First of all: I love Louis Castonguay. Second of all: I don't understand what's wrong with our field. Actually, that's not quite true; I have at least an inkling of what's wrong with it, and the inkling grows stronger with every article we read for this class. To elaborate: based on the articles we read over the past two weeks and those we read this week, it would seem, to the superficial observer, that a basic theoretical divide separates those who believe in specific, empirically supported therapeutic techniques as the driving force of therapeutic change and those (like Carl Rogers and, in a slightly more conservative and conciliatory way, Louis Castonguay) who think it's just "all about the therapeutic alliance." But what I fail to understand is, how on earth did these "opposing views" come to be parceled out and pitted against each other in the first place? And why on earth do we need decades of rigorous empirical research to re-integrate them, when in every other sphere of human endeavor it's considered basic common sense that to engage in any sort of joint, goal-directed transaction with another human being - be it going to the dentist to get a tooth filling, teaching algebra to high schoolers, or jointly raising a child - presupposes a certain degree of mutual trust and common ground? Even the specific quality and quantity of trust or mutual understanding required, which differs according to the nature of the "transaction," can easily enough be predicted and explained if one considers the common reason (or "mechanism," you might say) why trust is a prerequisite for virtually any collaborative human relationship - namely that if you're going to rely and act on the expectation of certain promised actions and outcomes from the party you're interacting with, you'd better first gain some assurance that the party is reliable. With this in mind, it's not rocket science why, for instance, raising a child with someone, which puts one of your most precious and high-stake values largely in the hands of another human being, requires a much more intimate trust and mutual understanding and congruence of goals (a much stronger "alliance," you might say) than getting a cavity filled.
So why, then, is it such a shock to psychotherapy researchers to hear that maybe, just maybe, if we can amass enough empirical data, we might perhaps be able to tentatively show that the patient-therapist alliance is neither the exclusive, end-all-and-be-all explanation for therapeutic change, nor is it an irrelevant and "nonspecific" byproduct of the real mechanisms of change in therapy, but that it is actually a crucial mediating factor that enables the other mechanisms of change to operate (i.e., enables the therapist and patient to actually work together)?
In reading an earlier Castonguay paper a while ago on "alliance ruptures" in therapy (Castonguay et al, 1996 - he actually references it in this paper, under the section "What do we know?"), I remember already being struck by the extent to which his conclusions seem at once "radical" (relative to the current status quo in psychotherapy research) and blatantly obvious. The paper reports his empirical finding that the use of CBT techniques can actually hinder rather than help a patient's progress when those techniques are persistently and rigidly applied despite a patient's growing dislike and resistance to them, and despite the resulting loss of trust and regard for the therapist. Well, duh! How can you expect a patient to muster the motivation (or even grant you the credibility) necessary to invest time and effort and often significant emotional distress in practicing your recommended exposure exercises, cognitive restructuring techniques, or whatever, when they aren't on the same page with you about the appropriateness or utility of those techniques, or you haven't checked in with them about their goals in attending therapy, or they aren't convinced that you truly have their best interests in mind? For a patient to keep on faithfully following their therapist's advice under such circumstances would be analogous, for instance, to leaving your child with a babysitter who may or may not believe in corporal punishment, belong to a cult that's devoted to the brainwashing and behavior control of little children, or think it a fine idea to show your 5-year-old child all her favorite X-rated films while you're away. Relatedly, how can a therapist even be said to have successfully implemented "cognitive restructuring" with a patient who remains mystified and unconvinced by the therapist's chain of reasoning, or feels that the therapist hasn't correctly understood or can't even begin to identify with the "distorted" beliefs that are causing the patient so much real grief and distress? How can one take a therapist's therapeutic advice seriously if one can't take the therapist seriously? For that matter, what about the ample volumes of cognitive and social psychology research on intrinsic vs. extrinsic motivation, social referencing, prerequisites and ideal conditions for cooperation, theory of mind and social learning, etc. etc.? If the psychotherapy researchers of the last umphteen decades had consulted even the most basic literature on the various cognitive and motivational mechanisms at play in interpersonal interactions, I believe they would've long ago concluded without much controversy or debate that most therapeutic techniques simply can't work, by their very nature, without a certain degree of empathy, trust, and respect on the part of patient and therapist alike.
Bewildered though I may pretend to be by this seeming failure of common sense among psychotherapy researchers, I admit I have at least some suspicions about what might explain it. At the risk of becoming a broken record, I must again point out the apparent rift between theory-driven research on the one hand and dogma-driven (albeit still every bit as "empirical") research on the other hand. The kinds of hypotheses that have been tested over and over ad infinitum by clinical trials of psychotherapy outcome - hypotheses that pit certain pre-packaged manuals against certain others (or against "treatment as usual") in the essentially arbitrary, allegiance-driven manner we talked about a couple weeks ago, while failing to look at theoretically obvious relationships such as the interaction between therapeutic alliance and particular therapeutic techniques - would not flourish for long in a culture of theoretically sound science (where rigorous attention is payed, not only to the empirical testing of hypotheses, but first and foremost to the development of hypotheses that are informed by and flow logically from the whole body of related knowledge about the relevant causal mechanisms and interactive factors that may be involved - whether that knowledge comes from psychotherapy research and/or cognitive psychology and/or social psychology and/or neuroscience and/or the logical insights reached through simple common sense). In other words, I'm once again compelled to tirelessly repeat the mantra I probably tired you all out with last week: a little more theory to guide our practice, please! Instead of chasing the infinitely recursive tail of our tired old hypotheses, let's stop for a moment and actually observe what's going on - what basic mechanisms we can isolate, and what interrelated phenomena from across the boundaries of cognitive and clinical and biological and neuropsychological science might be at play (based on what we as a broad scientific field have figured out about the nature of such phenomena, and about the ways they can be expected to operate). Let's not start fighting over categories before we even know what it is we're trying to categorize, let alone what kind of categorization would be meaningful or useful! Or, to allow myself just one more little mutated cliche, let's not keep sorting our apples with our oranges before we even know that the things we're dealing with are fruit (or even edible, for that matter!).
No comments:
Post a Comment