities.

Psychotherapy is rooted in the humanities. It deals with subjective human experience and last time I heard that cannot be measured. Courtesy of Ken Pope: In the Journal of Trauma & Dissociation Judith Herman writes about the strengths and weaknesses of “craft tradition” among which she considers psychotherapy. Herman is a very respected researcher in the field of trauma. Her book Trauma and Recovery is a landmark text.

Some strengths of craft traditions:

They are strongly embedded in the practicalities of daily life and, as such, are constantly subjected to empirical (though unsystematic) tests of utility. They preserve a highly complex body of knowledge and skill, resisting reductive standardization. They are taught relationally, through a long apprenticeship that fosters discipline, high standards for performance, and an ethic of care. Within their disciplined forms, crafts permit wide scope for individual imagination and creativity.

Here are some of the weaknesses:

Craft traditions also have many weaknesses. Because crafts are highly complex and resistant to reductive standardization, successful practice depends on individual skill, which is highly variable. Training through long apprenticeship fosters the development of authoritarian personality cults, schools of master craftsmen and their disciples. These schools or sects can become secretive, stagnant, ritualized in their practice, and grandiose and dogmatic in their claims. Examples from psychology abound: One has only to mention the psychoanalytic, behavioral, family therapy, and expressive therapy schools and the manifold schisms and sects within them, each named for its ruling patriarch.

Finally, an enlightened path forward for psychotherapy:

Though the practice of psychotherapy is still a craft, this does not mean that we have to perpetuate the worst features of craft-guild behavior by clinging to sectarian allegiances and claims. In physics one does not find Maxwellian or Einsteinian schools; there is simply physics…. Though psychotherapy is not yet at the level of a science, we can foster an attitude of scientific inquiry based in respect for the clinician’s craft. We can encourage more naturalistic observation and open sharing of therapeutic work, using whatever methodology seems appropriate to the question being explored. Most of all, we can cultivate an attitude of humility, curiosity, and wonder at human resiliency, acknowledging that we are still far from understanding the active principles in recovery from psychological trauma.

What is psychotherapy: Part 3

Not a blame game.
Psychotherapy is not about complaining endlessly about past injuries. It is not about painting family members as cause of all our problems. It can be about understanding one’s perceptions of past and present events and how those perceptions color our views of our daily life. Some misunderstand psychotherapy as playing a blame game, not accepting responsibility. Quite the reverse, psychotherapy encourages us to examine and challenge our own perceptions (which may or may not resemble historical truth) of the past. It is important to examine perceptions, because it is our perceptions which shape how we perceive our current world, and inform our decision making and actions.

When solutions become problems.
Often the problems we bring to therapy represent our best solutions to our problems — but they are solutions that have stopped working, and in some cases have become new problems. Psychotherapy is an intervention to help us not repeat endlessly the same unproductive solutions.

And yes, originally posted some years back. There’s also a part 4, which you can find here. Links to the other entries in the series can be found under the “Psychotherapy?” tab near the top of the page, under the blurry illustration.

The Self-Tracking Advantage

A curious article in last week’s New York Times Magazine, The Data-Driven Life, examined the somewhat geeky, but increasing phenomenon of tracking quantifiable aspects of one’s life, chiefly by means of computers. Things tracked ranged from coffee consumption, time spent doing roommate’s dishes, time spent sleeping, tracking cognitive performance — one man claims to have a record of every thought he has had since 1984. While some of these pursuits seem a tad trifling, many have practical applications — exercise logs, increasing awareness of drinking patterns, a mood chart for depressives — yet charges of navel-gazing self-absorption are difficult to fend off.

I think an important point emerges, however. The data that these people are collecting is their data. In an age where “evidence based treatments” are increasingly touted, this is not a small point. Such treatments carry weight with insurance companies precisely because they claim to measure the outcomes of their treatment. And they do, in a way. But what research deals in is generalities. Generalities. Just because, say, DBT, works quite well for many women with a certain diagnosis is no guarantee whatsoever that it will work for you. What people are doing is essentially research on what works for themselves, invaluable information if you think about it.

Self-experiments like Barbier’s and Roberts’s are not clinical trials. The goal isn’t to figure out something about human beings generally but to discover something about yourself. Their validity may be narrow, but it is beautifully relevant. Generally, when we try to change, we simply thrash about: we improvise, guess, forget our results or change the conditions without even noticing the results. Errors are possible in self-tracking and self-experiment, of course. It is easy to mistake a transient effect for a permanent one, or miss some hidden factor that is influencing your data and confounding your conclusions. But once you start gathering data, recording the dates, toggling the conditions back and forth while keeping careful records of the outcome, you gain a tremendous advantage over the normal human practice of making no valid effort whatsoever.

“Generally, when we try to change, we simply thrash about.” How often does psychotherapy resemble this statement? Don’t psychotherapists, in some sense, track data — the personal data of our clients’ fantasies, idiosyncrasies, miseries? Might we not incorporate some more quantifiable methods of tracking some of these data?

Good psychotherapy is exquisitely tailored to the individual. And how that tailoring occurs is in the give-and-take within the therapeutic relationship. Standard treatment, in some sense, fail from the outset. This last excerpt speaks to the potential cold comfort of standardized treatment, and how it is not in any way tailored to the individual:

“Here’s what they told me was the normal surgical course of treatment,” Adler explained. “First they were going to cut out my tonsils, and if that didn’t work, they would break my jaw and reset it to reposition my tongue, and finally they would cut out the roof of my mouth. I had one question: What if my case is different? They said, ‘Let’s try the standard course of treatment first, and if that doesn’t work, then we’ll know your case is different.’ ” Adler recognized what this proposal meant: it meant that his doctors had no cure for different. They wanted to see him as a standard case, because they have treatments for the standard cases. Before Adler underwent surgery, he wanted some evidence that he was a standard case. Some of us aren’t standard, after all; perhaps many of us aren’t.

Perils of a Colorblind Psychotherapeutic Approach

In my training one thing that was hammered into us again and again is the importance of addressing diversity immediately and directly. This idea was challenged by an psychoanalytic supervisor who opined, “you’re going to scare her away” — by addressing the issue of race. Fortunately, this gentleman does not represent psychoanalysis.

I do believe that addressing the issue of race directly goes a long way to establishing trust and respect. Some of us have the luxury of ignoring issues of race (or pretending to). Some of us don’t realize we have the luxury. Addressing difference is important. The research backs this up.

In my own practice, people are sometimes taken aback when race is addressed directly. Later, they often say it was very helpful.

Recent issue of the Journal of Personality & Social Psychology includes: “Seeing Race and Seeming Racist? Evaluating Strategic Colorblindness in Social Interaction.” If you take the time to wade through the academese, there are some important points about race and social interaction.

From the abstract:

One strategy practiced by many Whites to regulate the appearance of prejudice during social interaction is to avoid talking about race, or even acknowledging racial difference. Four experiments involving a dyadic task investigated antecedents and consequences of this tendency. Observed colorblindness was strategic in nature: Whites’ acknowledgment of race was highly susceptible to normative pressure and most evident among individuals concerned with self-presentational aspects of appearing biased (Study 1). However, this tendency was often counterproductive, as avoiding race during interracial interaction predicted negative nonverbal behavior (Study 1), a relationship mediated by decreased capacity to exert inhibitory control (Study 2).

Conclusion:

The present investigation identifies several factors that impact both the practice and the perception of a colorblind approach to social interaction. These studies demonstrate that the social consequences of Whites’ efforts to avoid talking about race differ depending on who their interaction partner is, how this partner talks about race, and the context in which this interaction takes place. Perhaps most notably, across four studies the data converge on the conclusion that White individuals’ intuitions regarding effective strategies for navigating the perceived minefield that is race-relevant interaction are sometimes inaccurate and can even be counterproductive. Whereas the attainment of a truly colorblind society remains an objective to which many continue to aspire, bending over backward to avoid even mere mention of race can create more problems than it solves.

Psychotherapy: A Series of Thoughts

Many books have been written in hope of defining psychotherapy. Here’s a very short attempt (has appeared as part 1, part 2, on the ‘psychotherapy?’ page):

Psychotherapy is a conversation between two people — where one person predominantly talks and the other predominantly listens. The goal of the conversation that develops is to foster insight into the nature of the person doing most of the talking, as well as insight into that person’s problems. But insight is not enough. The important work is somehow getting that insight to stick. To incorporate it into that person’s life in meaningful ways that in turn helps that person better adjust to her or his life.

Even such a simple definition leaves so much that is important out, and there are so many questions it raises, and statements that beg qualification.

Not a blame game.
Psychotherapy is not about complaining endlessly about past injuries. It is not about painting family members as the cause of all our problems. It can be about understanding one’s perceptions of past and present events and how those perceptions color our views of our daily life. Some misunderstand psychotherapy as playing a blame game, not accepting responsibility. Quite the reverse, psychotherapy encourages us to examine and challenge our own perceptions (which may or may not resemble historical truth) of the past. It is important to examine perceptions, because it is our perceptions which shape how we perceive our current world, and inform our decision making and actions.

Making meaning.
Human beings are meaning-making creatures. Faced with confusion, we will attempt to find meaning, even where there is none. Psychotherapy is about uncovering and addressing those meanings. Meanings may generated within one’s self, within one’s family, within one’s community, within one’s culture. Those meanings that may even be obscure to ourselves. A good therapist will gently challenge us to examine inconsistencies in our perceptions and beliefs about ourselves and our interactions with others — and to examine what they might mean. Psychotherapy does not generally come upon “Eureka, that’s it!” sorts of answers, although such insights may suggest further avenues of inquiry. It is a very process-focused endeavor that studies our questions about ourselves in a sustained, methodical, and patient manner.

Recognizing patterns.
Before we can begin to understand our patterns, we have to become aware of them. Part of what psychotherapy does is help to make people more aware of patterns and behaviors that they themselves might not have noticed. It is a process of teasing out the many possible sources that contribute to those behaviors. Many patients express a sense of relief when they are able to bring new meaning to a past situation they had viewed simply from one perspective.

When solutions become problems.
Often the problems we bring to therapy represent our best solutions to our problems — but they are solutions that have stopped working, and in some cases have become new problems. Psychotherapy is an intervention to help us not repeat endlessly the same unproductive solutions.

An authentic emotional connection.
Purely intellectual understanding is very limited. There has to be an authentic emotional connection in connection to our understanding of past events in order to effect meaningful change. A therapist will help you to hone in on, rather than gloss over aspects of your life which seem to be potentially loaded with emotional meaning. A good therapist will convey understanding and empathy for what you are going through. To a great degree, the connection you have with your therapist is what determines the success of your therapy.

Change takes time and collaboration.
Meaningful change does not happen overnight. Many of these patterns of behavior have been honed over years and years, and take time to examine, untangle, and reintegrate into our current lives. Since this type of therapy is more likely to focus on meaning rather than symptoms, it takes time.

It has been written that psychotherapy could conceivably occur between two people without one of them being a therapist. Yet this is quite unlikely. The way that therapists listen, without generally offering advice or solutions, is not the usual mode of casual conversation. A conversation dedicated, on a weekly basis, solely to the concerns of one person is not likely to occur outside of psychotherapy.

Listening in an informed, sustained way.
A therapist will listen knowing what types of life events are likely to have an impact on one’s style of relating to self and others. A therapist will listen knowing that each stage of life (e.g., adolescence, young adulthood, parenthood, middle age, retirement) brings its own unique set of problems, and what are the usual hurdles during these stages. Finally, a therapist will listen with an understanding of the pathologies that can develop in responses to certain problems and have experience in working with those pathologies (e.g., depression, anxiety, obsessive behavior).

Kalea Chapman, Psy.D.

A Blog For the Week: The Neurocritic

A blog of note: The Neurocritic. Just another great blog that keeps an eye on science and trends in scientific thought.

The full name of the blog is: The Neurocritic: Deconstructing the most sensationalistic recent findings in Human Brain Imaging, Cognitive Neuroscience, and Psychopharmacology. Neurocritic seems to specialize in keeping the “bio” part of biopsychosocial in its proper place.

Recent posts include, A Brain is Worth A Thousand Words (June 7):

Brain images are believed to have a particularly persuasive influence on the public perception of research on cognition. Three experiments are reported showing that presenting brain images with articles summarizing cognitive neuroscience research resulted in higher ratings of scientific reasoning for arguments made in those articles

Another post: Oh, great. Now we know what the right parahippocampal gyrus does. (June 3)

There was nothing very interesting in Katherine P. Rankin’s study of sarcasm — at least, nothing worth your important time. All she did was use an M.R.I. to find the place in the brain where the ability to detect sarcasm resides. But then, you probably already knew it was in the right parahippocampal gyrus.

Blog carnival Encephalon.

The Neurocritic also features, as of May 27th, the 46th inception of the blog carnival Encephalon, a neuroscience blog carnival. The carnival includes:

The persistence of racism even among the well-intentioned

The Neurocritic has a past post, Present Tense, that reviews the literature on neuroimaging studies of mindfulness-based meditation.

Next, Vaughan from Mind Hacks writes about the rare phenomenon of ‘supernumerary phantom limbs’ in Phantom extra limbs.

Next up are Brain Games or Drugs for Cognitive Enhancement, written by Sharp Brains guest columnist Pascale Michelon, Ph.D. She discusses the exciting recent finding by Jaeggi et al. (2008): Improving Fluid Intelligence With Training on Working Memory. It’s a growing field.

Speaking of which, Dr. Shock writes a critical piece about the pitfalls of supportive psychotherapy in Supportive Psychotherapy mostly Novice Pilots Flying In The Dark Without Maps.

That last one wins for best post title — along with doing a nice job of describing some therapeutic technique, comes to the shocking conclusion that doing psychotherapy actually requires training, skills, and patience.

Mindfulness, A Culture of Awakening, Psychotherapy

Warning: Twisted academic tone, grab bag of ideas — really curious about mixing psychotherapy and Buddhist mindfulness practices?

A culture of awakening. Should psychotherapies that employ mindfulness techniques incorporate beliefs from which mindfulness practices arose? Some suggest that taken out of their cultural context mindfulness practices are diluted.

Batchelor (1997) has suggested Buddhism is a “culture of awakening”(p. 20). Increasing insight, awareness, and satisfying functioning in society have all been goals of psychotherapy.

Separating mindfulness from religion. In some way, Buddhism or dharma practice addresses all of these concerns. In this context, dharma refers to the realizations and practices espoused by the Buddha. A number of writers (Kabat-Zinn, 2000, 2003, 2005; Batchelor, 1997) employ the phrase ‘dharma practice’ as a way of attempting to separate mindfulness from its religious origins. Kabat-Zinn (2003) states: “The Buddha was not a Buddhist”(p. 66) and points out that he never appointed a successor, as he enjoined others to be “a lamp unto yourselves”(Smith & Novak, p. 24). The spirit of his teachings appears not to be compatible with ‘isms’.

Ethical propositions and a plan. But Buddhism provides more than a technique for increasing awareness. It offers propositions (not rules) and ethical precepts (not commandments) that the practitioner is encouraged to try out for themselves, or at least be aware of.

As a 2500-year-old ‘culture of awakening’, Buddhism is heir to a rich, complex, and sometimes confusing literature (Lopez, 2002). It presents ideas – developed over thousands of years, transmuted through numerous cultures – about the nature of suffering and the reduction of suffering.

This involves a specific plan that details specific emotions to cultivate (often through meditation) when another other emotions weigh heavily. In its combination of propositions, precepts, and practices Buddhism could, in some sense, serve as a model for interventions that attempt to incorporate beliefs, as does ACT explicitly, and MBSR does implicitly. Incorporating ideas from the cultures of origin involves some picking and choosing, and what remains is hardly ‘Buddhist’. Not that there’s anything wrong with that. But the image portrayed in the media of ‘Buddhist’ ideas being brought into the culture is quite silly.

The leap from East to West. Just as Buddhist ideas and practices were adopted and adapted by cultures throughout history, so are they being adopted and adapted to American culture. But the previous cultures were all Asian. The leap from East to West is a big one.

No single culture. To describe Buddhism as a single entity is somewhat misleading. Meditation may be a thread that runs through many of the monastic orders, but many of these orders have not had contact with one another for hundreds of years (Smith & Novak, 2003).

Terms such as Buddhist psychology, Buddhist philosophy, and even Buddhism itself represent a complex variety of traditions, encompassing many practices. In this light, the idea that there is a single concept of mindfulness emanating from Asia seems improbable, if not romantic.

And, by the way, mindfulness practices are not exclusively Buddhist, either.

Kalea Chapman, Psy.D.

Termination

That’s what they call the end of psychotherapy. Chanced upon, at intueri, a very thoughtful post by a psychiatry resident on what termination is like. Intueri: to contemplate. Here’s a brief excerpt:

Termination sounds like a single, discrete event. It is rather a process, an unfolding sequence. In psychotherapy, the general guideline is to begin to discuss termination at least three months prior to the expected end of the relationship.

“If you don’t talk about it, your departure can manifest itself as abandonment,” supervisors consistently counsel. “Plus, most people often have strong reactions to loss. Discussing termination allows people to learn a lot about themselves and to learn that the ending of a relationship doesn’t have to be bad.”

Intueri has also written about relationship. In the mean time, check out termination – an introduction.

Family Therapy for Bipolar Disorder

Biopsychosocial model. Interesting article in today’s New York Times about incorporating family therapy for bipolar disorder. Family therapy, as the article points out, doesn’t always assume that the “identified patient” is the cause of the problem. Usually there are other dynamics within the family that contribute to the problem, even with a disorder conventionally looked upon as being biological in nature. In family therapy, focus sometimes shifts from the “identified patient” to another member of the family.

The key advantage of family therapy in this setting, is enlisting family members to assist in noticing symptoms, particularly oncoming mania. Here’s a bit about family therapy from the article:

Family-focused therapy, as it is called, breaks the image of the psychiatrist sitting in his chair, alone in a room with the patient, as well as the traditional wisdom that patient confidentiality is sacrosanct. In family therapy, the family might be treated as part of the problem; in contrast, in family-focused therapy the point is not to treat relatives, but to enlist their help in managing the patient’s illness.

And here’s a bit about the effectiveness of this kind of treatment:

“We’ve tested it in a number of different trials against different types of therapy, and consistently find that if you combine medication and family-focused therapy, you get quicker recoveries from episodes and longer intervals of wellness,” said David J. Miklowitz, a professor of psychology and psychiatry at the University of Colorado, whose pioneering research on the topic inspired the Beth Israel clinic. “So the relapses are less common, and their functioning improves, including relationship and family functioning.”

And a bit about the effectiveness of therapy as an adjunctive treatment:

For many years, Dr. Miklowitz said, the extreme mood swings of bipolar disorder had been thought of “as sort of an exclusively genetic, biologically treated illness,” to be managed primarily with medication. But his most recent study, reported a year ago in the Archives of General Psychiatry, showed that long-term therapy of 30 50-minute sessions over nine months, with medication, cut median recovery time to 169 days, compared to 279 days for those receiving short-term therapy of three sessions over six weeks.

One of the reasons enlisting the family is the opportunity they have for spotting early signs of mania:

… [the] founder of Beth Israel’s clinic, Dr. Igor Galynker, said their experiences with patients showed that families are in the best position to catch early warning signs of a manic or depressive episode.

“It can be something as subtle as a change in lipstick shade,” Dr. Galynker said. “Only a person who knows them very, very well would know.”

This is a nice example of where medication, therapy, and family work together in treatment. Hence, bio-psycho-social.

Kalea Chapman, Psy.D.

15 Variables in Relationship

Recently read a great article (when I find the citation I’ll attach it) about many variables that contribute to the way relationships (any relationship: coworkers, friends, lovers, etc.) function. What makes the list interesting is that each of these variables applies to both members in the relationship, which really speaks to the complexity of human interaction. Of course, relationship is one of those important aspects of subjective experience, which is an important focus of psychotherapy. Here’s the list:

1. mood
2. empathy
3. organization of events in time
4. familiarity of physical environment
5. predictability of self
6. ability to manage one’s arousal
7. previously established expectations of self and other
8. fantasy
9. projection, seeing aspects of oneself in your partner
10. novelty/familiarity of partner
11. explicit, verbal communication
12. implicit, nonverbal communication
13. history of relationship
14. patterns of how you do things together, who takes the lead, what are the ‘rules’ understood in the relationship?
15. ability to articulate thoughts, emotions, sensations, perceptions

Kalea Chapman, Psy.D.