Hi Jeffery, Michael K and Michael M,
Thanks for your interesting and thoughtful contribution to the thread. I founds the Michaels’ reflections on constructionism helpful and especially appreciated Jeffrey’s ideas about memory reconsolidation and related issues. But before addressing them, allow me to highlight one of Jeffrey’s summary statements: “ existing theories of psychotherapy and research methods are too broad and imprecise to reveal significant statistical effects related to ideas, technique, and experience.”
This phrase points toward the idea that if our research was better, we would find significant statistical effects related to techniques and privileged knowledge. As you might imagine, this is an idea that I encounter frequently when I present the research summaries. Here’s the problem: the research I’m citing is the basic research that validates that psychotherapy works. In sum, it is sufficiently precise and specific that it can detect positive improvements due to psychotherapy. However, it cannot detect any improvements secondary to the inherent power of techniques or expertise with psychotherapy’s privileged knowledge. This argues that while a more sensitive research approach could possibly detect some effects from these variables, their effect size would be so small that it would be clinically insignificant. In sum, from a pragmatic perspective, we all need to accept that we have been barking up the wrong tree and, despite a century of effort by brilliant men and woman, we have no techniques with inherent power and our vaunted knowledge is actually unrelated to outcome.
Both you and Gregg referred to the existence of exceptional therapists—super shrinks who get significantly better outcomes than average. As we know, we have tried to replicate their results mostly by asking them what techniques they use and then trying to generate their results by applying those techniques. We’re all aware that that strategy has consistently failed. I think that this suggests that these superior therapists do not demonstrate that “western psychology has made strides forward” but rather that we have no idea how they achieve their enhanced results. In its own way, our inability to learn from our exceptional therapists is as revealing about the constructed nature of psychotherapy as the absence of training and experience effects.
In most other fields, a genuine expert can teach others a better way and thereby enhance the learners’ results. A plumber or a pianist or a physicist could teach beginners how to become an expert, but we can’t. If we think about it, all the professions that operate in fundamental reality—engineering, metallurgy, chemistry—have no problem passing on expertise. Conversely all the professions that operate in constructed reality—leadership, sales, religion, psychotherapy, etc.—are baffled about it. We are faced with the fact that our experts can’t figure out how they are better than average. My theory, of course, is that the best way forward is to understand that we are operating in constructed reality and change our training strategies and our explanations to fit that paradigm shift. Put another way, they get superior results secondary to their charisma not because of some knowledge that they can pass on to others.
But my main response to your email has to do with exploring the concept of “techniques with inherent power” in more detail. Many people have pointed out that my conclusion about the impotence of our privileged knowledge has to be wrong because it includes techniques that obviously have inherent power—techniques like “healthy sleep leads to better mental health” or “having a good social support system is good for most people. The problem with this critique is that it confuses our privileged knowledge with common knowledge. Graduate students coming into training already know that exercise is an effective treatment for depression and that many people feel better if they get a dog. It’s not an exaggeration to argue that essentially all the techniques with inherent power in psychotherapy interventions are part of common knowledge; the part that only trained psychologists know—truly privileged knowledge like what does schizotypal mean and what is the definition of visual kinesthetic dissociation—is the part that doesn’t correlate with enhanced outcomes. All the effective stuff we know, we already knew when we arrived at graduate school. That’s part of why beginning therapists equal the positive results of experienced therapists.
Memory reconsolidation has been making a big impact with clinicians in the past decade but, as you point out, it’s been practiced in some form for centuries. In short, we have known for a long time that if a person continues to be bothered by old memories, they ought to share them with another person or group in hopes that they can work through them (reconsolidate them with different meanings and valences attached). Put another way, there’s no harm in pointing out that memory reconsolidation occurs and that it is one mechanism for healing; in that sense it’s just like good diet, sleep, exercise, socialization, and joining a positive peer group. These are all techniques with inherent power and have all been used for thousands of years. Everyone doing therapy includes some of these techniques when appropriate.
The danger is that practitioners might believe that the elaboration of these techniques will lead to an evolution of psychotherapy. We’re all aware that several new schools of therapy have sprung up around memory reconsolidation. One of Wampold’s most important observations is his recommendation that new approaches to therapy not be evaluated because they will be successful, but no more successful than the 300 other schools of therapy that preceded them. Yes, in memory reconciliation we have a technique with inherent power but we have all been using it for a long time and the elaborations coming from neuroscience aren’t going to fundamentally change the way we are using it.
Scott Miller has pointed out that since there are no specific effects in psychotherapy, we can argue that the crystals and Chinese gongs of New Age therapists are just as effective—and just as scientific--as the latest CBT or psychodynamic interventions. If their clients believe those interventions are helpful, their outcomes will be identical. If the New Age therapist has more charisma—if their client perceives them as wiser and more caring than the CBT client—they will get better outcomes.
Every therapist already puts attention on expectancies and beliefs to some degree; similarly, every therapist also attempts to enhance their own ability to be perceived as wise and caring by their clients. The amount of energy that therapists put into diagnosis and applying techniques is energy that is withdrawn from expectancies, beliefs and charisma. Having more time and energy for client beliefs and expectancies will give us a leg up towards superior performance but if we really want to maximize our outcomes, we need to perceive and even inhabit a different reality that is essentially fluid and malleable.
What Berger and Luckmann offered us when they developed the cross-cultural mental health model was not simply the ability to see our own model in a broader context, they also allowed us to understand that humans are flexible enough to believe in pretty much any model of psychopathology and pretty much any form of intervention. To fully experience the freedom and fluidity inherent in this kind of model requires a ruthless readiness to deconstruct whatever paradigms rule our culture’s mental health model. This means that we have to relentlessly deconstruct the medical model, simple scientism, and the concept that our clients change because of powerful techniques. While we are certainly required to do something in therapy—I still favor Jerome Frank’s idea that it’s all about rituals consisting of explanations and prescribed healing ordeals—it’s actually more accurate to claim that clients change simply because we ask them to. This commitment to ruthless deconstruction is exactly why we need to be very careful when it comes to terms like “entrenched maladaptive patterns.”
That’s why I like to use those 1950’s developers of clinical hypnosis as a metaphor. They were certainly intrigued with the idea that if a client is in an altered state, and if the suggestion aligned with their underlying dynamics, the client could change profoundly with a word, an idea, or a suggestion. They believed that the hypnotic state was conducive to generating epiphanies. Therapists who appreciate constructed reality feel that altered states are common and that reality itself is so fluid that clients change with a word or a gesture. When a therapist feels that level of fluidity with each client, then it becomes more possible to achieve superior results.
Michael M. and Michael K. brought up some important points about the problems inherent in using a concept like constructed reality. I have to agree that social constructionism has gotten kind of long in the tooth and that it struggles when it comes to generally accepted definitions. While I admire Wittgenstein and language games as a set of brilliant insights, I think that a pragmatic constructionism recognizes fundamental reality and the many places where constructed and fundamental reality intersect and influence each other. There’s also a natural fit with psychotherapy. I refer to a MD for a depression that I believe is connected to low thyroid (fundamental reality) but I treat a psychogenic depression with psychotherapy.
I also agree with Michael that the concept of “real” gets very tricky in psychotherapy. Essentially everything psychological is real when that is useful and it is constructed when that it more helpful. We need therapists who are so comfortable with fluidity that they can move between the two gracefully. Most important, we need therapists who are sufficiently accomplished at deconstruction that they can do case conceptualizations, client fit, and interventions without being hamstrung by our culture’s limiting and reifying assumptions. Such therapists, being relatively unlimited by programmed thought, are capable of imagining and creating more profound and useful change and healing.
Best,
Stephen
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Hi Stephen:
If I interpret you saying that psychotherapy is to be grounded in constructivist instead of metaphysical view, I, again argue that a both/and approach is more likely to succeed than either purely scientific or constructivist approach. Among my favorite thinkers, Neils Bohr, says people actor-spectators, or in Ricoeurian terms, intersubjective-analysts. As Kant might say, constructivist without science is empty, science without constructivist is blind. Of course, the categories with which we "construct" reality are universal. Taking constructivism too seriously leads to solipsism (as Boulding warns against).
Best,
Michael
############################On Sunday, April 17, 2022, 01:59:13 PM CDT, Stephen Bacon <[log in to unmask]> wrote:
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Hi Gregg,
I appreciate your last two posts and the clarifications in them. From our previous conversations, I already knew that you have a basically critical stance towards psychotherapy as a scientific endeavor and that you prefer a metamodern approach to a modern or postmodern one. I also believe that you and I have different emphases in our work. You’re attempting to ground psychology in a cohesive big picture and I’m focusing on the relatively small picture of moving psychotherapy forward.
The title of my last book, Practicing Psychotherapy in Constructed Reality, essentially says it all: conducting psychotherapy in constructed reality is radically different than imagining that it occurs in fundamental reality. I fully admit that my definition of “constructed reality” is more metaphoric than precise, yet the concept remains both central and useful. I think that the psychotherapy field—consciously, implicitly, and, most importantly, unconsciously—sees psychotherapy operating in fundamental, naturalistic and scientific reality. The medical model requires this assumption as does virtually all of our major schools of psychotherapy. This assumption is the major source of psychotherapy’s inability to flourish; at core, it’s why we can’t create training and experience effects in our practitioners.
Conversely, the concept of constructed reality imagines psychotherapy operating in another realm—a place of enormous fluidity, where limitations are only set by meanings, and where a word or a gesture can create a new reality. By extension, the psychopathology is as constructed as the healing rituals that cure it; moreover, this reality is sufficiently “big tent” that it can encompass spiritual and shamanic forms of healing as well. I’ve been using a number of metaphors to point towards this perspective. The first is the one included in my first post: imagine that you are an exorcist that knows the spirits are constructed; how does this knowledge free and empower you? Lately, I’ve been using another metaphor vis a vis Milton Erickson and my old graduate school mentor, Jack Watkins, both pioneers of the use of clinical hypnosis. Imagine you are a 1950’s era clinical hypnotist. You have created many hypnotic phenomena including hypnotic amnesia, post-hypnotic suggestions, and ideographic signals from the unconscious mind. You have seen many clients achieve rapid, profound changes in trance and you are experimenting with naturalistic trance experiences. You believe you have discovered a new reality, one that points the way to a more effective way to work with human suffering.
While we are all aware that clinical hypnosis did not end up being a cure all, it continues to provide a metaphor for what it means to exist in a clinically fluid reality, as does the imagination of being an enlightened exorcist. Fully accepting that techniques lack inherent power—taking the finding literally—opens another door to pragmatically experiencing this kind of reality. Helping therapists figure out how their assumptions about reality affects their work is central to psychotherapy’s evolutionary possibilities. (Those who want to follow my speculations further can take a look at my YouTube channel: https://www.youtube.com/channel/UC3uYv2Wqo5pluLHE9nMIiXA)
I have no trouble with the way that you are using maladaptive patterns because you have made the effort to ground the concept in UTOK and its critique of extant assumptions. It can still be useful, however, to compare your definition to the one from Buddhist psychology: human suffering is due to a misidentification with the false idea of self. Now, I’m not actually a Buddhist but I do appreciate that their definition points towards the idea that the world is fluid but it becomes reified when we enter cultural reality (identify with the false self.) The Buddhist worldview is derived from and is an extension of the concept of Maya (illusion) that arises from Vedanta and is a very nice metaphor for my understanding of constructed reality. Frankly, from one way of looking at it, “maladaptive patterns” and “misidentification with the false Self” aren’t really that far apart….
However much I recognize your underlying thought, I don’t think that’s how SEPI and the psychological world understands maladaptive patterns. They immediately use the phrase to validate their implicit underlying assumptions about psychotherapy and fundamental reality and the importance of using skills to remediate confusion. In short, they use the phrase to continue down a fruitless and unproductive pathway.
At present, even the constructionist therapies—e.g., Narrative, Collaborative and Buddhist psychotherapy—are overtly wedded to skills and techniques; much of their theory is helpful, their practices not so much. To my knowledge, Scott Miller and his colleagues are the only approach that has taken the research findings literally. His approach, which is atheoretical and primarily dependent on using feedback, is actually showing some interesting, positive results in terms of outcomes. While I certainly join with the crowd that respects Scott’s approach and work, I believe that it would be significantly extended by a theoretical exploration of operating in constructed versus fundamental reality.
In sum, you know that I believe that your UTOK work is a wonderful contribution and that I have told you that it fills in many of the gaps created by my more metaphoric approach to constructed reality. However, I do believe that your SEPI work with Goldfried will be misinterpreted by most as an endorsement of the status quo approach to understanding psychotherapy. I’d love to take up your invitation to have a UTOK conversation about this.
Best,
Stephen
Stephen Bacon, Ph.D.351 S. Hitchcock Way #B110Santa Barbara, CA 93105website: drstephenbacon.com(805) 563-2820
########################################################Thanks to all.
I would like to be clear about a few things. First, I do not think we can understand UTOK and view the world via the same old fashioned epistemological lenses. That is, I do not think we can frame the proper debate in epistemology as being a choice between a modernist, rationalist empirical account of truth (i.e., the scientific method reveals how to see the world accurately) and a postmodern constructionist view (epistemology is a function of the socio-historical justification systems and truth is constructed via power relations or contextually).
Perhaps the easiest way to frame this dispute is via Wittgenstein, and contrasting his early, picture theory of language and truth to his evolution in the concept of language games. Via the manner it holds and frames JUST into the ToK System, UTOK developmentally inverts Wittgenstein. That is, Wittgenstein goes from a correspondence theory of truth to a constructionist vision and his powerful insights are crucial in grounding the post-structural move in continental philosophy. Developmentally, UTOK starts with the equivalent of the language game insight via JUST. It then evolves into a picture theory of scientific knowledge via the ToK System. The result is a novel relation between epistemology and ontology. It is one well characterized as a metamodern synthesis of rationalistic empirical correspondence theory of truth frames for science and the social construction of reality by networks of propositions contextualized in their sociohistorical contexts and placed in the pragmatic space of dealing with problems in living.
It is from this vantage point that I am responding to Stephen’s important set of arguments and insights via psychotherapy. Psychotherapy has indeed failed to “show up” in a way that accords with modernist views of reality. Indeed, the academic branch of psychotherapy, with its focus on empirically supported treatments, modeled itself the medical model. Yet as Wampold shows in The Great Psychotherapy Debate, it is clear that psychotherapy is a participatory, psychosocial relational process, not a “diagnose the ‘true’ problem and treat it with the right intervention” system. It is a transjective, relational participatory process, such that the two participants (in one-on-one therapy) co-construct a healing narrative. In this regard, I am siding with Stephen and agree that the findings of research associated with expertise and outcome strongly suggest that our privileged knowledge has deep weaknesses in it, especially to the extent that they are framed via the Empirically Supported Treatment model or other models that place its work in a truth independent of the subjects and context.
Of course, this is the central point of UTOK proper. That is, UTOK highlights that the core of psychological science has deep weaknesses in it. It lacks a clear ontological framing that can afford cumulative knowledge. Thus, it is lost in a chaotic fragmented swirl. Mainstream scientific psychology, with its methodological behaviorism, is a patchwork of findings that is not up to the task of either organizing our knowledge of the mental nor informing us how to frame and treat the psyche. It is indeed a hapless endeavor to try to anchor psychotherapy in a methodological behaviorism.
UTOK’s mental behaviorism is different. It grounds the field in ontology and posits from their a clear understanding of scientific psychology that can coherently frame mental behavior at the Mind and Culture planes, and the idiographic psyche (i.e., the unique, particular, subjective knower in the contextual real). We can conclude from UTOK that psychotherapy is very much about creating a healing context that affords the psychological doctor or other therapist to align with the individual’s psyche and work to co-create epistemic shifts that afford new ways of meaning making. UTOK means we do not need to choose between rationalist modernist views or postmodern constructionist/constructivist views. Rather, we now have an ontology for human language games and how they evolve in the context of lived experience. Moreover, when I look at psychotherapy via a UTOK lens, I see it as a process of treating the psyche via helping individuals become aware of maladaptive problems.
Best,
Gregg
From: theory of knowledge society discussion <[log in to unmask]> On Behalf Of William McCartan
Sent: Friday, April 15, 2022 1:19 AM
To: [log in to unmask]
Subject: Re: TOK RE: Common Core of Psychotherapy/Entrenched Maladaptive Patterns
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What a thread, brilliant minds coming together to talk as adults and find a way forward, hopefully to help people like me. At 60 I'm not taking the help so knock it off, I'll make it the rest of the way just fine. The idea of this listserve and the cooperation of those involved can really bring hope to the generations following us in history, with the way the world is tearing itself apart these stones have to be laid. Discussion is important for clarity, just don't get lost in the words.
Have a great night everyone
Thank you Gregg for letting a knucklehead like me follow the discourse.
Peace
William J McCartan
Billy
From: theory of knowledge society discussion <[log in to unmask]> on behalf of Nicholas Lattanzio <[log in to unmask]>
Sent: Thursday, April 14, 2022 11:13:23 PM
To: [log in to unmask] <[log in to unmask]>
Subject: Re: TOK RE: Common Core of Psychotherapy/Entrenched Maladaptive Patterns
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Almost like we're playing word games.. like the French say, the more it changes the more it stays the same. Such is life.
Regards,
Nicholas G. Lattanzio, Psy.D.
On Thu, Apr 14, 2022, 12:59 PM James Tyler Carpenter <[log in to unmask]> wrote:
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Fascinating thread, Everyone. Gregg, we agree. It’s all made up;-)
Warmly, always,
Tyler
James Tyler Carpenter, PhD, FAACP
From: theory of knowledge society discussion <[log in to unmask]> on behalf of Henriques, Gregg - henriqgx <[log in to unmask]>
Sent: Thursday, April 14, 2022 12:50:00 PM
To: [log in to unmask] <[log in to unmask]>
Subject: Re: TOK RE: Common Core of Psychotherapy/Entrenched Maladaptive Patterns
Stephen,
I DO NOT think that we should consider Western psychotherapy to be currently scientific in a paradigmatic or ontological sense. And thus I agree that a better frame to understand its totality is constructionist. And so there is much that you and I agree on.
At the same time, this is precisely what UTOK is about. The basic issue from a UTOK perspective is that we have not solved the ontology of the mental or of human persons. And that we now can. And that is a game changer going forward. And the argument is not empirical, but grounded in logos.
I support many facets of your vision and your argument and believe it is a wakeup call that SEPI should listen to. But I also think that the fact that the problem of psychology could not be solved but now can be solved ontologically is a game changer. And so, clearly, that is where I am going to be placing my efforts. But I do believe yours is an important voice that should be wrestled with. But I did decide to orient SEPI for my Presidency in a different direction.
May be we should have a special UTOK conversation about this?
Best,
Gregg
From: theory of knowledge society discussion <[log in to unmask]> On Behalf Of Stephen Bacon
Sent: Thursday, April 14, 2022 11:16 AM
To: [log in to unmask]
Subject: Re: TOK RE: Common Core of Psychotherapy/Entrenched Maladaptive Patterns
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Hi Greg,
I appreciated your response and understand how your other priorities forced its brevity. However, given the imminence of the SEPI conference, I thought it appropriate to continue our dialog.
One of the key points in your response is that we need to be careful not to draw too many conclusions from the research findings about techniques lacking inherent power and our privileged knowledge failing to enhance outcomes. If these findings were actually isolated and standing on their own, I would agree that we should take care not to stretch them too far, but in actuality they are reinforcing factors tightly woven into an overarching theory—a theory that points in a significantly different direction than the theories pursued by psychotherapy in general or SEPI in particular.
In my first posting, I refer to Berger and Luckmann’s cross-cultural analysis of mental heath practices and note that they see western psychotherapy as one practice among many and believe that all of these practices are constructed. Western psychologists by and large agree with this analysis with one exception: they believe that other culture’s models are constructed but argue that our western one is not given that it is based on science. And certainly, small parts of our mental health model are scientific and based in fundamental reality; for example, clients with low thyroid get depressed and the depression can be ameliorated with thyroid supplements.
But psychotherapy is a different matter. And given this presupposition about science, it is incumbent on western psychologists to refute the Berger/Luckmann social constructionism hypothesis by advancing compelling arguments showing that western psychotherapy is indeed different. Instead, we get instance after instance supporting the constructionist perspective. For example, the dodo bird hypothesis, showing that systems with radically different underlying theories and interventions still get equivalent, positive results is a huge argument for constructionism and the importance of expectancies and beliefs. The fact that something as absurd as eye-movements has a prominent place in the treatment for PTSD certainly suggests that we have little superiority to shamanic interventions with crystals and chanting. And what about Donald Spense and his argument that clients improve equivalently whether they are resolving false memories or accurate memories. Finally, Scott Miller has documented that there have been no evolutionary improvements in the effectiveness of psychotherapy over the past 40 years; the effect sizes from psychotherapy are equal at the beginning and end of that period. I could go on and on with other examples that demonstrate that the kind of evolution we expect to see from a science-based professional discipline simply isn’t happening with psychotherapy.
And, yes, the biggest argument that our mental health model is as constructed as the ones from other cultures comes from the fact that we have been unable to develop techniques with inherent power and our privileged knowledge fails to correlate with outcomes. These are glaring findings. They don’t stand on their own. What they do is endorse the social constructionist theory of psychotherapy. Human suffering is real but our symptoms, explanations, and interventions are constructed.
What this means for SEPI is that the path to psychotherapy integration must begin with the concept that our approach to mental health is as constructed as other cultures. Indeed, it is the possibility that we have the capacity to become self-aware of this constructionist factor that should allow us to improve our extant outcomes and the outcomes of other cultures Every other culture, including ours, is absolutely fixated on validating our own particular constructs; however, we have a good shot at evolving because part of our intellectual world is working hard to develop the ability to deconstruct our assumptions. The way forward is to focus on the power underlying therapeutic explanations and rituals: beliefs, expectancies and the charisma of the therapist.
The most common response I’ve received for these arguments goes something like, “I can’t refute what you’re saying logically but, since I know that it doesn’t feel true, I’m going to ignore your points.” That would be the exact same counter argument one would get trying to convince exorcists that the spirits are constructs. We should be better than this… I believe, however, that our culture of open dialog—and all the work we’ve done on constructionism and Kuhn’s paradigm shifts—puts us in a position where at least a significant minority of us might move in another direction.
I’m going to close with a striking story from hundreds of years ago which illustrates all of the points made in this response. Constructionism didn’t begin in the west in the 20th century but had its origins in the east, particularly with Vedanta and certain Buddhist thought. In the following story, the teacher points out that when the disciple understands that techniques have no inherent power, then they will be on the right path. This story is attributed to Dogen Zenji.
When asked why he practiced zen, the student said, “Because I intend to become a Buddha.”
His teacher picked up a brick and started polishing it. The student asked “What are you doing?” The teacher replied, “I am trying to make a mirror.”
“How can you make a mirror by polishing a brick?”
“How can you become Buddha by doing zazen? If you understand sitting Zen, you will know that Zen is not about sitting or lying down. If you want to learn sitting Buddha, know that sitting Buddha is without any fixed form. Do not use discrimination in the non-abiding dharma. If you practice sitting as Buddha, you must kill Buddha. If you are attached to the sitting form, you are not yet mastering the essential principle.”
The student heard this admonition and felt as if he had tasted sweet nectar.best wishes,
Stephen Bacon, Ph.D.
351 S. Hitchcock Way #B110
Santa Barbara, CA 93105
website: drstephenbacon.com
(805) 563-2820
On Mon, Apr 11, 2022 at 4:28 AM Henriques, Gregg - henriqgx <[log in to unmask]> wrote:
Many thanks for this interesting argument, Stephen.
It warrants significant thought and a careful reply. I unfortunately do not have the time at this point to give it the attention it deserves. Indeed, I need to go back and respond to some commentaries on Dissociative Identity Disorder. Unfortunately, my life has placed a number of demands on me and limited my time.
Briefly, my response is: Yes, the lack of the correlation of expertise and outcomes is an important finding that must be wrestled with. However, I do not draw the same conclusion regarding its meaning. Indeed, the argument from that finding to the argument that entrenched maladaptive patterns is not what psychotherapy treats is too great a stretch. Here is a possible explanation for the findings. It is a fact that the ontology of psychology and psychotherapy is lame. The schools of thought have partial truths. You can enter into the common ground through them. And there are some expert/guru/charismatic figures who find a school and get good results (as you know there are master-class clinicians who do have qualitatively better outcomes). And then people form a school and train. However, because the school only had a partial truth, the followers of the school actually double down on an incomplete picture, such that their expertise is weak tea. And trying to become an expert in a specific school of thought does not help you much.
My point is this. I can’t draw much ontological insight from this finding. I do acknowledge substantial existential anxiety from it. Indeed, part of my decision to give up my license last year can be justified by the finding. But I don’t think it makes much sense to build a theory of human functioning from it.
Best,
Gregg
From: theory of knowledge society discussion <[log in to unmask]> On Behalf Of Stephen Bacon
Sent: Saturday, April 9, 2022 9:37 PM
To: [log in to unmask]
Subject: Common Core of Psychotherapy/Entrenched Maladaptive Patterns
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Hi Greg,
As you know, I’m a big TOK fan and really appreciate all you have been doing to put psychology into a larger context and to address some of the fundamental questions in our field. That said, I do have some disagreements with where you, Goldfried and Smith have been going on the common core of psychotherapy.
To keep this relatively brief, I’d like to focus solely on one of your initial principles: “The core problems of psychotherapy involve entrenched maladaptive patterns.” While this sentence appears fairly self-evident, I believe that it leads us in an unproductive direction.
While I know that you are familiar with my work, let me review it briefly for other readers. I am also concerned with developing the common core of psychology. My work is founded on an extensive literature review designed to ascertain whether psychotherapeutic techniques have inherent power. My basic argument in this area is simple: if psychotherapeutic techniques have inherent power, then experienced therapists should best the inexperienced given that they know more techniques and have practiced them more assiduously. Moreover, trained therapists should best the untrained because they know relatively more techniques.
I have conducted extensive literature reviews (Bacon, 2020, 2022) that document that therapist experience and therapist training do not correlate with improved outcomes. This leads to the conclusion that clients are not changing secondary to the inherent power of our interventions; rather, following Jerome Frank, they are changing because they believe in our explanations and expect that going through our prescribed cures will create healing. In sum, we are using therapeutic rituals not techniques with inherent power.
Even more provocative and alarming, the lack of experience and training effects mean that all of psychotherapy’s privileged knowledge—diagnoses, clients characteristics, psychological systems, research studies, etc.—also fail to contribute to enhanced outcomes. Certainly, psychotherapy works--approximately 55% of our clients get better pretty much no matter what we do (Bacon, 2022)—but when our privileged knowledge is of little use it’s pretty clear we have no real idea why.
Returning to the statement that psychotherapy treats entrenched maladaptive patterns: unfortunately, this concept runs directly into the two research findings about techniques lacking inherent power and privileged knowledge not enhancing outcomes. More specifically, treating maladaptive patterns implies that good psychotherapy replaces those dysfunctional strategies with more effective ones; in other words, you’ve been doing it the wrong way and I’m going to work with you so that you can do it the right way. If psychotherapy works like that, then our techniques must have inherent power. If I’ve been skiing the wrong way and falling down, and you know and teach me a better way to ski, that’s the definition of a technique with inherent power.
If mentally ill clients don’t know the right way to live and we psychotherapists do, then we have a technique with inherent power. That means that therapists who have practiced telling more people how to live right would be better than beginners and trained therapists—who have privileged information about how people should live—would best the untrained. It also implies that therapists should be quite a bit more effective at living well than the average person and simply saying that statement out loud is kind of embarrassing…..
The other argument, that therapists aren’t specially gifted at knowing the right way to live but are gifted at helping clients figure out their own right way to live fails in a similar fashion. If we really know how to do that especially well, then that ability is a technique with inherent power and experienced therapists should do it better than the inexperienced and the trained should best the untrained. In sum, logical as it may seem, we are not in the business of remediating entrenched maladaptive patterns and that is not the beginning point to develop a common core for psychotherapy.
There is an entirely different but highly useful additional perspective on “entrenched maladaptive patterns” that comes from the latest behavioral genetics research. Robert Plomin, in his 2018 book, Blueprint, proposes the radical idea that there are no lasting, sustained positive effects from the nurture side of the nature/nurture spectrum. More specifically, he states that the positive attempts made by healthy families and excellent schools to instill high functioning life strategies in children is ineffective.
Parents obviously matter tremendously in their children's lives. They provide the essential physical and psychological ingredients for children's development. But if genetics provides most of the systematic variance and environmental effects are unsystematic and unstable, this implies that parents don't make much of a difference in their children's outcomes beyond the genes they provide at conception. (p. 82) …. In essence, the most important thing that parents give to their child is their genes. Many parents will find this hard to accept. As a parent, you feel deep down that you can make a difference in how your children develop. You can help children with their reading and arithmetic. You can help a shy child overcome shyness. Also it seems as if you must be able to make a difference because you are bombarded with child - rearing books and the media telling you how to do it right and making you anxious about doing it wrong. (p.83)….. The shocking and profound revelation for parenting from these genetic findings is that parents have little systematic effect on their children's outcomes, beyond the blueprint that their genes provide (p. 85)
To understand how Plomin arrived at this shocking conclusion, it’s useful to examine a simplified example: the effects of environment on weight. Imagine adopted children who are being raised in a household with normal weight parents and very healthy eating strategies. While in the household, these healthy strategies have a positive influence and help the children have normal weight. After becoming adults, however, their weight has a correlation of 0 with the adoptive parents’ weight and a high correlation with the genetic parents’ weight. The healthy strategies learned in their adoptive household did not have a sustained influence once they are out in the world. Similarly, good strategies practiced by families and schools have a positive effect while one is there but the attempts to teach and instill life-long, healthy strategies fail.
Plomin sees human suffering and mental illness as an interaction between genetic vulnerabilities and environmental stress. He does not believe that mental illness comes from entrenched maladaptive strategies; if it did, then the adoptive children in homes with poor eating strategies would have a correlation with their adoptive parents’ weight. Our clients aren’t suffering from bad strategies and they won’t be fixed by teaching good strategies.
That said, one of the major confusing factors in terms of sorting out this area is how well psychotherapy works. Given that approximately 55% of our clients get better no matter what we do, it is tempting to view this client success as an endorsement of the extant explanations and the underlying assumptions. More specifically, the key assumptions receiving endorsement are that mental illness works like medical illness—i.e., diagnosis plus evidence-based intervention equals cure—and that mental illness operates in fundamental reality and follows a rational, rule-based order.
But a moment of reflection reveals that the research results radically challenge these assumptions. If the medical model is a functional representation, and if psychotherapy occurs in fundamental reality where science is the dominant paradigm, then we should have already been successful at developing techniques with inherent power and our privileged knowledge should correlate with enhanced outcomes.
We know psychotherapy works. The secret to developing the core is to figure out “why” the research documents such abysmal training and experience effects. “Entrenched maladaptive patterns” requires us to continue to use the paradigm that has been proven to be unproductive. It would be far better to explore psychotherapy’s core by following the implications of these provocative and unsettling research results regardless of where they might lead.
There is a famous Sherlock Holmes story about the significant clue in a murder is that the “dog didn’t bark in the night” (the lack of barking implied the dog knew the intruder). Similarly, we have an enormous clue that we have been reticent to pursue: how come the hundreds of thousands of books, articles, and research studies fail to enhance outcomes and how could the work of so many gifted and hard-working psychologists amount to so little? Our research doesn’t “bark in the night” and very few psychologists appear to care……
Fortunately, Berger and Luckmann, back in 1967, offer a compelling explanation. They examined mental health models cross-culturally and argued that human suffering is inevitable and, hence, every culture is required to develop a mental health paradigm and a class of healers dedicated to applying the paradigm. In addition, they pointed out that the cultural members will have symptoms congruent with the constructed model and achieve healing via the culturally-sanctioned technology. As most of us are aware, Berger and Luckmann concluded that the suffering was real but the explanations for the suffering and the technology for its relief were constructed.
If, therefore, we compare our mental health model with an “exorcism of malevolent spirits” mental health model, it becomes clear why our psychotherapy techniques lack inherent power. The secret is that for the 55% of clients that generally respond well to psychotherapy, they will get better no matter what model is offered—CBT, psychodynamic, EMDR, or primal scream—as long as they find the model credible. Our clients are just like the exorcists’ clients; they get better no matter what kind of spirit is diagnosed and no matter what kind of ritual is prescribed. The exorcism clients get better but no one would argue that the rituals have inherent power. The techniques have no inherent power; rather their power is derived from beliefs and expectancies.
In the exorcism culture, a great deal of effort is expended on determining exactly what type of spirit is possessing the person and which ritual will specifically eliminate that spirit. We, of course, see those efforts as a waste of energy because we recognize that the real healing factors are rituals, beliefs and expectancies. Thinking that “entrenched maladaptive patterns” is the first step in exploring the core of psychotherapy is equivalent to arguing that the first step is to determine what kind of spirit is present. It implicitly pushes us towards the next step—a continuing search for techniques with inherent power—which can redress the bad strategies. This, of course, will result in further additions to our privileged knowledge—additions which will be just as ineffective as the hundreds of thousands of preexisting concepts.
In your article you discuss the importance of moving beyond common factors: “we were able to lay out the argument that we can move beyond common factors and clarify the common ground of psychotherapy with much greater levels of specificity and utility.” This, of course, is what anyone who is interested in developing the core of psychotherapy must accomplish. While there is no time in this short note to explore the implications of how to move past common factors, there are intriguing clues inherent in our exorcism example. Suppose we were operating in a culture that required exorcisms to cure mental illness but we were in the small group of exorcists that knew that the spirits were a construct. What kind of edge would that give us over the standard exorcists who believe in the spirits? Exploring the implications of that question begins to take us beyond common factors; moreover, it suggests a different direction for developing the core of psychotherapy.
References
Bacon, Stephen. (2020). A Constructionist Extension of the Contextual Model: Ritual, Charisma, and Client Fit. Journal of Psychotherapy Integration, 30(4), 506–521. https://doi.org/10.1037/int0000188
Bacon, Stephen. (2022). Deconstructing the great psychotherapy myth: Therapists and clients are confused about how therapy works [Video]. YouTube. https://www.youtube.com/watch?v=L_54PhNY6vk&list=PLuSjXeuKpouUoV9vN4O9hZw-4oqTX6y29
Berger, P. L., & Luckmann, T. (1967). The social construction of reality. Anchor Books.
Plomin, R. (2018). Blueprint: How DNA Makes Us Who We Are. United Kingdom: Penguin Books Limited.
Stephen Bacon, Ph.D.
351 S. Hitchcock Way #B110
Santa Barbara, CA 93105
website: drstephenbacon.com
(805) 563-2820
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