Sunday, 17 January 2016

beck on psychodynamic psychotherapy - engagement, getting better, and 'what works'

In a brief clip on Youtube an elderly Aaron Beck talks of his historic disillusion with psychodynamic psychotherapy.

What he says is instructive, I believe, for what it tells us about poor psychodynamic practice. I make no claims here about whether such practice is the norm. I think we can all recognise it. Perhaps we (psychoanalytically-minded psychotherapists) have all slipped into it. Perhaps we've even been schooled in it. Hmm.
In this post I want to think about what makes this kind of psychotherapy a poor thing. And how this poverty relates to something else Beck says - namely that 'this was not a very efficient way of doing things. The patients did not get better the way they should... it didn't work.' (The connection I wish to draw between the therapy being poor and the therapy not working is not the obvious one... which is why I'm gonna write this post!)

Beck is talking of how,
when I was doing psychodynamic therapy... the patient would come in, and you'd say 'what's on your mind today?', and then they would talk and you'd keep them going. And then you'd kind of look for the themes. And they'd talk about a movie they'd just seen, and then about a relationship they just had, and some thoughts they had while they were driving, and maybe a recent memory they had. And then you'd say, 'well you see you can dissect, you see this little theme, the theme is that you've been the underdog, and it comes out in each one of these circumstances, but you're not really aware of that'. And then the patient would say 'You know doctor you're right, you've hit it on the head'. But what I found was that this was not a very efficient way of doing things. The patients did not get better the way they should. We were both intrigued by what was happening. [laughter] And it was very, very satisfying. It was the most satisfying experience I had, being kind of a detective and showing how smart you are. But it didn't work. I thought it worked, but when I switched to cognitive therapy which was more directive .... then the patients started to get better much sooner. So I had to be practical. 
What strikes me about this (parodic) description of therapy is what I will call the 'external relation' it posits or presupposes between a therapeutic method and a therapeutic outcome. The patient does one thing - allegedly saying what's on his or her mind. (I say 'allegedly' because Beck often acknowledges that his analytic patients actually weren't following the 'fundamental rule' of psychoanalysis, but were leaving very significant background thoughts - the ones he called 'negative automatic thoughts', ones which unsurprisingly pertained to the transference - unshared.) The therapist encourages this to continue for a while. Then the therapist does another thing: describes the patterns he or she finds in his or her patient's sundry musings. The patient then agrees or not. And finally another thing happens: the patient does or doesn't get better. The phenomena are, that is to say, not of a piece with one another; they are separate and merely causally related; the logic is that of applying a procedure to a process which should, all going well, practice going as theory suggests, result in a product. One could say that, in this scenario, the therapist and the patient too are, in their supposedly therapeutic encounter itself, here themselves merely externally related to one another. The result is a depiction of therapy as technique, as parlour game and, I believe, as facile and auto-parodic. And the result of this game is, naturally enough, merely intellectual insight; the patient's deeper emotional difficulties remain.

Now Beck's transition to cognitive therapy can be described in several different ways, but one of the best is, I believe, in terms of an increased engagement between himself and his patient. This can be seen in different ways - for example in what he describes as his asking 'a key cognitive therapy question, namely ''what are you thinking right now?'' It can be seen in the collaborative focus that the therapy takes. It can be seen too in the abandonment of the floaty parlour tricks of the putatively analytic technique. It can be seen in his direct and honest challenging of his patients' beliefs. Against the backdrop of the merely intellectually curious procedures of his psychodynamic practice what can one say apart from 'hooray for cognitive therapy!'?

As engagement increases in this way, what is in and on the patient's mind, what is happening in the room, what is happening in the mind of the therapist, become much more of a piece with one another. We have, one could say, an increase of the internality of their inter-relations. They become more of a piece with one another since they all partake in and of the interaction between the therapist and the patient. (I would say that, if only Beck had grasped the significance of the transference, he could have arrived at a still more intimately engaged and valuable therapy.) But in the psychodynamic therapy parodied or confessed by Beck we see little of that. The patient waffles on, not actually sharing her transference thoughts despite supposedly following a rule to say what is actually on her mind. (The pivotal case Beck provides is of a woman who fails to share her omnipresent worry that she is boring Beck.) The therapist encourages this waffling and, sitting back, makes theory-guided links between different things that are said leading, at best, to intellectual insight. (At worst, since the patient isn't really sharing her true preoccupations, we don't get any insight at all.) There is no very live connection between patient and therapist. The patient says stuff, the analyst says stuff; the latter ('interpretations') are somehow supposed to have an effect on the psychopathology which inspires what the patient says; unsurprisingly Beck finds that they don't.

What strikes me the most, then, about Beck's early psychoanalytic work is how distant it all is. We have a push button (an interpretation) over here, and a bell (the patient's feelings) over there. It is easy to see in such a setting how to pose a question 'does pressing the button cause the bell to ring?' - 'does this procedure (intellectual interpretation) lead to an effect (emotional relief)?' We can separate out the cause and the effect in such a way as to pose a question about whether such an such an intervention really does lead to such and such an outcome. But consider now situations in which we don't have to do with such a distance of cause and effect. Rather than press a button we go and gong the bell ourselves. Is it now so obvious what it would mean to ask  'does your gonging the bell cause it to ring or not?' The gonging and the ringing are internal to one another: the cause and the effect are of a piece and are unified by the action. Similarly, I suggest, with engaged therapeutic action. If I and the patient are truly engaged then when I offer not some remote intellectual 'interpretation', but rather say something which truly breaks through her defences, there will be no question of its therapeutic efficacy.

My claim, then, to take us back to the beginning, is that to the extent that it makes sense to ask whether a therapy 'works' or not, we probably have to do with a poor therapy. And this is not because good therapies always work, but because the concept of 'working' doesn't gain respectable application when we have the real deal. Beck talks of how psychodynamic interpretation, as he practiced it, 'was not a very efficient way of doing things. The patients did not get better the way they should... it didn't work.' My point here is that if we in the game of thinking of whether a therapy 'works' or not then we are in the game of something we should avoid. (Sometimes trainees say to me: 'With this patient I've done and said all of these things in my therapy book, but none of them seem to work!' I always feel like saying: 'So stop trying to doing things to your patient!') For what we want is for the patient to 'get better the way they should'. If we break through the defences, then the defences - which by definition are what stop the patient from truly getting over their disappointments, from truly overcoming their fears, from mourning their losses - will stop plaguing the patient. You don't need an outcome study to tell you that: you just have to learn the discourse of psychotherapy. If the patient is not getting better then this is because they are still really defended, or because you're not really engaging with them - i.e. with how they unconsciously feel in themselves.

Does making the unconscious conscious succeed as a way of making the unconscious conscious? It's a daft question. Does painting a picture work as a way of getting a successful picture painted? Well, doesn't it just depend on how artistic you are?