Thursday, 16 June 2011

psychotherapy and the relation of theory to practice in clinical psychology

I want to have another go at articulating a fundamental difference between the use of theory in clinical psychology on the one hand, and in psychoanalysis and psychodynamic (and other) psychotherapy on the other. It is, I believe, one which easily gets lost in the way that clinical psychologists - such as myself, too much of the time - articulate the relevance of different models of disorder, or of different formulations, for the treatment.

The psychologist's articulation typically has it that the job of the reflective scientist-practitioner is to formulate an explanation of the patient's difficulties within the terms of the model, and then to guide the therapy by this explanation. You treat the disturbance-as-formulated-by-the-model, and this treatment consists accordingly in the model-guided interventions that you make. The formulation may be in whatever terms seem most appropriate (cognitive, behavioural, phenomenology, psychoanalytical, systemic, narrative, etc.), and the treatment follows from the formulation.

There is perhaps nothing wrong with this way of putting things in and of itself. I think it is a very natural way to describe the relation of CBT theory to CBT practice for example. However it can come to seem just so obvious that it can force out other ways of understanding the relation of theory to practice. The way it does so is, I believe, a clear example of the way in which what we could call the 'ideology' of CBT comes to affect the way that all the therapies are understood and practiced with clinical psychology.

Recently I've been noticing how the very idea of the scientist practitioner, implementing theory-laden understanding in the clinic, can get in the way of my own clinical practice. Let me start by explaining what I am not going on about. Here is one way of reacting against the above-described practice - the practice of the scientist practitioner: 'It is far too non-collaborative; we have an expert clinician thrusting their interventions on the patient. Whereas what would be better would be a collaborative enterprise in which clinician and patient come together to understand the patient's difficulties and figure out what to do about them'.

Now that might sound just lovely, but it really isn't what I'm on about. And the pitfalls of it as a general approach are obvious: it may i) encourage the therapist to eschew the very real expertise they do have, relative to the client, and the way they can be helpful in and through that expertise, and it may ii) encourage us to ignore the way in which the client is unable to grasp what they need (in fact that is why they have come in to start with) because their defences and transferences get in the way of their access to the understanding in question, and it may iii) lead us to ignore the way in which the therapist must beware of getting caught within the re-enacted narrowings of experience, understanding, and relating which the patient brings with him. Further, for me I think it all-too-readily leads to a kind of 'virtual therapy', in which I and the patient discuss together what they would, as it were, need from their therapy (were they to have it!), what new understandings they would need to reach; the 'they' who this is to happen to now comes to seem like someone other than the 'they' who is in the room (explanation-driven approaches to therapy such as CAT (cognitive analytic therapy) seem in particular to run the risk of this) .

But in any case, I now understand, despite the above sometime cul-de-sac in my own thinking and practice, that I'm on about something quite different from this, when I question the rightful hegemony of the reflective scientist practitioner model in the psychotherapies. And here is an alternative - and, I believe, sometimes more fruitful, although my aim here is just to clear some space for it and resist the hegemony of the scientist-practitioner approach - construal of the relation of theory to practice, a construal which draws more on a psychoanalytical, than on a clinical psychological, self-understanding:

That what is curative or restorative for people is the extraordinary ordinariness of everyday empathic conversation, acceptance, love, sharing, connection, being understood and knowing one is understood. That new development, disintegrations and reintegrations, occurs in the context of such relating. That what happens in neurosis is that development, inner movement, becomes blocked. And that the therapist must therefore work to break through defences, work to find room to stand outside of transference and make himself available nonetheless, work to negotiate projections and ally himself with the patient's better self against these forces of inner stasis. This is the 'negative' work of therapy: i.e. it is here that psychological understanding must sometimes be deployed by the therapist to inform their practice of negotiating defences. But the 'positive' work of therapy is just the therapist making themselves available as a new 'object' (a new person who can make possible a new constellation and growth of personal being) through their personal qualities as a human being. That of course is also the work that is done, when it is, by the parent or priest, friend or boss. Their human qualities may outshine some of the best therapists. But the best therapists ought at least to have a good understanding of what gets in the way of psychological transformation - gets in the way of a process which, when unblocked, will happen by itself.

Along the way, then, the therapist will use theory. But this will not typically be to guide an intervention, but to un-derail the therapeutic process. The therapist finds himself thrown out of the healthy use as an 'object' by the patient, in a cul de sac, bored, caught up in a reenactment, stuck. Theory and supervision help him at this juncture. There may or may not be an intervention; what we have instead might be, say, an interpretation. Or some other such utterance which has the function of creating space for the making of meaning once again.

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In an interview in 1998, Jerome Frank put it this way: “Psychotherapy


is not applied behavior science. I think that is the wrong model. Because

all science is based on facts, but psychotherapy is the world of meanings,

which is far from the world of facts. Psychotherapy relies on the fact that

human beings react not to the facts or events themselves but to the meanings

of the facts as they interpret them. Psychotherapy is the transformation of

the meanings that patients attribute to events from negative to positive. I

think it should be taught as an art” (Holland and Guerra 1998).