Psychotherapy Article: Are Psychologists Afraid of Therapy?
This psychotherapy article was originally published in 1950 and addresses the possible reasons underpinning what the author believes to be negative feelings towards psychotherapy among the wider psychological community.
Among the possibilities raised are an overattachment to mental testing; the intangible quality of dynamic psychotherapy in comparison to research and diagnosis; the misconception that therapy and diagnostic research are dichotomous and the problem of the interprofessional relationship between psychology and medicine.
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As a psychologist in private practice, I have naturally followed with considerable interest the rise of clinical psychology as an applied art. After reading the latest report of the APA Committee on Training in Clinical Psychology, I feel that the future of this new development is in capable hands.
At the same time, I cannot escape having the feeling that psychologists by and large have not arrived as yet at anything like a clear formulation of their attitudes toward clinical psychology. Many of our current attitudes toward the .clinical field are in my opinion needlessly and harmfully hesitant, apologetic, timorous and unrealistic. A good many psychologists in our university centers -how many I can't say-actually minimize or deprecate this new direction within the profession. These negative feelings are directed especially. I should say, at therapists in private practice. If I sense the situation correctly, a good many academic psychologists look upon psychotherapy either with indifference or apprehension or with a feeling that therapy, if it must exist at all, is one of the lesser concerns of graduate training in the field of clinical psychology.
Let me illustrate. A few academic people who are clinically oriented have been frank to tell me that they are sailing without a compass, that they have never stopped to formulate what they consider to be the proper aims of their efforts at graduate training. This indeterminate attitude is reflected in the minds of a large number of graduate students who are interested in therapy. In a recent issue of the American Psychologist, a responsible British author gave it as his opinion that psychotherapy is the exclusive province of the psychiatrist and that the clinical psychologist has no place whatsoever inside that domain. The APA Committee on Training in Clinical Psychology tells us that most American departments of psychology are opposed in principle to the private practice of clinical psychology. Some departments, the Committee reports, will not admit a student who intends to go into private practice. Of all the attitudes which I loosely choose to regard as being "anti-therapy," the commonest in my opinion is the point of view that psychotherapy has its place as an object of graduate study or as an eventual post-graduate focus but that research and diagnosis come first. Seen in this light, therapy is admissible. But it comes limping after as a necessary evil, as a kind of after-thought, as a lesser thing which needs watching and is to be tolerated only so long as it remains subordinated to the "legitimate" and loftier ends of research and diagnosis.
I am forced to conclude, therefore, that we are somewhat at sea in our thinking about therapy and that some of our attitudes toward therapy are openly or covertly negative, to say the least. If I have read these feelings correctly, what explains them? To be sure, our university departments of psychology are feeling their way into a new situation. Anything so new and so complex as the setting up of professional standards of training for therapy must proceed slowly. It stands to reason that those psychologists and graduate students whose major interest lies in the theory and practice of psychotherapy must not expect too much, too soon. I also appreciate the need for growing slowly and soundly. Furthermore, I have great respect for those officers of the American Psychological Association and for those university spirits who are adequately dealing with this tremendous problem.
Nonetheless, I feel that psychologists must take stock of themselves in order to understand some of their timorous and negative attitudes toward psychotherapy. Before the looking glass I think we shall discover, among other things, that we minimize and underestimate the role of therapy because we fear it.
This fear has, as I see it, four separate variants. 1 should like to list each of these offshoots. Under the circumstances, my analysis can be little more than a mere enumeration.
In the first place, I feel that the tendency to assign an inferior or lesser place to therapy as such stems in part from the fact that we still suffer from an over-attachment to the tradition of mental testing. Since the new clinical orientation came into being, the psychological literature has simply teemed with tests and scales which purport to assess the personality as a whole or this or that facet of the neurotic personality. I am sure that this activity within the hive will produce something of lasting value. It already has.
If we are thinking of the cultivation of therapeutic skills, however, it might pay to face a number of realities which delimit the usefulness of tests in the clinical situation. These realities are as follows: For ninety to ninety-five per cent of his efforts-at least on the adult level-the therapist has no occasion for using tests or any other kindred diagnostic instruments. He relies on his clinical judgment. He must rely on his clinical judgment. Moreover, I can think of any number of therapeutic situations, for example, when a patient presents himself in a gravely depressed or anxiety-ridden state, in which the use of any formal psychological tests would add nothing to or would actually impede the clinical action that is called for. It is my further conviction that the final test of the success of any brand of therapy is now, and will always remain, a social one. That is. we must answer these questions: Is the subject making a go of life? Has he freed himself of his anxiety or conversion symptoms? Is he living productively? Has he learned to get along with others?
Again, I am not saying that tests have no place as diagnostic instruments or as research tools. But I do contend that if we hew too closely to the mental testing tradition in our clinical psychology, we will remain strangers to any real comprehension of the psychodynamics of growth and the art and meaning of psychotherapy will elude us quite completely.
I come now to my second basic question about our seeming resistance to making the study of therapy one of our primary graduate objectives. Are there those among us who stress research and diagnosis in contradistinction to psychotherapy because these presumably favored processes, diagnosis and investigation, are ostensibly easier or more tangible in the doing than therapy? Therapy is dynamic. It does not lend itself to the categorizing or to the neat patterns which we have come to identify with a great deal of our research activity. The subject-matter of therapy is, likewise, dynamic. The world of inner feelings is in a state of constant flux. It varies in an ever-changing relationship with outer social forces. This subject-matter does not stand still for the convenience of the old-style investigator who longs to pigeonhole and codify his material.
If I am right in suspecting that we have eschewed therapy to some extent because of its greater difficulty or because it is so intrinsically fluid and elusive, is it not likely that we will come to a standstill at a stage of development which psychiatry is now at the point of leaving? Psychiatry has long been addicted to classification. The run-of-mine psychiatrist has functioned for the same length of time as a mere diagnostician or as a Kraepelin who could tell the patient in one or another vocabulary what ailed him. These classifiers were, for the most part, unversed in the dynamics of movement or in the art of helping the patient to help himself. Today, however, the psychiatric picture is rapidly changing. Our departments of psychological medicine are coming over to the dynamic point of view, both in their therapy and in their theories of growth and personality. Is this, then, the hour for the psychologist to forego an interest in the psychodynamics of his subject-therapy included-in favor of a science of static measurement and classification, because the latter offers scientific data that are neater or simpler or more manageable?
I have a third query in mind. It is this: How much of our apparent indifference or over-cautiousness toward psychotherapy is a function of sheer remoteness from the problem? This possibility suggests itself every time I read or hear it said that research and diagnosis, rather than therapy, is the psychologist's proper sphere.
To my way of thinking, any attempt to dichotomize these ends or interests, placing therapy in one compartment of clinical psychology and research and diagnosis in another, is not only undesirable; it can't be done. Surely in the clinical field, therapy on the one hand and diagnosis or research on the other are complementary and inseparable. I, for one, cannot think of a single original worker in psychiatry or its sister sciences who has not been a close observer of troubled human beings in the process of accepting help. All the great innovators in this area-Freud, Rank, Adler, Sullivan, Ross, Fromm, and the rest-were mental healers. All were clinicians. All were steeped in therapy. Could it have been otherwise?
The art of psychotherapy should be stressed by our university departments of psychology both for its own sake and for the reason that clinical research cannot possibly find a deeper well-spring of inspiration. Where, outside of the therapeutic situation, is the psychologist in a better position to assess the compulsions of the hypertensive personality, the motivations of the sadist, the anxieties of the cardiac patient, or the inner conflicts of the person suffering from a psychogenic skin involvement? Who has a richer opportunity than the therapist to gauge the forces of health within the neurotic personality, to put to the test the validity of our theories of psychodynamics, or to learn firsthand the limits of our knowledge?
Is it not also true that from a pure research standpoint, therapy is the most important problem clinical psychology has? Our knowledge of the structure and origins of personality is far in advance of our knowledge of the art of helping people. The practicing psychiatrist or clinical psychologist falls down oftenest not in his failure to grasp the psychodynamics of the relationship or disorder he is up against, but rather in knowing where to go from there or in knowing how to help the patient solve his problems. Otto Rank was one of the first to foresee this predicament. Rank predicted that with a rise in the popular level of psychological sophistication, we would encounter more and more in the therapist's office the patient who arrives armed in advance with a pretty fair awareness of what ails him, even to the point of knowing a great deal about the dynamics of his own case, but nonetheless quite powerless to free himself from his problem. If the universities are interested in research, what problem promises greater rewards, what subject is richer in riddles, than therapy itself?
To put my point another way, I should say that the only psychologists who seriously insist on a separation of therapy from research and diagnosis must be psychologists who have never had much first-hand experience with therapy. These same psychologists probably doubt that therapy is even possible. They include, I am sure, those academic perfectionists who frequently remark, "Do we really know enough to attempt therapy at all at this time?"
I do not wish to deify empiricism or subjectivity when I express the conviction that all teachers and investigators of clinical psychology will be compelled to send their roots down into the clinic. Clinical psychology cannot avoid becoming clinical. The "knowers" in this field will be participant-observers. We are dealing with feelings. Only participation in the helping relationship can give the masters of the art any real appreciation of the subject they profess to teach. Who can imagine a William Osier cut off from the source of his vitality, the clinic and the hospital bed! What was necessary for the growth of a great pioneer in internal medicine-an intimate union between therapy, research, and diagnosis-is certainly mandatory for the clinical psychologist.
Now to my fourth and final question about some of the motives which underlie our diffidence toward therapy and our seeming scorn for the private practice of therapy: Do we shy away from psychotherapy because we fear the reaction of the medical profession?
It will certainly not behoove us to ignore the relationship between psychology and medicine. At times, I feel, we have been guilty of doing just this. For example in one or another of our psychological journals, I have read with no little concern the recommendation that counselors or therapists-of the non-directive school, I believe-are free agents, that they may launch into therapy completely in the dark as to what ails the patient, somatically or psychologically. This advice, to my mind, is a counsel of irresponsibility. It implies that the lay analyst, if you will, can ignore all medical and psychiatric considerations. All I can say is that the therapist who acts on such advice is playing with fire; he will also invite ill will and retaliation on the part of both the American Medical Association and the general public.
Let me cite another example of psychologists refusing to face the problem of their correct interprofessional relationships. In this case a group of psychologists recently introduced into their state legislature an ambitious and far-reaching bill for the licensing of psychologists in private practice. The measure was dead before it reached the state capitol. It was killed by the state medical society.
Any licensing bill of this character might have suffered a similar fate at this time. I can't say. But I think I know why it was that this particular measure was buried after its first reading. The sponsors of the bill were, for the most part, academic people of unquestioned integrity. But they overlooked two realities in the situation. They drafted their measure in vacua without making any real or sustained effort to court the aid or criticism of the medical profession. And the bill that was presented asked for something that the clinical psychologist will probably never get and has little reason to expect-the privilege of setting up an independent healing art without check or hindrance from medicine in general or psychiatry in particular. The sponsors of the measure were well-intentioned, I am sure. They were eager to give legal status to the trained psychologist as a qualified practitioner in his own right. In going about it the way they did, these same sponsors revealed a self-consciousness or a desire to overcome inferiority feelings of a sort that have long beset psychologists in their feelings toward the medical profession.
When we do get around to the point of facing our relationships with medical men, we will doubtless run into problems of an economic character. We will have a power situation on our hands. There are analysts and psychiatrists and numberless other practitioners of medicine who will frankly do what they can, legally or otherwise, to discourage or prevent competition from the psychologist.
On this ground particularly, psychology may be underestimating its own strength. It cannot be assumed that all medical men, especially those in the field of internal medicine, are altogether pleased with psychiatry and psychoanalysis as these arts are practiced today. I can only surmise the reasons for this state of dissatisfaction. Perhaps the average psychiatrist is still prone to diagnose an ailment and let it go at that. He probably still approaches his material, with or without electrotherapy, too mechanically. The psychiatrist of today may still be too insensitive to the dynamics of emotional states and either unprepared or unwilling to "sweat it out" with the patient. The analysts on the other hand are hardly meeting the existing need for psychotherapy. The typical analysis, as everyone knows, still lasts too long and costs too much, thus delimiting its availability, even when brilliantly successful, to a handful of patients who are well-to-do. I would suspect, finally, that the physician who is not a psychiatrist is none too impressed as a rule with the therapeutic results he sees with the patients whom he refers to any class of therapists-be they psychiatrists, analysts or psychologists.
In terms of economics alone, therefore, the practicing psychologist may not be as unwanted as he sometimes seems to feel. Medicine in a sense is waiting for him. The unmet need for psychotherapy is there. It is illimitable, as any sophisticated practitioner of medicine well knows. From a scientific standpoint as well, competition from clinical psychology may turn out to be one of the healthiest things that ever happened to psychiatry and analysis. To be sure of his welcome by the medical fraternity, however, the psychologist who engages in psychotherapy must meet the need more adequately than it has been met to date, and he must be able and willing to acknowledge his own very real limitations.
The moment we try to define the proper scope of the psychologist in a therapeutic setting, we shall, of course, run into .trouble. Here, I suppose, we have the most to learn and are least sure of ourselves. We have heard the questions, "Where does one draw the line between psychology and medicine?" "What are the functions of the psychiatrist as against those of the psychotherapist?" (I might note in passing that psychiatry itself has not precisely defined its own areas of maximum usefulness, for example, in relation to neurology or psychoanalysis.)
I am sure I cannot answer these questions. As a practicing psychologist, I know what kinds of cases I try as rapidly as possible to screen for psychiatric referral. It is partly a question of the depth of the presenting symptoms. Certainly the patient with psychotic symptoms requires immediate psychiatric care, not psychotherapy. One comes to recognize as properly psychiatric material those classes of cases, such as certain obsessive-compulsive types and certain psychopathic persons (of the sort described by D. K. Henderson in his little classic, Psychopathic States), all of which seem to defy any standard techniques of analysis or psychotherapy. No one questions the fact that the psychiatrist instead of the psychotherapist should be dealing with the epilepsies, the migraines, or any other neurological states. The responsible psychotherapist who is conscious of his limitations is also scrupulous in accepting for therapy no person who has not been adequately diagnosed by a physician in the field of internal medicine. Even this precaution is not entirely adequate for the full protection of the patient.
This problem of inter-professional relationships is, obviously, too big for any one therapist to settle privately. The issue requires intensive exploration by the American Medical Association and the American Psychological Association. Such study will entail, no doubt, sustained experimental work on the part of clinical psychologists working closely with dynamically trained psychiatrists. We may discover in the end that no mental specialist, be he psychiatrist, analyst, social case worker or psychologist, should be permitted to work alone, and that no person who works in any of these fields can function at his best in the area where he belongs until clinical or team relationships become the rule rather than the exception in the treatment of neurotic or psychotic human states.
In the meantime the clinical psychologist in private practice must be discreet. If he does not police himself, others will police him. At this very moment, for example, it is illegal in the State of California for anyone but a licensed practitioner of medicine (unless he be otherwise licensed by law) to diagnose or "ascertain or establish any fact concerning the physical, mental, or nervous condition of a patient." These words were written into the State medical code in 1949 for the purpose of outlawing quackery in the realm of psychotherapy. They have not been invoked as yet against any practicing psychologist with doctorate training. They can be used, however, to discipline or drive from practice the psychologist who fails to acknowledge and observe his professional limitations.
May I conclude by saying that the psychologist in private practice feels he has a function to perform, even though the exact boundaries of that function are as yet indistinct. He looks to the American Psychological Association and to the university departments of psychology for leadership. That leadership will not take us very far, at least in my opinion, until psychologists become less afraid of therapy.
END OF ARTICLE
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