The Talking Cure

A funny thing happened to me this past Friday. I was driving home when I turned on the radio and had to pull over because I could not believe what was being said.

In a nutshell, some very “respectable” scientists were on a very respectable station (NPR) “informing” the general public. Hey, general public. Psst, yeah, you. Erudite listener, you. Come over here.

We’re scientists. You can’t see, because we’re on radio, but we have collars — I mean white coats — on. This means that what we say should be taken as the Gospel — I mean scientific — truth. Do you have pencil and paper ready? Ahem.

There are evil psychotherapists in the world who do not follow the scientific literature in their field. Even worse, some of these terrible people’s work has no evidentiary basis whatsoever.

We should know. We’re evidence-based, you see, and they’re not. And yes, we know what the definition of evidence is, and we believe it to be a settled matter.

We know about these non-evidence-based folks because we’ve been following them. For a long time and veeeery closely. And do you know what? Come closer.

These people are a threat to you, me, and our scientific and American way of life.

At best, these evil people will take your money and waste your time. At worst, they’ll do you grievous harm. That’s why you must insist that your treatment be behavioral, evidence-based, and straight out of a cookbook.

Thank you, and may God bless you and the Scientific States of America.

These people got on the air and claimed the authority of at least three views.

One was that research has “shown” that most psychotherapists don’t do what the research tells them they ought to do for particular disorders or conditions, instead doing what colleagues have said works or “flying by the seat of their pants.”

Another is that psychotherapy is just like medicine, which is regarded as a field consisting purely of discrete, fully separable conditions (i.e., no such thing as comorbidity), each with one and only one “treatment of choice.”

A third is the view that psychotherapy is or ought to be a laboratory science, with very strict and narrow rules as to what constitutes “evidence” for a successful intervention or treatment of a particular disorder.

Then they went on to insult the graduates of Psy.D. programs, suggesting that their scientific training was inferior to Ph.D. programs simply because some programs were not affiliated with universities and/or their primary mission is to produce thoughtful consumers rather than effective producers of research.

Now the naive listener might just have listened and said, “yeah, sure, whatever, what’s the big deal.” Sure wish I could have called in. Here’s what I would have said.

First of all, let’s define our terms. Psychotherapy. What is that? I like to call it something else, and not just because some of its most effective practitioners go by the name of social workers, counselors, or even coaches. I like to call it what its founder called it: the talking cure.

But let’s start at the beginning.

Someone is suffering. Before or after trying everything humanly possible on their own to fix things, they decide to seek the assistance of someone with expertise in the presumed area of difficulty.

They do a little research, either online or by asking people they trust. They interview one or more trained professionals. When someone suitable is found, a decision is made to meet for a certain number of sessions.

They sit (or lie down) and talk. Discuss. Inquire. Recall. Problem-solve.

Risk. Express. Laugh. Cry. Sit through periods of time when words won’t come out at all.

After some period of time, they get better. Situations and feelings which were once overwhelming and seemingly immutable become clearer. This helps the suffering individual get purchase on them and begin working towards a set of solutions.

They say good-bye, farewell, or see you for a tune-up.

Or they don’t get better. Then patient and treater scratch their heads, retrace steps, and try to figure out what to do next. If things don’t get better in a timely manner, a referral is made for diagnostic testing and/or a consultation with another professional.

The patient may or may not leave treatment unilaterally, to seek another therapist or try things on their own again. While they may or may not have given up hope in one or more treaters, they may or may not have given up hope in treatment itself.

They may or may not seek a psychotherapist again.

This is the wild and wooly world of psychotherapy.

There’s been quite the tempest brewing in this world since it began more than a hundred years ago. That was when a physician by the name of Sigmund Freud stopped trying to fix his most difficult patients according to his medical training and started, instead, to listen to them.

And when he did, something fascinating happened. They started to get better.

This, in a nutshell, is the talking cure: the use of a skilled, highly crafted conversation to bring about therapeutic change in suffering individuals. And as soon as Freud invented it, the fur began to fly, and for a number of very good reasons.

If Freud was right, we only think we control our bodies and our lives. Instead, he suggested — with evidence — that we are ruled by the outcome of a powerful underwater battle between unconscious forces.

The Enlightenment says ouch. So does anyone who thinks passion is the mortal enemy of reason, or thinks the heart exists only to make the head look good.

If Freud was right, sexual feelings occur throughout the lifespan, and they’re not the exclusive possession of those who’ve learned to attach words to them. Ouch, or perhaps even “yuk.”

If Freud was right, many fears hide wishes, and disgust exists in direct proportion to unconscious desire. Think murder, theft, adultery, and incest. Ouch, or once again “yuk.”

Those are just some of the cultural eyes Freud poked with his “talking cure.” There were, however, other, more landed interests.

If Freud was right, physical medicine was not always the treatment of choice for problems in living or particular physical symptoms. Ouch. In the United States, this prompted some to ensure that psychoanalysis and psychotherapy were medicalized by law. This situation ended in the 1950s, but the effects of this coarctation on the theory of therapy continue.

If Freud was right, curing some patients is more like interpreting a sacred text, unraveling a murder mystery, deciphering hieroglyphs, or inquiring into the nature of a work of art, than it is fixing a very complicated sink.

If this is true, then the most effective doctor for some patients wasn’t necessarily the one with the medical or even the most socially approved degree. She was the one most conversant in the symbols of culture – literature, philosophy, art, music, and language.

She might even be the lady – or gentleman – who knows what play is and why people like Winnicott and Gadamer give it pride of place in their thinking.

Now if it had been Galileo who’d invented psychotherapy, his critics would have called him an atheist. But because it was Freud, and because belief in God had fallen out of fashion by that time, he had to be criticized with the contemporary equivalent: failing to worship Science.

Of course, the science police have always been nice about it. Is psychotherapy scientific? Does it really work? If so, how? For whom and under what conditions?

Normally, these are fine and necessary questions to ask any discipline that makes claims to truth and therapeutic effectiveness. But that’s not how they’re being asked in the present day, at least not by researchers under the sway of the science police:

Let’s run some “fair and balanced” experiments, not designed to favor any one particular *cough* *empirical* *cough* *behavioral* modality, and see what we find!

After all, how could anything be therapeutic that isn’t scientific or something fully under the control of humans? So let’s do some “science,” shall we?

Hey, would you look at that? Solution-focused, time-limited, manualized treatments win the day over Freud’s talking cure! Who’d have guessed?

Boy, I can’t wait to tell the insurance companies and third parties the news. Now when they tell their customers they can’t have extra sessions, they can point to a study or two. Legal, and as legit as sea salt.

Most of all, let’s ignore the mountain of evidence – scientific as well as anecdotal – that suggests the best predictor of psychotherapy outcome is not modality, degree, or even years of experience but how well the patient feels understood by the therapist.

And while we’re at it, let’s assume nobody seeks (or ought to seek) psychotherapy for general help with living but only for discrete symptoms. That way the “literature” looks much better.

But questions about psychotherapy aren’t bad, nor is science. They only make the discipline stronger. What’s not good is a stacked deck, or a sign outside the profession saying “non-scientific need not apply.”

What should the qualifications of a therapist be? To what degree is this question asked in the interest of public health, and to what degree is it informed by tribal, marketplace, and guild interests? How can the the law be marshaled to address the concerns of those in charge?

And who gets to be in charge of the talking cure? Medicine? Psychology? Social work? Education? Nursing? Whoever’s in charge gets to set the rules, after all.

It should come as no surprise that the turf wars which began over a hundred years ago still rage. Today, the battle rages on between a new “coalition of the willing” and everyone else. This coalition is well-armed, well-funded, and enjoys a tremendous amount of social, university, and legislative support. And they have a mission.

Having more or less successfully purged university psychology department faculty (at least in the United States) of any remaining Freudians, having helped squash the funding for psychoanalytic training programs, and having designed and marketed their own competing forms of treatment, they’re once again going for the jugular.

Behaviorism once again ganging up on Freud, except this time with the kind assistance of managed care.

“Hey you, psychologist. Yeah, I’m talking to you. Have you read our — I mean, the — literature? No? Well then, we just can’t keep on accrediting your alma mater, now can we?”

A call is made to a friendly legislator. Suddenly psychologists are on trial, asked to defend something as immoral and unscientific as Freud. Maybe a few dissatisfied customers are even brought in for effect.

You see, psychology has its own Taliban no less than political or religious parties. These people, you see, think they own the copyrights on the terms “scientific,” “empirical,” and my favorite, “evidence-based.” And when they speak, they think people should not just listen, but do what they say.

Why? Well, because they’re scientists, and everyone who disagrees with them is…well, they’re just not. The high priests are “evidence-based,” you see, and everyone else…well, you get the idea.

To be against them is to be against mom, science, and apple pie. Come on, who would dare?

As if everyone who doesn’t grow the evidentiary beard their way should be caned. I’m sure you’ll be surprised to know that these people have a definition of “science” that was the state of the art in the seventeenth century – no relativistic or quantum thinking here.

That’s heresy, after all. Just ask yourself: don’t all physicists work exclusively in labs with machines that go “bing?” What, theoretical physicists? No, that would just confuse the general public – let’s just say that psychology should be a laboratory science, and leave it at that.

No philosophy. No humanities. None of that “soft,” mushy stuff our culture has so graciously come to associate with the feminine and devalue against the “firm” “bedrock” of “hard” – that is to say real – science.

At least for the new defenders of psychological “science.” Watch it, graduate program – they’ll cane you with their new accreditation standards!

Anyway, what would have been nice on the radio last Friday are a few of the things psychology needs, in short order:

We need some real conversation about what science is and is not, may or may not be. Is the laboratory always and everywhere the only legitimate source of knowledge for the practice of psychotherapy? What about anecdotal evidence, case studies, single-subject designs, or even — gasp — the humanities?

I remember telling a colleague I thought Dostoevsky was far more useful to me in some respects than some of the journals in my field. She gasped, poor thing – “but Dostoevsky was an N of 1!” I asked her if she’d ever learned anything of consequence in her work from poetry, literature, or movies, and she replied, with indignation, “absolutely not; I don’t fly by the seat of my pants.”

That’s right, I forgot. The humanities are a diversion, and the sciences are for getting down to work. Gotcha.

As a profession, we also need to question whether or not it still makes sense – for theoretical, political, or economic reasons – to model psychotherapy along the lines of medical practice.

We could also use a conversation about just what “evidence” is and who gets to decide. We could also stand to detach the glue some clever individuals have put between the terms “empirical” and “quantitative.” Anyone who listens to the effects of their words on another and modifies what they say as a result is being empirical. Get over it.

And if you really want to see some people turn red with rage, try saying the word “countertransference” in their face. Works like a charm.

Most of all, we could stand to stop using the humanities (and the feminine) as a cultural urinal for the natural sciences. We might, for example, admit that philosophy, literature, art, and music, each have an intellectual rigor that is not the same as (or reducible to) that of physics or mathematics.

And by the way, they’re called the humanities for a reason, you know. Now try telling me the human encounter to address suffering by way of conversation has, or should have nothing to do with the humanities.

I know, for example, that without a working knowledge of philosophy – in particular existentialism – I’m of no use to many of my customers.

It’s also advanced my street cred considerably to know what heavy metal, hip-hop, jazz, and cumbias are, as well as how to cook, play a tune, and be a father.

So with all due respect, the defenders of the scientific faith can go, well…let me invite them to consider how self-righteous their self-appointed stance appears from time to time.

I think what makes psychology great is the fact that it is both art and science. We don’t have to sacrifice the armchair for the laboratory; at least not if we want to bring the very best of what we learned in college to bear on our work.

When the scientific fundamentalists read Thomas Kuhn, they can call me, and then we’ll have an honest and fun conversation about what science is. When they tell me how you can take the temperature of a teacup without the temperature of the thermometer affecting the result in any way, we’ll chat.

And not like it should matter, but yes, I know how to shake the secrets out of toys like the WAIS, D-KEFS (everyone has a favorite and this is currently mine), NEPSY, MMPI, TAT, and Rorschach (Exner if I have to, Rapaport-Schafer when I can). I’ve also almost gotten into fistfights (legal as well as physical) with people who try to deny, delay, or dilute ABA services for kids who desperately need them, and for whom the treatment clock is ticking fast.

So no, I’m not anti-science, nor do I fly by the seat of my pants.

All right, maybe when I’m cooking.

Or when I’m working in the kitchen.

Look, I read my opponent’s stuff, including the honest pieces.

I just wish they’d read mine.