The Art of Psychotherapy

Rembrandt_van_Rijn_181The word ART has mainly positive connotations and that is why so manypeople (especially psychotherapists) would like to see psychotherapy as an art.

(…)

I have repeatedly sought to understand how it is possible to teach therapy that represents an art? Most likely, as in every art form, a special talent is required and a few available methods include the observation of the “master” at work and an effort to gain an insight into the master’s wisdom and skills. Many a time masters of “artistic therapies” cannot clarify mechanisms underpinning their treatment methods. This is how Bert Hellinger, a German psychotherapist associated with a therapeutic method best known as Family Constellations and Systemic Constellations, commented on an attempt to explain how his own therapy system worked:

Actually the theories aren’t important to me. I can see that these things happen, and explanations after the fact don’t add anything to the practical work. Many people would be interested in an explanation of exactly what happens and how it’s possible, but I don’t need an explanation in order to work with the phenomenon.[2]

It would be interesting to know whether Hellinger’s students and followers also have this gift of “seeing” and thus do not need any explanations to understand what the master is doing. I wonder how they pass on this knowledge. Theory has to this day been the only known source of knowledge and description of the world. Another one, relevant to religious cognition exclusively, is revelation. Can it be that in psychotherapy we have already reached this boundary?

Eclectic psychotherapy, which currently represents one of the most popular approach, is also absent from the quoted reports and research studies. The eclectic approach allows the therapist to choose methods and measures that, in their view, will work for a particular patient. On what grounds? This must undoubtedly be that unerring intuition and experience that in no way can be explicated to an amateur.

Imagine a novice artist-painter striving to emulate his master’s style or to develop his own. Before he reaches perfection, many canvases are just thrown away or reworked with a bit of luck. It takes a lot of tools and supplies in order to achieve a satisfactory outcome. However, the cost of artistic experimentation is limited to the cost of canvas, stretcher bars, paints, as well as the time spent on using them all together. How do psychotherapy-artists develop their professional competence? Is psychotherapy by any chance the only art form that can be mastered without making mistakes? And if not, then which works of this art find their way to the waste heap of psychotherapy?

Let’s have a look at the research results. Quite often therapy brings negative results and a considerable deterioration of the patient’s condition. Successive studies have demonstrated that as a result of therapy no fewer than 10% of patients feel worse and even display psychotic reactions. Many couples who underwent therapy went along with their therapists’ suggestions to such an extent that their family lives disintegrated as a result. What is more, those recommendations and suggestions were formulated solely on the information presented by only one of involved sides, that is the patient.[3]

Interesting conclusions can be drawn from an analysis of the results of the Cambridge-Somerville Youth Study:

In evaluating the effectiveness of a project designed to prevent delinquency in underprivileged children, 650 boys of six to ten years old were randomly divided into two groups with equal chances of delinquency. One group received individual therapy, tutoring and social services; the other received no services. The treated boys rated the project as “helpful” and the counselors rated two-thirds of the group as having benefited. However, the researcher, Joan McCord, followed the boys over time looking at effects on criminal behavior.The results showed little difference in terms of the number of crimes, but the counseled group committed significantly more serious crimes. A thirty-year follow-up showed the same pattern and revealed that, in terms of alcoholism, mental illness, job satisfaction and stress-related diseases, the treatment group was worse. McCord summarizes the results as “‘More’ was ‘worse’: the objective evidence presents a disturbing picture. The program seems not only to have failed to prevent its clients from committing crimes… but also to have produced negative side effects…”[4]

When interpreting the results of her research, McCord identified three factors that might contribute to the harmful effects: encouraged dependency, false optimism and externalized responsibility. She suggested that:

1) Through therapy, the psychologists might have fostered a dependency among the boys, rendering them less able or inclined to cope with life’s problems on their own; 2) “the supportive attitudes of the counselors may have filtered reality for the boys, leading them to expect more from life than they could receive;” and 3) counseling may have taught the boys that they were not responsible for their behavior because it was a consequence of their underprivileged childhood experiences – an external cause to blame.[5]

This was by no means the only such study. Keith Ditman and associates studied three groups of alcoholics who had been arrested and charged with alcohol-related offences.

The court had assigned these individuals to AA, an alcoholism clinic, or a non-treatment control group. A follow-up found that 44 per cent of the control group were not re-arrested, compared to 31 per cent of the AA group and 32 per cent of those treated in a clinic; 47 those that received treatment did worse than the untreated. “Not one study,” Peele asserts, “has ever found AA or its derivatives to be superior to any other approach, or even to be better than not receiving any help at all. Every comparative study of standard treatment programs versus legal proceedings for drunk drivers finds that those who received ordinary judicial sanctions had fewer subsequent accidents and were arrested less.”[6]

Other documented cases of adverse effects of therapy include decompensation, that is a failure of the adaptive mechanisms of an individual overburdened with difficult situations, problems and tasks; deterioration of depressive states, including attempted suicide; lower self-esteem coupled with feelings of shame and humiliation; weakened self-control manifested in aggressive behavior or uncontrolled sexual behavior; the already mentioned dependence on therapy and/or therapists; loss of a sense of responsibility for one’s own life[7]. There have also been cases of incomprehensible impulsive behavior of patients undergoing therapy in their own social environment. The behavior in question did not occur before the start of therapy.[8] In another article Handley and Strupp have demonstrated that most psychotherapists agree that the problem of harm done during therapy is real and that it often leads to suicide.[9] Moreover, the research results I have referred to, do not really worry the therapists, who make no effort to eliminate them.[10] Robert Spitzer of the New York Psychiatric Institute once said with disarming honesty that: “negative effects in long-term outpatient treatment are extremely common.”[11]

Carkhuff was of a similar opinion: “the evidence now available suggests that, on the average, psychotherapy may be harmful as often as helpful, with an average effect comparable to receiving no help.”[12]

Is it possible that all these cases of adverse effects were a result of improvements in therapy treated as an art? Perhaps these are the discarded canvases, damaged stretchers, wasted lumps of precious metals that help artists to improve?

 

[1](see more: www.therapyconsumerguide.com and: http://voices.yahoo.com/how-avoid-getting-abused-psychotherapy-8878091.html

[2] Hellinger, B. & ten Hövel, G. (1999). Acknowledging what is: Conversations with Bert Hellinger. Phoenix, AZ: Zeig Tucker & Theisen, p. 66. More about Hellinger: http://www.hellinger.com/

[3] Lambert, M. J., Bergin, A. E., & Collins, J. L. (1977). Therapist induced deterioration in psychotherapy.  In A. S. Gurman, A. M. Rogers (Eds.) The therapist’s contributions to effective treatment,(pp.452-481). New York: Pergamon.

[4] Dineen, T. (2007). Manufacturing victims: What psychology is doing to people. p. 48. Retrieved from http://tanadineen.com/documents/MV3.pdf

[5] Ibid. p. 55.

[6] Ibid. p.55.

[7] Lakin, M. (1988). Ethical issues in the psychotherapies,New York: Oxford University Press.

[8] Strupp, H. H., Hadley, S., & W. Gomes-Schwartz, B. (1977). Psychotherapy for better or worse. The problem of negative effects. New York: Jason Aronson.

[9] Hadley, S. W., & Stupp, H. (1976). Contemporary views of negative effects in psychotherapy. Archives of General Psychiatry, 33, 1291-1302.

[10] Mays, D. T., & Franks, C. M. (1985). Negative outcome in psychotherapy and what to do about it. New York: Springer.

[11] Spitzer, R. as cited in Sarason, Psychology misdirected,p. 42.

[12] Carkhuff, R. R. (1969). Helping and human relations: A primer for lay and professional helpers,New York: Holt, Rinehart & Winston.

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22 responses to “The Art of Psychotherapy

  1. Your comment, “The eclectic approach allows the therapist to choose methods and measures that, in their view, will work for a particular patient. On what grounds? This must undoubtedly be that unerring intuition and experience that in no way can be explicated to an amateur,” resonates with my experience with therapy. One therapist (under whose “treatment” I deteriorated considerably) often said things that didn’t make sense to me. When I asked why she said something, I got replies such as, “Are you sure you’re not second-guessing me?”, “Do you realize you’re asking me to give up my control,” or “Because you need to know what other people think of you.” One day she came in and said she had figured out a way to explain to me what she was doing, saying, “Consider me to be something like a computer: what you say goes in, mixes around with my experience and training, and out comes a response.” (I suspect that her metaphor reflected a lack of understanding that what comes out of computer depends on the algorithms built or programmed into the computer.)

    However, there does seem to be a movement recently (advocated in the publications by Duncan, Miller and coauthors) toward the idea that the client probably knows better than the therapist what will work from them. This gives some hope for improvement in the field.

    • Dear Mary, thank you for you comment. Unfortunately, your experience is quite common among many patients. Your also wrote, “However, there does seem to be a movement recently (advocated in the publications by Duncan, Miller and coauthors) toward the idea that the client probably knows better than the therapist what will work from them.” If so, what for do we need therapists? A friend with a bit of emapthy is not enough?

  2. In response to the question at the end of your reply: Sometimes a friend with a bit of empathy is indeed enough. But often it is not enough — or is not available. Friendship is a give-and-take relationship, and sometimes a friend may not be able to give just what a person needs, or may have their own needs that take precedence. And friends may often be short on accurate empathy.
    So I see a place for some version of “therapy” where a professional is paid in return for giving what is likely help the client, with lots of input and feedback from the client. This might include (but is not be limited to) confidentiality; a dedicated time and place where helping the client is the only thing on the agenda; the ability (perhaps part nature but partly training) to have accurate empathy for the client; good listening abilities. It is not always possible to find these (or at least in adequate supply to really help) in a friend. Indeed, friends can often be as well-intended-but-misguided as many therapists are. In particular, friends may mistakenly believe that their friends are just like them when they’re not.
    I would guess that most people who try therapy try it because talking with a friend has not been helpful, or maybe has even been counterproductive.

    • Maybe a good expresion to describe what we really expect from therapists is “prostitution of friendship?” Let’s have a look at this quotation from Hans Eysenck:

      “Many of those who go to the psychoanalyst are not in fact neurotically ill at all. For the majority of them psychoanalysis constitutes on what one critic once termed the ‘prostitution of friendship’. In other words, unable because of defects of personality and character to make and keep friends to whom they can confide, they pay the psychoanalyst to serve this function, just as men buy sex from prostitutes because they are unable or unwilling to pay the necessary price of affection, love and tenderness which is needed to achieve a sexual relation on a non-commercial basis.”

      Perhaps shedding illusions about the efficacy of a given therapy and the correctness of its explanatory apparatus might improve this “prostitution of friendship” to the benefit of patients? Perhaps it is in this direction that re-search and therapy should be heading. Eysenck’s views, controversial as it may seem at first glance, are not isolated. The psychiatrist Fuller Torrey once described psychotherapy as: “the world’s second oldest profession, remarka-bly similar to the first. Both involve a contract (implicit or explicit) between a specialist and a client for a service, and for this service a fee is paid.”

      • Tomasz,
        Using a metaphor of prostitution to describe therapy has often occurred to me, but not in the way that Eyesenk describes. My experience points to a different metaphor in which the therapist may be the one “unable because of defects of personality and character to make and keep friends” who will give them what they crave – whether it be intimacy, power, influence, control, authority, sadism, adulation, “raw material” to mold, “being right,” or whatever. The profession of therapy all too often serves as a mechanism whereby people with such cravings can use clients as prostitutes, to meet the therapist’s desires – and, in contrast to typical prostitution, the prostitute (the client) pays the therapist. Indeed, the therapist can rationalize their greediness by saying they are helping the client, working for the client’s own good.

        I do not mean to say that all therapy is like this; I do know of instances where therapy has been genuinely helpful to people. At the same time, the lax ethical standards of the profession attract amoral individuals and enable such individuals to enter and survive (or even thrive) in the profession, using clients as prostitutes to serve their own desires.

      • Since the proliferation of therapy, burdening one’s friends with one’s woes seems less tolerated. I’ve read numerous discussions around the troubled friend and the crowd consensus the pathetic complaining soul be sentenced to the psychotherapy banishment. Some therapists label friends emitting negativity or squandering our time with problems as “emotional vampires.” Avoid from anyone who troubled or distressed. Friends are no longer qualified to help each other, even as sounding boards;therapists are the appointed Life Experts. So much is outsourced these days, even extending oneself to friends.

      • So true… Two quotations worth consideration:

        “The therapists transformed age-old human dilemmas into psychological problems and claimed that they (and they alone) had the treatment… The result was an explosion of inadequacy.” Charles Sykes

        “While psychologists say “trust me,” they question and often discourage one’s trust and reliance on family and friends. As a substitute they offer artificial empathy, cultivated warmth and phony genuineness, through which they can persuade people to see life the way they see it, and to live their lives in a psychologically ordered fashion. Years ago, psychotherapy was described as “the purchase of friendship.” What people need today is less of this synthetic experience and more genuine relationships, which, however imperfect these may be, are reciprocal rather than purchased.” Tana Dineen

      • Dear Mary, it is quite new point of view for me, very fresh and quite complex. I used to think about such asymmetry as about pathology. In spite of all negative facts connected with psychology I assume that most psychotherapists start his work with positive motives. Of course, it is only my assumption, I do not know numbers.

  3. Tomasz, thanks so much for discussing these topics. My blog is now up to 1,000 replies from former clients exploring these same concerns and how we were hoodwinked by treatment we expected from “professionals.” I’ll link to your blog from mine.

    • Thank you very much. I hope they would be interested also in problems and frauds of academic psychology as well. Soon, I will prepare a page with useful links, so I’ll link to your blog as well.

  4. Thanks for this post on the art of psychotherapy — and the disregarded scraps or collateral damage that is an inherent part of the process of creating a work of art. It’s a very honest and under-appreciated point. Clinical psychology doesn’t stand up well as a science, but if treating it as an art causes unforeseeable harm to random clients, then what’s left? (Here’s another article that points out the fact that harm happens but tends to go unrecognized in psychotherapy: http://www.ncbi.nlm.nih.gov/pubmed/24607768)

    I recently came across some interesting writings on the non-scientific/pseudoscientific status of clinical psychology that may be of interest:
    http://www.arachnoid.com/psychology/index.html
    http://www.arachnoid.com/reader_exchanges/can_psychology_become_a_science.html
    http://www.arachnoid.com/building_science/index.html
    http://www.arachnoid.com/trouble_with_psychology/index.html
    These links are also posted here: http://trytherapyfree.wordpress.com/links/

    In any case, from my perspective, the fact that clinical psychology/psychotherapy doesn’t hold up as an art or science is important, but almost secondary to the more fundamental problem that the structure of the artificial asymmetrical therapy relationship depends on an unethical, dehumanizing way of relating to our fellow human beings.

    • Thank you very much for your comment and links. It seems that there are a lot of good readings!
      The problem of artificial asymmetrical therapy relationships is very important and deep. I very seldom discuss it as I am still fighting against therapists and psychologists who denay even the fact that therapy could be harmful. I have many problems, how to articulate some questions and not being clasyfied as a fantic. This is very difficult, but as far as I can maintain reliable image, many people would like to listen me. How do you copy with this?

  5. Pingback: Art, Science, and Ethics | TryTherapyFree·

  6. Tomasz-Just in my experience as a consumer blogger, the usual defensive tactic from psychotherapists is ad hominem attack or insinuation. A client who’s experienced negative effects either 1) failed to give therapy her full commitment. “You have to WANT to change, dear.” 2) is a perennial discontent, or as we call them in the USA, the unhappy camper 3) failed to shop sufficiently to find a good a “good match.” Therapists promote that they’re no bad therapists, only…bad matches.

    Meanwhile professional critics of psychotherapy, Masson, Smail, Dineen etc have received fury from the their colleagues. It’s ironically comical to watch professionals use their training like missile launchers to “analyze” and “diagnose” anyone who threatens their comfortable little order.

    Note I blog and opine anonymously and I think it courageous to challenge the status quo under your own name. I’m unsurprised your colleagues name call–that’s how they subdue their clients! I’ve found they have a relatively shallow bag of recrimination tricks and it can be fun to call them on it as “Sue” did with “Gerald” and “Don S” in this review discussion.http://www.amazon.com/review/R21EO2WEQ56PJX/ref=cm_cr_pr_viewpnt#R21EO2WEQ56PJX

    I think the issue of asymmetry, delivered in a contrived, fantasy-like setting, worthy of extensive discussion, and I’d love to see professionals take this on.

    • I am afraid, I do not understand what do you mean while saying: “delivered in a contrived, fantasy-like setting”. Could you explain me this more clearly?

      Last time I was thinking a little about denialism and it was striking for me that we do not call all this psychologists who argue like you described above as denialists. Maybe we should do it consequently and constantly?

      • In my experience, therapy is a contrived, fantasy-like setting in that in creates a delusion in the client’s mind and perhaps the therapist’s mind as well.

        It creates the fantasy that the therapists is imbued with mysterious healing powers that the client mysteriously absorbs. It creates the delusion that the therapist can be omniscient and even clairvoyant, with the powers to know more than the client and interpret events the therapists never has even witnessed.

        It perpetuates the myth–that if the client “opens” herself, recalling her most painful history and confessing it aloud, that demon obsessions and behaviors will magically depart the client’s body. I’ve also read clients who believe that their “unhealthy attachments” can the “worked through” via their therapists’ attentions or love or their “bond” is a “corrective emotional experience.”

        In short, I’ve experienced therapy fostering magical, delusional thinking.

        Denialists–I’ll take it.

      • Great points, disequilibrium1. I think the term “denialist” would apply well to the psychologists/psychotherapists who deny the importance of science and evidence in clinical practice.

      • Thank you. Now it is quite clear for me. So, let’s use the term “denialists” in relation to psychologists and psychotherapeutists as well. One of the main purposes of my activity is result in a situation, that bad psychotherapists and bad psychologists would be ashamed of what they do and would need to explain themselves.

  7. Tomasz, based on my experience as a client and now a blogger, so many psychotherapists seem well-practiced in maintaining their dominance. Like sleazy politicians, they have well-practiced talking points to explain everything away. I’m so happy to see the difficult questions explored by you on the inside.

  8. Apparently, the moral standards are quite different in Poland and in the US. In the US it would be unthinkable for anyone to quote pieces of a private correspondence and to post them for a public view without the explicit permission of the person who you had corresponded with. Besides, it’s also illegal here as well.

    Under the circumstances, all I have to say is that since the American public, generally speaking, respects privacy, things that are quoted from private conversations are not accepted as a part of a public dialog in the US and are generally rejected as a valid argument in the court of a public opinion. I object to this violation of my privacy, and, even though I understand that Mr. Witkowski doesn’t care about it, my public objection to his actions needs to be made.

    • Dear Marina Tonkonogoy,
      I apologize you for my heartedness. It was not my intention to violate you privacy. It was my misunderstunding as I treated our correspondence as an exchange of arguments between professionals not as a private correspondence. I removed the quoute of your correspondence from my post.
      With expressions of respect and appreciation for your work,
      Tomasz Witkowski

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