Consultation to Inform and Refine Therapists’ Awareness, Perceptions and Skills

I’ve just completed presentations on consultation for therapists at the annual conferences of three professional associations:  The National Association of Social Workers- Illinois Chapter, the Illinois Psychological Association, and the Illinois Counseling Association.  Each presentation was organized around a lecture/slide show about consultation, and included a live demonstration in which I provided consultation to a volunteer therapist consultee.  Each presentation also had its own emphasis:  more information about consultation, and psychodynamic and cognitive-behavioral concepts, for the NASW-IL; less focus on consultation in general, in order to allow for an additional focus on trauma-informed consultation, for IPA; and less focus on consultation in general, in order to allow time for participants to practice peer consultation with one another, at ICA.  Each of the programs went well, based on participant engagement, comments, and the feedback I’ve received.  In this post, I’ll cover some of the consultation presentation, with the caveat that the live demonstration is what makes it really, well, come alive.

There is an infinite amount of learning about how to do therapy that mental health professionals can explore and accomplish after achieving licensure.  Consultation is a key way for working therapists to inform and refine our therapeutic awareness, perceptions and skills.

Consultation is not supervision, which has specific legal meaning in licensure law for each profession.  In supervision, the supervisor, or program for which the supervisor works, is clinically and legally responsible for the supervisee’s work.  The supervisor is a professional gatekeeper who is responsible for evaluating the supervisee’s qualification to enter the field.  Supervisees cannot select their supervisors at will, and may have to work with supervisors whose therapeutic styles, methodological preferences, and theoretical commitments are not a good match for their own talents, skills or interests.  Nor can supervisors select supervisees; they may have to work with supervisees in whom they have little confidence, or about whose talents and abilities they may have doubts, due to program commitments.  And supervisees have to work under supervision for a legally designated number of hours in order to be eligible for licensure.

Consultation, on the other hand, is a relationship between independently licensed professionals, which aims at informing and refining the consultee’s therapeutic awareness, perceptions and skills.  It confers no formal certification and is entirely at will.  Consultees can select any consultant they’d like to work with who will work with them (and with online consultation, their consultant can be anywhere in the world).  Frequency of meeting is up to the consultant-consultee pair; weekly, every other week, every third or four week, etc.  There is no required amount of time for consultation; it continues until either or both parties decide to stop.  Basically, we select people to consult with from whom we can learn.

There are different types of consultation.  Mentoring consultation is a teacher-and-learner relationship, in which the consultee works with a consultant from whom the consultee has something to learn.  In peer consultation, colleagues consult on an equal basis for mutual benefit.  Either mentoring consultation or peer consultation can take place on a 1:1 or group basis, and either form of consultation can be time-limited or ongoing.

In addition to types of consultation, there are styles of consultation.  The length of time the consultee prepares to present a case can vary from none (a completely spontaneous presentation) to some (some forethought, review of therapy notes, making some notes to present from), to extensive (preparation involving hours of writing and pages of text).  The length of time after the consultee begins presenting the case, before the consultant (or, in a group, consultants) begin to engage by asking questions or making comments, can vary from a few minutes to half an hour or more.  Some consultation is strictly within a particular theoretical model, while other consultation uses any model of mind, and of how therapy works, that helps to make sense of the cases and experiences which consultee and consultant are discussing.  The amount of coherence expected in the consultee’s presentation of the case can also vary.  My preference is not to expect too much coherence, because that risks the consultee and consultant trying to make the therapy fit a particular theoretical model.  I prefer to allow coherence to emerge in the discussion of the experience of the therapist, the experience of the client, and the experience of the therapist-client pair.

What do consultants and consultees talk about?  We talk about the client’s situation, history and experience, past and present, outside the therapy office.  We also talk about the client’s experience, feelings and behavior in the therapy office, and the therapist’s experience of being with, and working with, the client.  We talk about how the therapist understands the client, and her therapeutic relationship with the client, and about areas where the therapist feels confused or stuck; and ways the consultant might see the therapy that the consultee is describing.

We also talk about the “frame” of the therapeutic relationship, which means the therapeutic, economic and professional roles and responsibilities of the client and therapist to themselves and each other in their work together.  This includes such areas as late arrival, extending sessions, missed payments, missed sessions, control of the focus of the conversation, etc.   We talk about the therapeutic agreement or contract, meaning the goal(s) or purpose(s) of therapy, and whether they are clear, achievable, and agreed by client and therapist.  A lot of therapy takes place in a kind of preliminary phase, where the goals and purposes of therapy are, at best, implicit and emerging.  Clarifying goals itself can be a therapeutic process.

From psychoanalytic culture comes the idea that there are two levels of therapy.  The first is where the client receives the attention, respect, caring, concern, presence and empathic support of the therapist.  These are all necessary ingredients of the therapeutic relationship, and that can often be as far as the therapy goes.  The second is where the therapy is providing that support and also making it possible for the client to work on her- or himself.  This means that the client is looking at his own issues outside the room, in life outside of therapy, as well as inside the room, in the therapeutic relationship.  Some analysts call these two levels the supportive relationship and the analytic relationship.  I’ve referred to them as the supportive relationship and the working relationship, in order to make headroom for work, with and on the self, that may include, and also extend beyond, the traditional mental models of psychoanalysis.  Consultation can help therapists establish the first level, and then co-create bridges, with their clients, to the second.

Since consultation is so valuable, why isn’t it more widely known, recommended and practiced?  Part of the explanation lies in the fragmentation of the world of psychotherapy, in which people in different therapeutic cultures keep pretty much in their own silos. Psychoanalytic culture does feature what it still calls supervision, even after licensure and certification.  But that culture tends to be wrapped up within itself, and affords few points of entry for mainstream therapists who don’t wish to steep themselves in its theories, terminology, or fealty to Freud or other iconic figures.  Jonathan Shedler, a leading psychodynamic researcher and practitioner, commented that he had learned, from teaching therapy to beginners, that if he couldn’t explain what he meant to them in ways they could understand in the context of the therapy they were doing, that meant he didn’t understand it well enough.  “If you’re only talking to other people steeped in the same history and traditions, you operate on the assumption that you both understand what you are talking about.  I thought I understood (basic psychodynamic concepts) until I had to explain them to someone who wasn’t steeped in that tradition, and I floundered with it” (personal communication).  He emphasized that it’s up to consultants to “bridge the gap” between what they know and what their consultees need to learn.

Cognitive-behavioral therapy, on the other hand, has tended to be narrowly focused on specific conditions and treatments, allowing little space for the complexity of human experience involved in the exploration of relationships, identity and meaning.  Nor has it tended to recognize the potential wellspring of learning that can be harvested from the complexity of the client-therapist relationship itself.  That is beginning to change with the development of hybrid treatments like Dialectical Behavioral Therapy and Acceptance and Commitment Therapy, but a narrow focus on problems and goals tends to be characteristic, as does the role of the therapist as director rather than collaborative guide in the work.  What’s needed is a general practice of consultation beyond therapeutic silos, by consultants who can add value to consultees without requiring them to spend years acquiring a new culture–most of which will be irrelevant to them–or to trim and package their work with clients to fit within a silo’s theoretical framework.

Therapy cultivates reflection:  the client’s reflection on himself, the therapist’s reflection on the client, and both client’s and therapist’s reflection on their therapeutic relationship.  Consultation adds another dimension of reflection, in which the consultant helps the therapist reflect on herself. her client, and their work together.  The therapist “polishes the mirror” for the client, and the consultant “polishes the mirror” for the therapist.

 

At the 2016 Spring Psychoanalytic Psychology Conference, Part 1

I attended the annual spring conference of Division 39 (Psychoanalytic Psychology) of the American Psychological Association.  The conference, entitled “Hot and Bothered,” included presentations on sexual and erotic issues, although there were a wide range of other presentations.  There were a lot of programs and I could only attend some, so here are notes from “my” conference.

Relational Dream Work:  The Bridge Between I and Thou

Kendle Hassinger, LPC

This preconference workshop was one of the most enjoyable and personally useful programs in “my” confefence.  Hassinger’s approach to dreamwork was as a relational process in therapy.  That is, it’s not a matter of the therapist being some sort of dream expert and pronouncing interpretations, but a process of therapist and client moving together into a deeper understanding of the client’s dream.  Hassinger sees the relational process itself as mutative, regardless of theoretical orientation.  (“Mutative,” in psychoanalytic context, means it facilitates a beneficial change the state or self-organization of the client or analysand.)  She sees the therapeutic relationship as involving two I-Thou relationships: one between the analyst and analysand, and the other between, as it were, the client and herself; between the client’s conscious self and her inner process, objects, and private experience.  By definition, the process of striving toward health in these I-Thou relationships is never complete, and the therapist’s job is to facilitate them.

Hassinger asked what we thought dreams were for, and I commented about the relationship between dreams and learning in mammals.  This sparked a discussion among the participants, during which a Mexican graduate student said that mammals dream “because they have mothers.”  I’m still reflecting on that!

Hassinger encouraged us to participate in discussion, and we talked about research into dreams (REM sleep increases during periods of intense learning) and different analytic perspectives.  Freud saw dreams as concealing meanings whereas Jung saw dreams as revealing the unconscious rather than disguising it.  Her perspective integrated a number of analytic and non-analytic elements, but was more Jungian than Freudian overall.  This was one of several presentations that had an inclusive attitude toward methods and concepts in different approaches to psychoanalysis, contrary to the history of divisive conflict between schools that characterizes so much of psychoanalytic culture, both then and now.

For example, Hassinger mentioned Jung’s comment that “The ego is a complex among other complexes,” and described therapeutic exploration as finding and exploring “feeling-toned complexes” (another Jungian term), which is a different way of looking at the inner life than the more dichotomous “I-it” (ego-id) of Freud; yet her discussion integrated both and flowed easily from one to the other as it suited the context.

Jung saw exploring the “feeling-tone” as the way into exploring the dream, and focused on the details of the dream image.  For example, if a barn, in a dream, is full of healthy animals and fodder, or neglected and dirty, it will have a different set of meanings associated with it.

We paired off to do brief explorations of one another’s dreams, and I was paired with a graduate student from Mexico.  Interestingly, both of our dreams involved animals—hers were birds, and mine a dog—and both yielded deeper meanings upon exploration.

An Evening With Nancy McWilliams

Nancy McWilliams is a distinguished and prominent teacher, leader and writer in psychoanalysis.  This pre-conference gathering was mainly an appreciation of her, and a Q. and A. session.  Some selections from my notes:

Q:  “You don’t belong to any camp, though you speak to every camp.”  NM:  “I used to walk the halls to find someone to have lunch with.  I’m an integrator temperamentally.  I approach anyone from (the perspective of, “What can I learn from this guy,” not “I’m better than this guy.”  Different patients make different therapists look good, and and different theories evolve to (explain different kinds of patients).”

Responding to a question about the difference between psychoanalytic diagnosis (which she’d written a book on) and the usual DSM-type psychiatric diagnosis:  “Psychoanalytic diagnosis is basically about individual differences,” which, she added, helps explain why it is so popular in Eastern Europe and other more collectivist cultures.  She recalled a question she’d received when teaching in China:  “What do we do about our depressed grannies?”

I had submitted a question (questions were submitted in writing) on the similarities and differences between the terms “psychoanalytic” and “psychodynamic.”  She replied:  “That difference has never been salient to me.  I think it’s a very artificial difference made up by psychologists who are not familiar with psychoanalytic ideas, who tend to define psychoanalysis as a technique, passé, on the couch, three days a week, etc.  If you define it as a treatment, then you have to have another word for all the rest of psychoanalytic knowledge that applies to everything else we do that’s not on the couch.  I’m an integrator, what Darwin would call a lumper rather than a splitter.  I prefer Freud’s definition, he had a lot of definitions, but I prefer the definition as any activity in which you are attending to transference and resistance.  It’s psychoanalytic to work with psychotic people, borderline people, and so forth.  I see what the distinction is but I think it’s created more heat than light to try to make that distinction.”  (I appreciate Dr. McWilliams’ inclusive perspective, which was characteristic of the attitude toward psychoanalysis in this conference, but I respectfully disagree.  The conflicts about what is really psychoanalytic and what isn’t goes all the way back to Freud and Jung, is a distinguishing feature of the history of psychoanalytic culture, and has been particularly virulent in the USA.  As Dr. McWilliams said, Freud had a lot of definitions, but she didn’t mention his requirement that his associates agree with whatever his definition of the moment was.  I prefer the term “psychodynamic,” because it includes all the perspectives from within the various schools of psychoanalysis, bypassing their conflicts and turf wars, and also has room for perspectives of neuroscientifically and spiritually informed views of mind from outside of psychoanalysis per se.  Still, I appreciated her personal warmth and professional inclusiveness within the culture of psychoanalysis.)

In response to a question about eating disorders, Dr. McWilliams said that she thinks extreme eating disorders should be considered psychotic, “when someone weighs 80 pounds and believes she’s fat and is starving herself to death.  We’ve been criminal in our treatment of psychotic and other persons, we just medicate them, as if they don’t have souls, as if they don’t have lives.”

Asked about the difference between psychoanalysis and cognitive-behavioral therapy, Dr. McWilliams said, “The important differentiation isn’t between psychoanalysis and CBT, they run into the same issues we do, they develop their own language to describe it.  The biggest abyss we have is between clinicians and researchers who have increasingly become alienated from what clinical work is really like.  It’s not their fault, it’s conditions in academia (where) it’s so hard to get grants (that) it would be professional suicide to have a small practice on the side.  (So) researchers have no idea what it’s like to be a clinician, they think it’s like what they do in the lab.  I think we should be allying with cognitive-behavioral, humanistic, family therapists, anyone who is in the trenches.”  (This is the direction that we have been moving in with CAPP, the Chicago Association for Psychoanalytic Psychology.)

Q:  “How do you understand resilience, beyond ego strength?  Do you have a dynamic formulation around resilience?”  NM:  “No, but I’ll hazard a guess.  It all has to do with whether you have somebody who can bear your pain.  If you have somebody who can be there with you, you can go through pretty bad pain, you go through a mourning process, mourning is the process by which we adapt to the painful aspects of life.  If you have the same traumatic experience and you have nobody who can go with you through it and bear your pain and bear witness to what you’re going through, I think you’re much more likely to be dissociated, because it is unbearable to go through crisis without someone who can bear witness.  That’s a time-honored goal of psychoanalytic therapy.”  (Note:  I see dissociation as a normal aspect of brain function and self-formation, and find support for this view in the “neural networks” model of neuroscience and the “multiple selves” model of spiritual psychology.  Psychoanalysis has described traumatic dissociation, and specialized in treating it.)

Q:  “You’ve talked about a number of different camps.  There’s an ideological process of all this, perhaps a tribal component, who’s on the inside, who’s on the outside.  In the history of psychoanalysis, and in many respects of CBT, the ideological component has been so important, to define themselves against (other schools), how do we begin to look at these tribes that we form and bridge those divides?”  NM:  “In this field, where ideas matter so much, I don’t think it’s been so bad, as long as we can come together in the fight against torture, against accreditation that’s depersonalizing” (here she’s referring to issues within the American Psychological Association).  “The danger in psychoanalysis is that we get so distracted by these internal differences between us that we’re fighting over deck chairs on the Titanic.”

President of CAPP

In September, I became President of the Chicago Association for Psychoanalytic Psychology.  It’s been a very busy time, creating programs for therapists and helping CAPP take care of its business.  Here’s the President’s Message, from the CAPP website, www.cappchicago.org/:

President’s Message, Winter 2015

President’s Message, January, 2015: Jay Einhorn, Ph.D., LCPC

Welcome to CAPP, and thanks for being here!

Jay_Office

Historically, CAPP was in the vanguard of the movement to open the doors of psychoanalytic training to non-physicians. Today, we seek to bring together therapists for mutual learning through the study of therapeutic experience in the light of psychoanalytic/psychodynamic concepts and methods. Since we see all forms of therapy as having psychodynamic activity, we think that therapists of various training and back-ground help refine one another’s understanding and perceptions and learn together.
Our programs include:

•CAPP Conversations: monthly (more or less) informal meetings on topics of therapeutic meaning, providing opportunities for therapists to consider and discuss important issues. CAPP Conversations do not grant CEs. At the time of writing, we’ve done programs on: “Fundamentals of Psychodynamic Psychotherapy: What Are They?!”, “Psychodynamic and Cognitive Psychotherapy: Overlapping Dimensions or Separate Universes?”, and “Adoption: Development and Psychodynamic Issues,” and we are planning programs on “Gossip: We Love It, We Suffer From It, Do We Need It?” and “Relational Cultural Therapy in Psychodynamic Perspective.” And we plan to do more!

•Building Bridges: Psychodynamics Across Psychotherapies: more formal programs that grant CEs; often upward extensions of topics first presented as CAPP Conversations.

•Peer Study Groups: Ongoing and time-limited groups in which therapists re-fine their perceptions by considering analytic-dynamic therapy together. Current groups include a Chicago analytic readings/cases group, a Hinsdale cases group, an Evanston cases group, and an Evanston psychodynamic-neuroscientific readings/cases group. Time-limited peer study groups have included “Religion, Spirituality, and Mental Health,” and “Multicultural Therapy.” We plan to do more.

•Partnering with Co-Sponsors: We are interested in exploring partnerships with co-presenting groups and organizations.

•Presentations for Consumers: We are interested in talking about the value of therapy to groups of potential consumers. We can say that “Therapy Works” because ALL therapy contains psychodynamic processes, whether it is called psychoanalytic/dynamic or not.

CAPP creates opportunities for working therapists throughout their careers to share and learn about analytic-dynamic therapy through discussing the actual experience of it. It is neither an academic nor a training program, but a complement to both.

I have been CAPP’s Chair of Peer Study Groups for a decade, and in the peer study groups we see the value of therapists of various backgrounds meeting to discuss cases, with an open mind to analytic-dynamic formulations that increase our under-standing of the experience of the patient or client, the therapist, and the patient-therapist pair. Therapists with various kinds and levels of training can help one another in this process.

A word about psychoanalysis and psychodynamics. The term “psychodynamic” is used in different ways; sometimes as an equivalent to “psychoanalytic” (when the speaker or writer means “psychoanalytic” but fears that the reader or listener might have an attitude about it); sometimes to include all schools of analysis (Freudian, Jungian, Adlerian, Self, Relational, etc.) in contexts where “psychoanalysis” might be seen as referring exclusively to Freudian-classical psychoanalysis; and sometimes to refer inclusively to all the microcultural schools within the macroculture of psychoanalysis, plus other dynamic formulations of mental life and therapeutic activity. It is in this latter sense that I am using the term. One of the great discoveries of psychoanalysis is that there can be splits within the self, in which different parts of the self interact dynamically. Emerging neuroscience both supports long-term reflective empathic therapy, and gives us the model of a modular and dynamically networking brain.

It might even be that the splits within the self reflect the splits within the cultures within which we grow up and live. In a time of accelerating social and economic change, analytic/dynamic therapy provides one of the few resources with which we can reflect on, recollect, and reorganize ourselves, the better to reclaim ourselves and live a more meaningful life. I happen to believe that it is not accidental or coincidental that analytic/dynamic therapy developed in Europe just prior to World War I, when the empires that defined the geopolitical world were about to collide and disintegrate. Sabina Spielrein, an overlooked mother of psychoanalysis, presented on “Destruction As a Cause of Coming-Into-Being.” I’d say there’s still a lot to think about in that.

CAPP is a therapeutic home for some members, and a good place to visit for others. You don’t have to be a member to attend our programs, so come and taste, listen, experience. I invite you to consider joining if you like what you see, hear and feel! There is a lot to learn. Let us learn together!

Advocating Psychotherapy–Sort Of–In the New York Times

(This column is Dr. Einhorn’s article in the current Cappstone, the newsletter of the Chicago Association for Psychoanalytic Psychology. Dr. Einhorn is Chair of the Advocating Psychotherapy project at CAPP. To arrange for a presentation about psychotherapy, contact Dr. Einhorn through the website contact link.)

In this time of the prevalence of a one-dimensional medical model of mental suffering and treatment, and the increasing marginalization of psychotherapy as health care reorganizes under intense economic pressures, a colleague has advanced, and perhaps also hindered, the cause of advocating psychotherapy, in a recent column in the New York Times (9-29-13). Op-Ed contributor Brandan A. Gaudano, clinical psychologist at Brown University, writing on “Psychotherapy’s Image Problem,” begins by pointing out that “In the United States, from 1998 to 2007, the number of patients in outpatient mental health facilities receiving psychotherapy alone fell by 34 percent, while the number receiving medication alone increased by 23 percent,” despite the fact that “a recent analysis of 33 studies found that patients expressed a three-times-greater preference for psychotherapy over medications.” “As well they should,” he continues, “…Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn’t work well or if the patient isn’t willing to try counseling.” (entire article at: http://www.nytimes.com/2013/09/30/opinion/psychotherapys-image-problem.html?emc=eta1&_r=1&/)

Dr. Gaudano attributes “the gap between what people might prefer and benefit from, and what they get,” to the fact that “psychotherapy has an image problem.” And what is that problem? “Primary care physicians, insurers, policy makers, the public and even many therapists are unaware of the high level of research support that psychotherapy has. The situation is exacerbated by an assumption of greater scientific rigor in the biologically based practices of the pharmaceutical industries–industries that, not incidentally, also have the money to aggressively market and lobby for those practices.”

So far so good. We heartily agree with Dr. Gaudano’s comments, which are entirely in harmony with the perspective of CAPP’s Advocating Psychotherapy project. But when it comes to identifying what constitutes effectiveness in psychotherapy, Dr. Gaudano is beating the drum of randomized controlled trials. “For patients with the most common conditions, like depression and anxiety, empirically supported psycho- therapies–that is, those shown to be safe and effective in randomized controlled trials–are indeed the best treatments of first choice.” Referring to a recent survey that he completed with his colleague Ivan W. Miller, for the November edition of Clinical Psychology Review, Dr. Gaudano states that “It is clear that a variety of therapies have strong evidentiary support, including cognitive-behavioral, mindfulness, interpersonal, family and even brief psychodynamic therapies (e.g., 20 sessions).”

“Psychotherapy’s problems come as much from within as from without,” Dr. Gaudano states. “Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which–like some old-fashioned Freudian therapies–should be abandoned.”

Here, I am afraid that some of Dr. Gaudano’s comments tend to muddy the waters about what psychotherapy is and how it can be of value, at the same time that he’s trying to clear them up. For example:

•The use of randomized controlled trials (RCT) as the “gold standard” of outcome study is misleading. RCT requires the standardization of patients into relatively pure diagnostic groups (depression, anxiety, etc., with careful pre-screening to have as close as possible to “pure” diagnostic groups) and therapies into methods defined by techniques (cognitive-behavioral, interpersonal, etc.), overlooking the individuality of patients, therapists, and patient-therapist pairs. Such clarity, simplicity and replicability are not found in the real world, in which patients are usually quite complex, therapists have to adapt whatever methods they are using accordingly, and the interaction between patient complexity and therapist adaptability often has more to do with outcome than diagnosis or treatment method per se.

•The largest contributor to outcome in therapy is quality of relationship between client and therapist (as Jonathan Shedler described in his overview of studies, “The Efficacy of Psychodynamic Psychotherapy,” in American Psychologist (Feb-Mar. 2010). This is not to dismiss the importance of methods and techniques, or the value of a well-stocked toolbag for therapists with more than a narrow specialization. But the methods and techniques are applied within a relational context, which has as much to do with their efficacy as technical skill per se.

•The practice of treating psychodynamic, cognitive, interpersonal, etc., interventions as if they are separate is misleading. I’ve never seen any successful therapy in which unconscious factors in the patient weren’t elicited and transformed, in which the patient didn’t learn to think and perceive differently, and in which the interpersonal life of the patient wasn’t in some ways altered for the better through interaction with the therapist.

•A key mistake, often repeated in the history of modern psychology, has been to reduce our understanding of human behavior and experience to the currently available scientifically accepted methods. “Science” does not mean “whatever we can study with RCT.”

•While it’s good to see psychodynamic therapy included in the winner’s circle of empirically proven methods, the emphasis on short-term therapy overlooks the need of many patients for longer-term work. Symptoms may be resistant to treatment, and can change into a focus on underlying existential issues as therapy proceeds; all of which can take a lot longer than 20 weeks.

•Dr. Gaudano’s assertion that empirically supported therapies are superior to medication still takes place within the medical model, in which mental and emotional disorders are disconnected from the facts and experiences of people’s lives. “Safe and effective” are statistical abstractions within this model. In practice, what is safe and effective for one person may not be for another; thus the lengthy caveats about problems with safety and/or effectiveness in medication advertisements.

As to “psychotherapy’s image problems,” psychoanalytic authorities and institutions have certainly contributed to them, but so have proponents of “empirically validated” treatments. In fact, just about every form of treatment in the field of psychotherapy has been heavily influenced by gifted authoritarian empire-builders and their followers, resulting in a mine field of claims and counterclaims, in which conviction based on reductionist thinking at the expense of wider truth, together with contemptuous dismissal of alternative paradigms, is the currency of the realm. There is no “one size fits all” therapy, or therapist, or method of determining efficacy.

This mine field is the main “image problem” of psychotherapy. The basic method of therapy, in which two people meet to discuss, and try to understand and resolve or improve on, the mental, emotional, and relational problems of one of them, during which they form a particular kind of working relationship which evolves if the work goes well enough–and each of those relationships is unique–continues to be more powerful than the ability of any theoretical model to explain.

Neuroscientific advances will contribute to our understanding of what’s happening in psychotherapy. Neuropsychologist Elkhonon Goldberg, in his The New Executive Brain, states that “even relatively brief but sustained cognitive activity is capable of affecting brain morphology and is detectable in neuroanatomically specific ways” (p. 239). Goldberg is talking about kinds of learning such as new languages or music, but the application to therapy is clear. All this work between patient and therapist, when effective, cultivates salutary brain changes in the patient; and perhaps also, to a lesser extent, in the therapist. Research in this area is already proceeding, although the methods and conceptual frameworks remain relatively crude. Such research, when it reaches maturity, has the potential to reformulate how we understand schools and methods of therapy.

In wider perspective, we can see that therapy and medication, mental and emotional disorders, have all evolved within our society, where rhetoric and practice in politics, education, economics, medicine, the military, religion, government, and business, are characterized by misleading oversimplifications, dogma and ritual mistaken for knowledge and truth, turf wars, cult-like processes, and successive fads; each claiming superiority until it, too, is debunked. And the people, including professionals as well as consumers in each field, tend to be blind to the process itself, caught up in the cycle of fads, one after another. Why should psychotherapy be any different?

What’s needed, across the board, is better information and better informed consumers and practitioners. Now that’s a long-term process; it will probably take more than 20 weeks. But contributing toward it, in whatever ways we can, is the goal of our little Advocating Psychotherapy project here at CAPP.