Philosophers, Engineers, Ecologists and Gnostics: Four Approaches to Psychotherapy
My last essay on 'non-specific factors' in psychotherapy, got me thinking. You'll recall that the non-specific factors in therapy have to do with the quality of the relationship (or rapport) that builds up between therapist and client. Non-specific factors are non-technical because they have a lot to do with the therapist's ability to be genuine and present; something that is not easy to fake or to teach. In a sense, you either have them to offer or you don't. These non-specific factors are definitely an important and fairly basic part of what makes therapy effective. Therapy that consists of nothing more than non-specific factors can be of great help to people faced with relatively minor concerns and life issues. However, there are a great many other people out there who are forced to cope with rather more severe mental and physical conditions and issues. These other people can also be helped by psychotherapy, but the form of psychotherapy that will be effective for such problems will necessarily be more technical in nature. It will include non-specific factors as a base, but it will also offer something more directive.
There are a lot of useful specific technical interventions that a skilled therapist can offer to clients. Such techniques include assistance with reality testing and education, the offering of helpful perspectives and concepts for thinking about problems and issues, practical techniques for managing emotions, thoughts and behavior, and the provision of direct guidance and advice regarding decisions, to name but a few. My plan is to devote some essays to describing a few of these 'specific factors'. However, before I can do that, it seems important that I provide some background information on where the various techniques I'll be discussing in those future essays came from. It turns out that in psychotherapy, most all techniques have a pedigree and originated from a unique vision. Essays on psychotherapy techniques will make more sense if I can present them in the context of their 'school of origin'.
For better and for worse, psychotherapy is not a unified field. A field is unified when all the people working in that field agree on basic principles. Instead of one basic perspective, you have in psychotherapy several competing schools of thought. The situation is made worse because there is more than one profession involved in offering therapy services. There are four major schools of thought that dominate: including psychodynamic, behavioral (and cognitive-behavioral), family systems, and humanistic schools. Each of these schools has a unique perspective on what causes people to have mental problems and how best to fix those problems. As bias in presentation is unavoidable, I will reveal mine up front (I was trained as a cognitive-behaviorist), and will do my best to present the information in a fair way.
Psychodynamic psychotherapy (originally "psychoanalysis") offered the first (and for a time the only) way of thinking about therapy. Invented by the famous Dr. Freud, this school of therapy took a very philosophical approach to helping ill minds. Mental problems were seen as occurring because of conflicts within the ill person's mind; conflicts between various parts of his or her mind that could not be directly measured. You're likely familiar with these concepts, which include the division of the mind into conscious and unconscious areas, and into ego, super-ego and id components. The basic idea was that therapists could help fix patient's illnesses by uncovering hidden conflicts that caused those illnesses to occur (inferring their existence based on patients' thoughts and actions) and then interpreting those conflicts to patients so that they could become conscious of those conflicts. Conflicts were originally supposed to dissolve upon contact with consciousness, although as we know today, this is not typically the case. Sometimes it worked, but often times, it did not. Since there was nothing better to offer patients of the day, and since all new techniques and medications tend to be assumed to work miracles before their flaws become apparent, the psychodynamic school of therapy grew to become hugely influential during the first part of the 20th century.
Early psychodynamic therapists were really quite a bit like modern day philosophers. They were great at building complex intellectual models of their patient's problems, but they fell down when it came to testing whether those models could really be used to help patients overcome their symptoms. They just didn't worry too much about measuring whether their techniques and models were effective. They also did not put much stock in the transformative power of non-specific factors like relationship quality. Early practitioners put their patients on a couch and avoided eye contact so as not to interfere (as they saw it) with their patient's inner process. These problems with the psychodynamic approach were duly noted by critics, and served as the starting point for the other schools of psychotherapy we'll cover next.
The behaviorist school is roughly as old as the psychodynamic school (around a century each now, give or take a few years). Behaviorism started out life as a form of research psychology. For the early part of the 20th century, the behaviorists were merely scientists, working in universities on psychological research problems. They did not really do significant therapy work until the 30s and 40s, well after the psychodynamic therapists had cornered the market. Given their scientific backgrounds, those behaviorists that became therapists were deeply distrustful of mentalistic psychodynamic notions like "ego" and "id". It's not that they couldn't relate to these notions on a practical "lived" level. Rather, they objected to the fact that there was no good way to measure these things. Behaviorists are like engineers. They don't trust things they cannot measure. If a psychodynamic practitioner might state that a patient's anxiety and paranoia was caused by an overactive "id" trying to break into consciousness, a behaviorist would instead dispense with the whole idea of consciousness entirely. Again, it is not that behaviorists weren't aware of being conscious; it was just that they couldn't measure consciousness, and so decided to not use it as an explainitory concept. Behaviorists did find things they could measure, however, and measure away they did. For example, patients' anxiety could be measured in terms of the behaviors it produced. To measure anxiety, then, you could count the number of paces patients made while in the waiting room, or compute the increase in patients' heart rate while talking about stressful topics. By making such measurements both before and after providing a treatment, behaviorists could determine with mathematical accuracy exactly how effective their treatment had been.
The early behaviorists drew heavily from scientific research concerning animal learning. You've heard of Pavlov's dogs, right? Dr. Pavlov taught dogs to salivate as though food was present whenever he rang a bell. It isn't natural for dogs to salivate to the sound of a bell. In order to make this happen, it is necessary to train dogs to associate the sound of the bell with the onset of food by pairing bell and food many times in a row. When this conditioning process is complete, dogs will salivate when they hear the bell, even if you don't present the food because they have learned that the bell sound means food will shortly be available. Even more interestingly, their salivation response to the bell will continue for some time after you stop providing food.
To the behaviorist mind, people's anxiety problems had nothing whatsoever to do with ego-super-ego conflicts, and everything to do with dysfunction learning. If anxiety could be learned, they reasoned, it could also be unlearned. The behaviorists took what they knew about how animals learned and unlearned particular associations and applied this knowledge to human beings with good effect. For example, they figured out how to decrease patient's phobias (fears of specific things, like blood, dogs, spiders, public speaking, etc.) by teaching them how to relax. Specifically, they paired a calming relaxation technique with successive approximations of specifically feared things (like blood, dogs, spiders, etc.). After being taught a method for relaxing, a person with dog phobia might relax while looking at a photograph of a dog. Once able to maintain a feeling of relaxation in the presence of the photograph, the fear factor would be ratcheted up a notch, so that they would now practice relaxation in the presence of an actual dog, but one safely in a kennel on the other side of the room. In stepwise fashion, this pairing process could be repeated until the dog phobic person became comfortable actually interacting with dogs. This particular technique, often called systematic desensitization, is still in use today.
While the early behaviorists were definitely more grounded in reality then the early psychodynamic therapists, the therapy school they developed had its share of flaws as well. Like psychodynamic therapy before it, behavioral therapy was heavily technical in nature. Both groups thought that their special techniques were pretty much solely responsible for effecting their 'cures', and neither group was winning awards for good bedside manner. Another problem was becoming clear as well by the time the 1960s rolled around. Both behaviorism and psychodynamic psychotherapy treated patients as isolated individuals; as though they weren't affected by family members, co-workers and cultural factors. It was becoming increasingly clear that this was an incomplete way to look at illness.
The family systems approach to psychotherapy grew out of an awakening within academic circles to the reality of ecology (or "cybernetics" as it was first popularly formulated). To be aware of ecology means to understand that things do not exist in isolation, but rather are parts of a larger system. Each thing within the system affects the other things within that system. If there is a problem within one part of that system, that problem reflects a problem faced by the entire system. A ready example can be drawn from biology where you have systems like that between bees and flowers. Bees need flowers for raw materials for honey (I think), while flowers need bees to carry pollen from one flower to another so as to enable reproduction. A problem with the bees affects the flowers, and vice versa. You can point to each part of the system as separate, but it is an illusion to think that one can live without the other.
The family systems therapists are thus the ecologists of psychotherapy. Family systems therapists saw individual patients' problems as being visible symptoms of larger "systems" problems within the family. It is not enough to treat a depressed woman, they might have reasoned, if the reason she is depressed is because her marriage is crappy. In such a case, the woman's depression would be a symptom of a larger marital problem that would need to be addressed before her depression would go away. As a result, the entire system (in this case, both marriage partners) should come for therapy and be treated as a whole. Earlier schools had written about the contribution of the family environment to the development of patient's problems, but they never tried to do anything about that contribution in any organized sense. The family systems approach was thus entirely new and a major upgrade for how therapy could be understood. Unsurprisingly, the family systems therapy school was championed by the social work field, a group of folks already attuned to the impact of society on the individual. Today the school continues to be a dominant force shaping how therapy for marriages, couples and families is performed.
The humanists went in a different direction still, reacting to the over-emphasis on technique found in the other schools. Call them the Gnostics of psychotherapy, a term I'll borrow from religious studies. As I understand it, various religious movements can be placed onto a continuum or dimension describing their approach to worship. On the orthodox side of this dimension, you find movements who emphasize a highly ritualized, formal and rigorous approach to worship. Correct practice of ritual and adherence to religious law and dogma is seen by such groups as essential to pleasing God. On the other "gnostic" side of the dimension are movements who consider rituals to be mere formal, and mostly useless. Such groups often consider their direct relationship with God to be more important than adherence to particular laws, dogmas or rituals.
Most forms of psychotherapy that existed before the humanists came on the scene could best be described as orthodox, in the sense that they were more focused on correct technique and conceptualization than on the quality of their relationship with patients. It's not that such therapists ignored patient relationships, but rather that they did not consider their relationships to their patients to be an active ingredient necessary for creating positive therapeutic change. The humanists took a more gnostic position than any previous therapists. They came to believe that, while good psychotherapy technique and conceptualization was important for creating therapeutic change, it was not the most important thing driving change. The most important thing for creating positive therapeutic change, according to humanist psychotherapists, was the quality of the relationship between therapist and client. A good therapy relationship would transform clients for the better even if lacking in technique, while a bad one might actually harm them.
The humanistic approach to therapy probably peaked in the 1970s. It certainly has had less intellectual weight behind it as the country has become more conservative in orientation. However, in no way should this approach be written off. For better and for worse, there are still vast numbers of humanistically oriented therapists out there (many of whom call themselves "counselors"). Also, the other three more technically oriented psychotherapy schools have largely come to recognize the importance of the humanistic focus on rapport, and have incorporated this emphasis into their own approaches. Pretty much these days rapport is considered to be the foundation upon which the various psychotherapy techniques stand. It is regarded as a necessary part of effective therapy, but one that is probably not sufficient all by itself for helping people to effectively cope with more difficult problems and issues.
The more things change ...
I've only scratched the surface of the character of these different approaches to psychotherapy. Many changes have occurred over the years as each school has adapted to the times, sometimes so much so that they bear little resemblance to what I have described. For one thing, most all forms of therapy have become dramatically shorter in length. Where they might have originally have been ongoing affairs that lasted several years, they are now generally time limited programs of several weeks to several months duration. For another, most all schools have learned the humanistic lesson, and now pay a lot of attention to the quality of the therapy relationship.
Psychodyanmic psychotherapy has changed a whole lot. It has become vastly more conscious of the important role of the therapist client relationship. The couch is gone and patients now may have eye contact with their therapists if they want. The older emphasis on unconscious conflicts and primitive "id" motivations is largely gone now, replaced with a focus on understanding how patients' problems can be understood in the context of their social and emotional histories, for example as repeated attempts to master or overcome actual dysfunctional relationship patterns (sometimes called 'object relations') experienced in childhood or earlier life. Therapists are far more willing to share their thoughts and to provide guidance than they used to be (they have to be more active because they have less time in which to work). While the therapy is still not as science-based as behavioral approaches, it is catching up rapidly. For example, an important psychodynamic therapy for depression, known as "interpersonal therapy" has been studied enough for us to know definitively that it is an effective treatment for depression.
Behavioral therapy has morphed into cognitive-behavioral therapy as therapists have become more willing and skillful in measuring things they cannot see (like thoughts). Behaviorists have now become comfortable in discussing mental events such as thoughts and feelings, and have continued to expand their basic animal learning models in increasingly sophisticated ways so as to address specific mental problems such as depression, panic disorder and complex mood disorders such as borderline personality disorder. Even largely biological illnesses such bipolar affective disorder and schizophrenia which must be primarily treated with medicine have been shown to show benefits from secondary treatment with cognitive behavioral therapy approaches tailored to their specific needs. More on that (and on all techniques) in another essay.
Despite these very real changes and adaptations the psychotherapy schools have made, I think it is safe to say that their basic characters have not changed too much. The psychodynamic therapists are still more or less philosophers, the behaviorists still engineers, the family systems folks still ecologists, and the humanists still gnostic in approach. Having described the basic personalities of each school in this essay, I'll spend the next few essays going over some of the major techniques associated with each school and try to make clear how each schools' techniques fit in with their overall approach. Understanding the differences between the schools of psychotherapy is important because knowing the distinctions between the different schools can help you to know what sort of psychotherapist or therapy approach to look for the next time you are looking for a therapist. You're likely to find that your own way of thinking is more closely allied with the basic approach of one of the schools than with the others. If you don't buy into the assumptions that a particular therapist is making when he or she offers you techniques, you are less likely to benefit from them.
Having reached the end of today's essay, I'll leave you with a few questions to think on. Which of the psychotherapy schools makes the most sense to you? Which fits your own personality and way of thinking best? What sort of therapist would you want to hire if given the choice? A philosopher, an engineer, an ecologist, or a gnostic?