Tuesday, 22 January 2008

On Clinical Practice

In a previous post (What is Clinical Psychology?) I tried to articulate the logos - the essential nature - of clinical psychology. Here I argued that what makes the clinical psychologist distinct (from the counsellor or psychotherapist) is not their plethora of models or investigative or therapeutic skills, but rather the general stance they take. And this stance can be characterised as one which provides for the possibility of combining an empathic engagement with the client with an external perspective on their difficulties. This external perspective allows the clinician to comprehend the client's distress from without rather than within. It notices what it is that is framing the client's distress.

The client's world is constrained by this frame, and so they are not able to see it, nor notice the possibilities that obtain outside of it. The psychologist's job, however, is very much to notice it, and to gradually enable the client to foreground what had previously been background. In an existential-phenomenological idiom, we may say that the psychologist's aim is to take the structure of the 'clearing', or take the 'atmosphere', and bring it itself into view in a wider clearing, or to condense out of the atmosphere distinct visibilia.

I briefly described in the previous post ways in which different (behavioural, third-wave-CBT, narrative, etc.) therapies, as conducted by clinical psychologists, can be seen as fulfiling this 'externalising' aim. However I didn't yet describe what I take to be the relation between theory and therapeutic practice. Here I want to take issue with, rather than attempt to articulate an implicit logos of, mainstream forms of clinical psychologist. For it seems to me that they are generally somewhat arrogant, imposing and intellectualising.

Let me own up straight away: What I am largely reacting against now is what memory provides me of versions of my own former self. Having finished three years of clinical training and two years of personal therapy, I'm in a position to look back at the encounters I had with others, and to wonder about what it was that was, or wasn't, therapeutic in what I brought to these relationships.

And what I've come to doubt is the value of my own attempts to implement, as it were, the formulations of the client's distress I derived. The typical model is: assess, develop a psychological formulation of the client's difficulties, and then develop an intervention based on this formulation. The therapeutic interaction conceived thus is a kind of targeted intervention where the solution is designed to fit the problem.

One way in which this disturbs me is if I start to imagine that this was what was going on for my own therapist in relation to me for the last two years. Did I want my difficulties to be formulated, and to have an intervention targeted at them? Or isn't this really rather disturbing? For one thing it seems to leave me, the agent and the subject, rather out of the picture. It also completely leaves out the live subjective moment in the session and the real value of the relationship itself. None of this is to say that I didn't want to be understood. Being understood, offered acknowledgement, regarded - to have my own self-understanding heard and encouraged, sometimes sensitively questioned - seemed to be what was important. This enabled me to come to new understandings and new insights. The therapeutic journey was of course joint, but it was me that was 'in' therapy, and to this extent the journey and the discoveries on the journey were principally mine.

Carl Rogers

This largely leaves behind the psychologist's 'intervention'. (The very word should be enough to make us suspicious...) But what of the formulation, what of the clinician's understanding of the difficulties and the relationship this understanding bears to the practice. Here I want to suggest a quite different relationship between understanding and practice. I shall call the relationship I want to promote a 'negative' relationship, and the one I want to demote a 'positive' one.

In a 'negative' relationship the clinician's externalising understanding need not directly drive their practice. Rather it has a preventative function. It prevents them from getting caught up in the implicit world- or -self- view contained in their client's talk and action. It enables them to maintain their independence, it helps them to withstand the impact of the client's projective identifications. It enables them to continue to think about what the client brings. And as such it enables them to maintain their distance from the client's difficulties.

I want to make it clear that I am not advocating an emotional distance from, or a kind of objectivising coldness towards, the client. That is not to the point at all. The relevant form of distance here is one which actually enables me to hear the client. Unless I am able to experience them as distinct from myself, to hold onto the differences between us, and the differences between the way they are currently viewing their situation, and the way that others without the client's emotional difficulties may view the client's situation, I will not be able to be in any genuine relationship with the client. It is precisely this distance that enables me to keep an open, listening, relating, empathic, regarding, stance towards them.

Without an understanding of what is troubling the client, they will either remain opaque to me, or I risk becoming identified with them. In the one case I am 'external' to them in a non-comprehending way. As such I am useless to them, except perhaps temporarily as a sounding board, or to fulfil a phantasised function of 'being a psychologist' that they may have. In the other case my empathic identification has stopped me being able to think for them; their 'frame' or 'clearing' or 'atmosphere' has become my own, and I can no longer do the work of helping them to arrive at a different perspective.

By maintaining that kind of distance that enables me to be in a genuine relationship, however, I am able to function as an other for the client. They can test out their understandings of relationships and feelings with me. They can themselves come to see the subtle yet pervasive disturbances that have constructed their emotional relationships to their parents, partners, bodies, feelings, bosses, friends and colleagues. They can trust in my understanding enough to allow themselves to risk new emotional learning, exposure and response prevention, mastery of new tasks, taking of new risks, inhabiting of new and at first uncomfortable feeling states.

I have not yet seen any good critiques of Lambert's view that 40% of the variance in psychotherapy outcomes is due to extratherapeutic factors, 30% to the therapeutic relationship, 15% to technical factors, and 15% to expectancy. (Lambert, M. (1992). Implications of outcome research for psychotherapy integration. In J. Norcross & J. Goldstein (Eds.), Handbook of Psychotherapy Integration (pp. 94–129). New York: Basic Books.) To relate this to the above discussion, it would appear that what the clinician brings by way of capacity to relate to the client may be twice as important as the technical strategies they attempt to implement.

It is striking, then, that clinical psychological trainings - which attempt to train clinicians to bring psychological understanding to bear upon therapeutic relationships - typically stress the ways in which such knowledge can affect the interventions offered by the clinician. They propose a 'positive' rather than a 'negative' view of the relationship between understanding and practice. If Lambert's metanalytic research is on the right lines, and if Rogers' research on the value of the relationship is also to be trusted, and if we want to become better clinicians, then it is surely important to spend our time training clinicians to be able to enter into better relationships. To become more accepting, open, genuine, honest, listening, empathic, etc. in the clinical encounter. And to use their clinical knowledge of the client's difficulties not to try to change the client, but rather to 'keep the channel open' - i.e. to remain able to carry on listening and relating and understanding even in the face of the client's psychopathology. To keep the frame in sight. To not get lost in the foggy atmosphere in which the problem resides.