Psychotherapy and Complexity

My basic orientation when it comes to psychotherapy would best be described as integrative or eclectic. I see the different orthodox schools of psychotherapeutic practice as being legitimate and useful in their own ways. The particular client, their personality, their social position, their culture, their life history, their specific issues and the contexts of those, are all factors that play into what type of therapy they will respond to and what will be most useful for them at that time. I don’t believe, though, that every type of therapy is equally good or valid.

Numbers are sometimes thrown around that there are this-or-that many different forms of psychotherapy. Many recognize this fact and at first glance it can seem like a problem. It can look like there is a certain arbitrariness in the field , or at least in any “specific ingredients” of a certain form. People are always inventing new types of therapy and counseling, with styles ranging from the purportedly scientific all the way to the hopelessly new-age stuff. This kind of entrepreneurialism in psychotherapy schools is somewhat worrisome for the same reason I mentioned above, namely, that it makes the form used, if not the whole field, seemingly arbitrary. What’s the foundation if one will choose a theoretical orientation depending on the party line, mere personal preference, like and dislike, yum and yuck?

This is where the world of the empirical study of psychotherapy, and EST’s and all that come in. Of course, it is in the service of science (and third-party payers). Yet, I am skeptical of some aspects of this project. While I am a firm believer in empirical study and knowledge, my qualms relate back to the complexity of actual therapy. I sympathize with Yalom’s view that empirical study of psychotherapy in academia is essentially not able to handle the multitude of factors at play in the therapy room. Hence more humanistic or abstract forms like existential therapy are dismissed in academia as invalid, whereas actually they are arguably valid but just too complicated to do experiments on and still capture all the relevant factors and meaning.

Evidence-based practice, which is a tradition borrowed from medicine, where actual practitioners reference relevant clinical data in their work, is a little better than the psychotherapy “battles” that take place in academic labs with undergraduates. Clinical psychology has its own tradition of experiments where it has essentially aped the experimental tradition of psychology. But the nature of its clinical subject matter is far different from the simpler levels of analysis that the behavioral animal psychologists were dealing with. Throughout most of the 20th century, the lab scientists were watching rats in a maze, and the clinicians were smoking their pipes while their clients free-associated on the couch about God knows what. Bravo to all of those who have done great work to try and bridge that gap. It has been a tough job, and will continue to be so for a long time.

The fact is that the evidence from meta-analyses supports the so-called contextual model view of psychotherapy. Specific effects are a small factor in comparison to the interpersonal factors of the therapeutic relationship. I think that specific effects do have their place, and for certain forms of psychopathology there are specific therapies that clearly work better than others, but as one moves into the broader spectrum of issues and problems that clients present with, the sheer complexity of actual psychotherapeutic practice does not lend itself easily to pre-made formulae.

It is important to note that I do not subscribe to relativism. I do believe in objective truth, but I also believe that humans are evolved and embodied with interests, biases, and inherent limitations. Our minds are not singular but plural, modular, and full of differing thoughts, representations, drives, motivations, feelings, emotions, memories, states, processes, etc. They are embedded within and greatly influenced by a complicated biological meta-system known as the body. All of this interacts with countless different physical, cultural, political, economic, and interpersonal environments, which produces behaviors of an enormous variety. This is no doubt an interconnected system with feedback loops and a tremendous amount of multi-causal factors and modulators at work at any given point in time and space. Oftentimes, certain aspects of this delirious, kaleidoscopic riot are more saliently problematic for an individual or group, and therefore certain therapies will be more relevant and useful. But, oftentimes, we are at the mercy of this complexity and our best tools are our wisdom and educated intuitions, which have to work on the fly without consciously processing “technique A” or “method Z.” Our therapies are wonderful tools, but they are just that. They are not panaceas and they do not bring us toward omniscience.