Renouncing Psychology

Deutsch: Phrenologie (Photo credit: Wikipedia)

Well, maybe not quite yet. 

It did get your attention, though, didn't it? 

And it's true, I do have a beef with psychology. My introduction to psychology was accidental, a story many of you have heard. I wandered into a psych prof's office when I was getting signed up for a business degree, and the rest, as they say, was history. 

But these were academics. I got introduced to clinical psychology through Ann McAllister and Stuart Strenger, Ph.D.s who practiced together in Buckhead back in the '70s. They were wonderful clinicians and even better human beings, and I wanted to be like them when I grew up. 

Twenty years later, I was surrounded by so many psychologists whom I could not even like, never mind respect, that I began to wish I'd never let my counseling license go. I no longer wished to identify with the arrogance, callousness, unscientific thinking, unprofessional behavior, and outright greed that I was encountering on a daily basis. The profession, however, I still loved. I was proud of the science of psychology. 

Psychology was already changing, however, and I can't say I like the direction it has taken. So while I am not quite ready to disavow it, I do have a beef. 

Once upon a time, the scientists in psychology were all rat-runners. The psychotherapists were all theorists. And their theories generally took into account the whole human being. Psychotherapy was an emotional, intellectual, psychological -- dare I say it? -- even spiritual journey that the therapist and patient/client took together. 

And then, along came Skinner. That was the start of our slippery slope. 

Don't get me wrong: Behaviorism is a damn good theory, and behavioral therapies have some great applications. But what happened next was that, coincidentally with our long-standing desire to be taken seriously as doctors came the push to be included in insurance reimbursement, to be classed as healthcare providers. And that, my dears, was the beginning of the end as far as I'm concerned. 

 The number of mental illnesses we can diagnosis (and of course this is psychiatry's fault, not psychology's, but it stems from the same sources and we've been on board with it from the git-go) has multiplied astronomically from what it was 50 years ago. Everything's abnormal now, treatable, and most importantly from the point of view of many practitioners, reimbursable. 

The twin drives to be taken seriously and be paid as doctors has spawned the evidence-based practice movement, a child of the devil if ever there was one. Ironically, perhaps, it is also the part of the science of psychology with which I most identified in the early days. Why would we waste people's time and money, and offer false hope, for silly woo-woo therapies that don't work? Let's study what does! Sounds great, right? But somehow, in the process, we have reduced diagnosis and treatment if not to the level of the petri dish then to something scarily close to it.

Therapies are manualized. Follow this cookbook recipe with every client you have with this diagnosis, and they'll get better. It's pigeonholing clients, and reducing professionals to technicians. Everything, even assessment, is by the numbers. The person's humanity is out the window, all their experiences and dreams and complexity reduced to three symptoms from group A, two from group B, for a duration of not less than two years, and not due to some other specified disorder or circumstance listed in Appendix C.

Worse, the therapies don't work. Or they only work in the lab. One I got all excited about last year after a workshop turned out to be this sort of dud. Thirty percent of the potential participants in the big study its proponents were trumpeting were weeded out before the study ever started. They had more than one problem, or they were on medication, or whatever variation in their circumstances that normal human beings coming into clinician's offices every day exhibit. So at best, I'm thinking as I'm reading this, the new treatment works with 70% of people with this diagnosis, right?

Not so fast, Virginia. No fewer than 50% of the folk enrolled in the study dropped out! So now, if the new treatment helped every single one of the completers (which, of course, it didn't), we're talking about a therapy that is effective for 35% of the folk for whom a clinician might consider it. Thirty-five percent.

And yet this has now become the only approved therapy for this disorder.

I kid thee not. It works for maybe 35% of the population with this disorder, but if I don't deploy it with every one of them who walks through my front door, I will not be treating my people according to the standard of care, once this gets written into the standards, which it will. Mark my words.


Ironically, chasing the money has led us to fly directly in the face of the best and latest science, offering "treatments" that are absolutely proven not to work for "disorders" that are pretty much proven by now not to exist because they are lucrative. Jumping on the weight-loss bandwagon, as psychology has over the past year or two, is perhaps the best example.

I'm done.

I want to go back to sitting with my clients. And no, they're not patients. They're not sick! I want to go back to being with my clients, not sitting there trying to look attentive while running algorithms in my head or jumping ahead to what I'm supposed to say next according to the treatment protocol. I want to go back to the day when the therapeutic relationship was the primary healing factor, when my own best tool was my self, not a checklist with lines and boxes and graphs to complete to tell me what's the matter with the person. I want to go back to the day when my care was caring, not steps I followed in a manual, to a time when good therapeutic technique mattered, yes, but when there was an art to it.

Is that too much to ask?

Therapeutic Texting

Image via Wikipedia

My young client arrived in tears. Seems she'd not only had problems with a date this week, but also with the friend to whom she'd turned for support. A good deal of these problematic interactions had taken the form of text messages back and forth between the three of them. My client scrolled back to some earlier texts to quote both the date and the friend.

And then, and this is where it gets interesting, while we were talking about all this, she received a text and dashed off a response. I considered asking her not to do that during the session, but what the heck? Here was the very interpersonal issue we were discussing unfolding in the here and now! So I sat back and waited.

Pretty soon, the little phone buzzed with a response, I asked her about it, and so it began: We would talk a bit, she'd send a text or receive a response, and we'd process them. The whole thing was most interesting, and different from work I've done in the past. People have printed out e-mails before and brought them to therapy, and have even brought their laptops in to show me MySpace pages, but this is the first "live" internet interaction I've processed in session as it unfolded. I think it was productive.

Having the actual texts as they unfolded gave us accurate data from her interpersonal world as a basis for discussion of gender roles and expectations--this gave the work a here-and-now immediacy, vs. the there-and-then that is all too often the stuff of psychotherapy. In the course of the hour we were able to establish that she doesn't like confrontation. Smart, perceptive, and funny as hell, she responds with sarcasm when wounded. She is a feminist. She is highly empathic and tries to be supportive to the important people in her world, yet finds herself again and again in non-reciprocal, sexist relationships.

If I have a problem with how the session unfolded, it is that if one has needs that aren't getting met in one's relationships, then the phone is a tremendous distraction from the face-to-face opportunity to get those needs met, available right here, live and in real time, in the therapeutic relationship. So I guess I wouldn't want to do this every week. But today? Cool.

Disturbed patient, disturbing therapy by St. Cloud psychologist | StarTribune.com

Somebody on Twitter alerted me to this story. Briefly, a therapist got over-involved with two of her clients and was disciplined for it. The problem, at least as it is framed by the local newspaper, is that she has poor boundaries and poorer reality testing: As they so cutely put it, she believed the client's delusions more than the client did.

The line between a memory and a delusion is a fine one, especially in Dissociative Identity Disorder (DID). DID occurs in people who have suffered especially severe and often bizarre, but quite real, abuses while at the same time there is an unreal quality to the disorder itself. Real memories, in other words, quite commonly exist side-by-side with unrealistic beliefs in DID.

Therapists are not, and cannot be, in the business of validating clients' memories. However, when a client questions her/his own memories, we can encourage reality-testing by the client. In doing so we must not forget that perpetrators of abuse quite naturally go to great lengths to hide what they are doing, so that validating a specific memory may simply not be possible. We also need to caution clients against attempts to validate that may be dangerous, such as directly confronting perpetrators.

Sometimes the only validation available is indirect: We are working on a dysfunctional behavior in therapy, a memory surfaces, and the behavior “spontaneously” clears up. Other examples of indirect validation that come to mind include addicted and sexually-acting-out siblings (possible co-victims) and an arrest of a relative for a related crime. None of these things proves the validity of a specific memory, but it does lend credence to the client’s family portrait.

It is a myth, by the way, that a person has to remember in order to heal. Or that survivors have to remember more: To quote the late Ann D. McAllister, Ph.D., "What [they] already remember is more than enough." Digging for additional memories runs the risk of (a) producing "memories" that aren't, and (b) completely unraveling the client's ability to function in the present.

Since disbelieving real abuse can be as harmful as becoming part of a delusional system, the therapist serves the client best by focusing on current functioning. The focus of treatment becomes teaching the client to manage flashbacks, switching between alters, emotions, appropriate boundaries, insomnia, self-harm, addictions, self-image, etc. And the key phrase here is “teaching the client to manage,” not managing it for the client. Treatment for DID is emotionally intense, and it’s not going to happen without a degree of dependency developing. But throughout the therapy, the therapist maintains the boundaries of the working relationship and encourages the client’s independence.

Please Hold While I Connect Your Call

We had a spirited discussion in supervision last week about what it is exactly that we as therapists do for our patients. Job #1, as I see it, is to make connections.

Our clients are invariably suffering from some form of alienation. Perhaps they are alienated from their feelings: They don't know what they feel. Or they don't know why they feel it. Perhaps they are alienated from their selves: They don't know who they are, or what they want. They don't know why they do the things they do. They see-saw back and forth between contradictory wants, thoughts, feelings, actions, and self-images. Or they might be alienated from others: They can't maintain a relationship.

So what we do is we help them re-connect to alienated, denied, repressed, suppressed, split-off, and projected parts of themselves.

If people are alienated from their feelings, we help them get back in touch with them. Some people are all in their heads, some have split off their feelings and either projected them onto someone else or created alter personalities to handle them. Still others drink and drug to numb their feelings. Some just deny that they have any, and hope that will make it so. Women in my practice are frequently (if not usually) especially alienated from their anger. We might help them make the connection between their abuse of alcohol and drugs and their wish to avoid feeling angry. Or their wish to reduce inhibitions to the point that they can let loose some anger. We help them re-own anger they have split off and projected, be it onto another person or into another personality. We help them look at patterns in their lives and what their anger might mean in response to people, places, and things. Maybe we help them learn to use their anger as valuable information, as signals.

Which brings us to power. Most of my clients are no more or less powerful than the next person. But women in particular tend to believe they are powerless: They have become alienated from their own strength, usually by the same social process that alienated them from their anger. Therapy, therefore, may involve getting women to exercise that particular muscle as well.

Other people are alienated from their reason and ruled by their feelings. These folk need to be re-connected to their rational sides. We can do that, too. Therapy is a whole lot more than getting in touch with your feelings.

Some folk have become alienated from their very selves: Their parents split off experiences that would otherwise be intolerable and projected them onto the patient. Or tried to live vicariously through the patient. Instead of mirroring for the child what the child is actually like, these parents' eyes are as inaccurate as funhouse mirrors: No child looking into them all day ever day is going to grow up with a realistic self-image. Therapists, if we are doing our jobs, help clients look at themselves with their own eyes (through ours) and begin to see themselves as they actually are. They learn what they really want, not what somebody else has been telling them all their lives what they should want. We reconnect them with their own opinions.

And we reconnect them with their voices. Perhaps a child has been told all his life that what he has to say isn't important, or is incorrect, or must not be spoken of at all. This child, as an adult, is alienated from her own voice. We help her re-learn to speak her piece, often by simply listening objectively, without judging her or injecting our own points of view.

As a psychodynamic therapist, of course, I thrive on making connections between peoples' pasts and their presents. Why do they do what they do? Where did they learn that? What impulse/fantasy/wish/fear are they acting out? Where are its roots in the distant past? How does what goes on in the therapy session connect with how they conduct (or fail to conduct) themselves in their "outside" relationships?

The list of possible connections is endless. What is alienated and needs to be brought back into self-awareness varies with each client. Our job is to help them ask the right questions, observe themselves, analyze the data. We listen. We observe. We make connections.

So that's what therapists do. We are the telephone operators of the psyche.

The basics

I am reading Jane Hall on Deepening the Treatment. It's a book for beginners (she teaches technique at an analytic institute). I didn't realize it was for beginners when I bought it, otherwise I would not have.

Liv Ullman wrote in her memoirs that the book you need comes into your hands when you need it. I picked this one up the other day because every time I walked past my bookshelf it called out to me.

So far, and I'm a couple of chapters in, I haven't read anything I didn't already know. But I'm hanging on every word, nevertheless, partly because Hall says what she says so well, but mainly because she is reminding me why I became a therapist in the first place.

Managed care and training as a psychologist exert a powerful pull. Hall reminds us all of our roots.