Luis Botella, Ph.D.
Ramon Llull University
Plenary talk presented at the XIIIth International Congress on Personal Construct Psychology. Berlin, Germany, July 1999.
Despite the growing and well documented interest toward integration, the field of psychotherapy is still characterized by a wide variety of competing discourses. Attending to the content of most of these competing discourses, one could end up believing that each one is unique, markedly different, and supposedly better. In fact, each one has developed its own terminology, rendering dialogue among them confusing, if not impossible. The problem transcends the terminological question, since different epistemologies and world views are also a potential barrier to dialogue among different psychotherapeutic approaches. No doubt, the process of developing one's identity as a psychotherapist entails, at least for some practitioners, positioning oneself within one of these competing discourses. Belonging to a theoretical persuasion does not only provide a way to approach clinical practice, but also has important social functions such as providing a language and a supporting structure made up of Journals, Conferences, training courses, Associations, etc.
Psychotherapy research established years ago that some of the reasons to defend one's favorite approach over the rest (i.e., that it is unique, markedly different, and supposedly better) are all lacking empirical support. As far as we know, no therapeutic approach has been proven to work better than the rest in general (Lambert & Bergin, 1992; Lambert, Shapiro & Bergin, 1986; Luborsky, Singer & Luborsky, 1975; Sloane et al., 1975; Smith, Glass & Miller, 1980; Stiles, Shapiro, & Elliott, 1986), and they all seem to work more for what they have in common than for the specific techniques they use (Lambert, 1986).
Despite this growing body of well established empirical evidence concerning the importance of common factors in order to explain equivalent therapeutic outcomes, there is a recent trend towards the establishment of a list of so-called Empirically Supported Treatments by the Task Force on the Dissemination of Psychological Procedures (Division 12 of the APA), and parallel movements in the United Kingdom and Germany. At least in the United States, the intention of such a movement seems to be to influence policy makers by 'speaking their language' (Barlow, 1996; Shapiro, 1996). In fact, criteria for the establishment of a treatment as Empirically Supported are patterned after the Food and Drug Administration guidelines for approval of new drugs (manualization, diagnostic specificity, two studies) (Elliot, 1998).
Given the European tradition of following American trends, I would like to use this presentation to stop for a moment and reflect on what will we be doing to psychotherapy if we non-reflexively adopt such a list and the drug metaphor it is based on. Particularly, I would like to contrast the discourse of the medico/biological model, within which the drug metaphor makes sense, with a discursive approach to psychotherapy practice and research. My intention is to argue that the discursive approach is totally compatible with PCP and constructivism, and that psychotherapy research from such a position is not only possible, but already available in some instances.
1. The Medico/Biological Approach To Psychotherapy Practice And Research
The medico/biological model applied to clinical psychology has been sketched by Vallejo (1985) in a series of related assumptions regarding the nature of 'mental diseases' and their cure:
(a) Mental diseases have an etiology or cause; (b) Etiology is organic; (c) Organic etiology produces the symptoms; (d) The set of symptoms of a mental disease leads to its diagnosis; (e) The diagnosis leads to a prognosis; (f) The biological treatment of a mental disease must be focused on its cause (p. 27).
Two examples of this approach to therapy can be found at the following excerpts:
#1: The optimized use of structural and functional neuroimaging methods in the study of mental illness can provide new pathophysiological and pharmacological classifications of patients (mental diseases have an etiology or cause). These findings can be related to the genetic and cellular pathophysiology of disorders that affect the brain in precise ways (etiology is organic). The pathophysiological classification of patients (the set of symptoms of a mental disease leads to its diagnosis) should help provide better and more efficient treatment selections for individual patients and refined, neurobiologically based classification schemes for psychiatric disorders and addictions, in general (the diagnosis leads to a prognosis; the biological treatment of a mental disease must be focused on its cause). (Mazziotta, 1996).
#2: Is Prozac for you? If you have been seriously asking this question, then the answer is probably yes. As opposed to days past when medication was given only to those deeply depressed, today, psychiatrists are treating more young, active, healthy people who are burdened with anxieties and feel they could be performing at a higher level. Prozac increases levels of serotonin, a neurotransmitter. It is effective in treating the entire spectrum of depression from the milder types to the most severe. It is also very valuable in treating obsessional thought and compulsive behavior. Prozac is useful in panic disorder and other types of anxiety and phobia. As a result, it usually increases concentration, energy, and mental acuity. The vast majority of people with any of the above problems start to function at a much higher level. They claim to feel less oppressed by life and generally happier. East End Mood Disorders of Manhattan specializes in treating such people.
The medico/biological model in psychology, as a manifestation of an objectivist discourse, has its own logic of justification, research programs, forms of practice, ethical principles, and even professional and academic communities. It relies on a positivistic approach to research--according to the definition of Guba & Lincoln (1994)--based on the notion that research can converge on the true state of affairs, on an objective description of the 'way things are' in the form of value- time- and context-free generalisations, some of which take the form of cause-effect laws. Therefore, controlled experimental or quasi-experimental methodology should be privileged, as the criteria for the establishment of Empirically Supported Treatments demonstrate.
Undoubtedly, there is research evidence supporting the medico/biological approach to some forms of psychological distress. Such an evidence led some authors to statements as bold as this one:
Pharmacotherapy has been well demonstrated to be effective (…) psychotropic drugs have been a major tool for the study of brain function and have contributed to psychiatry in the area of evaluation technology while behavior therapy arose out of an experimental science and has retained the scientific rigor of its parentage (Werry, 1989, p. 378). (Notice the association the author makes between pharmacotherapy and behavior therapy. No doubt this is a consequence of behavior therapists 'speaking the language' of biologically oriented psychiatrists).
Those who present the medico/biological approach as the only legitimate (i.e., scientific, empirically supported) way to construe clinical psychology and psychotherapy should bear in mind that it has turned out to be more fallible than they usually admit. In his detailed and documented critique, Vallejo (1985) highlights, for example, the difficulty of defining the term 'mental disease' (and 'mental health'), to find the 'organic cause' of most psychological disorders, the subjectivity and controversial nature of some diagnostic labels (see also Kleinke, 1994), and the only partial effectiveness of some biomedical treatments even in the case of disorders whose causation may be genetically linked.
Critiques to the medico/biological model have also been voiced from within the field of psychotherapy research. In their detailed review of well controlled and executed studies the members of the Institute for the Study of Therapeutic Change found that such studies often fail to find a difference favoring drugs over psychotherapy or even an additive benefit from combining drugs with psychotherapy. Besides, data from the National Institute of Mental Health Treatment of Depression Collaborative Research Project (Blatt, Sanislow, Zuroff, and Pilkonis, 1996) showed again that the variance attributable to the therapist overshadows any difference between the forms of treatment that are offered (IPT, CBT, Pharmacotherapy, and placebo for the treatment of depression). This large-scale study once again found that differences in outcome were more 'related to differences among patients and therapists than to types of treatment' (p. 1277). Effective therapists: (1) had more experience treating depression prior to the study; (2) were more likely to treat with psychotherapy alone; and (3) rarely used medication either alone or in combination in their treatment of depression. In conclusion, 'more effective therapists (in this study) have a psychological rather than a biological orientation in their treatment approach'.
Despite the growing body of critiques and discontents (ranging from psychotherapy researchers to former psychiatric patients), the medico/biological model is alive and well, probably due to the world wide billion dollar pharmaceutical industry that supports it. I'm sure we all have our favorite horror story about the power of money from the pharmaceutical industry. I was recently told by a Spanish psychiatrist and family therapist, that a given pharmaceutical company is paying for the whole fees of taking 100 Spanish psychiatrists and their accompanying persons to the 1999 Annual Congress of the American Psychiatric Association in Washington D.C.--and that includes registration, accommodation at a first class hotel, travel expenses, and an extra free week spent in Hawaii prior to the congress. If you were one of these psychiatrists, would you dare presenting data challenging the effects of drugs during the Congress? Anyway your chances to do so are very little, since the company I am referring to also made a generous offer to write (and publish) the presentations for the psychiatrists. Why don't they write their own presentations? Well, maybe they belong to the group of 'young, active, healthy people who are burdened with anxieties and feel they could be performing at a higher level'. If they don't I definitely do as I am sitting in front of the computer sweating and writing this while I fantasize about surfing in Hawaiian beaches. Well, I can always trust Prozac to 'take my blues away'.
A different source of critiques to this or any other approach can be based on the positions it invites, i.e., on the relational possibilities it opens (or closes) once one is 'making sense' in terms of that given form of intelligibility. In this case, as could be seen in the excerpts I presented before, therapists are positioned as experts, treatment as the main factor in the patient's cure, and patients as non-responsible either for the problem or its cure. None of these positions has received support from psychotherapy research on factors contributing to client's change (see, e.g., Lambert, 1986). The psychiatrist I mentioned before told me an apparently not-so-well kept secret of his profession: biologically oriented psychiatrists love working with depressives because if they don't respond to antidepressant medication, they never accuse the psychiatrist or the drug but, as can be expected from someone who is depressed, they accuse themselves.
As an alternative to this medico/biological approach to clinical psychology and psychotherapy, there is at least another picture of human beings and their modes of life that have been available in various branches of human studies since the nineteenth century. As discussed, among many others, by Harré (1999):
There is the picture of human life as a collective activity, in which individuals work with others to fulfil their intentions and achieve their projects according to local rules and norms.
The alternative to the study of psychological processes as manifestations of a biological substratum with a real existence is to approach them as inherently linked with discourses. In a recent formulations of a similar position, Martin (1994) highlights how most psychological processes (in contrast with physical/material processes) cannot be decomposed in 'atoms' with an ultimate referent in reality. Would it make any sense, for example, to approach the study of an emotion such as love from the perspective of reducing it to its manifestations or tangible causes (be them biological or behavioral)? To adopt such an approach (as some clinical and social psychologists have done in the past) means ignoring the extent to which love is defined and experienced differently by each culture, in each historical period, and, probably, by each one of us. It means to attribute an ontological status of objective existence to something that is, inevitably, a socially shared form of discourse to refer to a highly subjective experience. Ultimately, it represents a blind alley that only leads to irrelevant or misguided results.
From a constructivist and discursive position, approaching psychological processes always entails approaching a form of social or personal construction of these processes. Psychology cannot reach reality in its essence, as objectivism claims, but the way in which individuals or communities make sense of their experience. As Zen Buddhists would say, 'the finger pointing at the moon is not the moon itself'. This may seem like a subtle difference, but it is a fundamental one.
From a discursive approach, psychological distress can be conceived of as a 'block' in optimal personal and relational functioning, as is the case with some PCP approaches to disorders based on the Cycle of Experience. Optimal functioning entails an ongoing joint process of meaning making and positioning oneself within a relationally sustained network of discursive practices (narratives, construct systems…). Diagnostic labels are thus interpreted as social constructions, i.e., socially sustained ways to make sense of such 'blocks'.
For example, in a recent paper by Caro (1999) she refers to the work of Chesler (1973) Women and Madness to highlight how the historical origin of the diagnostic label kleptomania began with the opening of the first department stores in major European cities in the early 19th century. The anonymity of such stores fostered theft among all kind of customers. However, when theft was committed by a working class woman, she was considered a delinquent and taken to the police. Conversely, when theft was committed by an upper class woman, it was considered the product of a mental disorder (how could an upper class woman be called a 'delinquent'?), the family was informed, and she was sent home after giving back the stolen property.
Before closing this section, however, I would like to highlight a point mentioned among others by Martin (1994) that I regard as essential, since it can lead to a misunderstandings of constructivism and other discursive approaches. Stating that the objects of psychology are products of a social or individual discursive construction does not mean that their effects are an 'illusion' or that they cannot be the object of research. Collective or individual constructions of experience are anchored in social, cultural, linguistic, historical, and discursive conventions that, even if they change, do not do so overnight. It is within these conventions, not at all ephemeral, where psychology as a science makes sense. In other words, even if 'depression' is approached as a socially shared label to make sense of a form of human experience, and not only as a disorder with a medical cause, this does not mean at all that depression does not exist, that it does not cause suffering to depressed people, that nothing therapeutic can be done about it or that it cannot be the object of scientific research. The difference between these two approaches to depression, however, is the ontological status attributed to the phenomenon. An objectivist position would consider depression as something located in the biological substratum or in some psychological entity with an objective existence, while constructivism would locate it in the domain of socially shared forms of construing human experience.
There are many potential ways to approach psychotherapy from a discursive position: constructivism, constructionism, postmodern and narrative therapies… However, what is common to all of them is a move away from medical or drug metaphors. Rather, psychotherapy is addressed at helping clients regain a feeling of agency and movement, and it is construed as the activity of generating meanings which might potentially transform experience through collaborative dialogue (Kaye, 1995).
This stance towards the encouragement of the client's agency and involvement (instead of seeing him or her as the passive recipient of a medical intervention) is supported by Luborsky's et al (1988) review of client's factors that contribute to positive therapy outcome. Particularly, this review showed the significant effect of the client's developing a problem solving stance and of the creation and maintenance of positive expectations towards change.
A discursive approach to research relies, according again to the definition of Guba & Lincoln (1994), on a constructivist paradigm. Whatever 'reality' is, it is only apprehensible through people's constructions of it. Thus, research cannot reveal the true state of any domain, but people's socially and experientially based constructions of it, local and specific in nature. There is no reason to support a single methodology over the rest, provided they all contribute to elicit and refine our knowledge of such constructions by means of unforced consensus through open dialogue.
Reflexive methodologies such as the one proposed by Viney (1988), as well as the variety of methodologies (quantitative and qualitative) that characterize PCP, constructivist, and narrative psychotherapy research are a good example of this point.
In sharp contrast to the medico/biological model, a discursive approach invites positioning the therapist as a facilitator of a change-promoting therapeutic conversation. As Kelly (1969, p.220) discussed:
The task of the therapist is to join with the client in exploring the implications of the constructions he or she has devised for understanding reality. From this point of view therapy becomes an experimental process in which constructions are devised or delineated and then tested out.
Therapeutic relationship is considered the main factor in the fostering of the client's change. Also, a deconstructive stance towards 'responsibility' is encouraged, since from this position it is quite arguable that one's 'problems' belong to oneself. As highlighted by some narrative family therapists, people are not the problem, but the relation a person has to a set of resources (or constructs) for making sense of his or her situation can position people 'in' problems. This is why the client's active stance towards reconstruction and increased awareness and reflexivity is encouraged in almost all of this therapies.
I'll end up by quoting just a few examples of empirical support for this approach to the therapeutic relationship. Process research such as the one carried out by Angus and her colleagues (e.g., Angus & Hartdke, 1994) focusing on the narrative processes in psychotherapy has consistently found that good outcome therapies are related to the client's development of a reflexive stance towards his or her narratives. Also, Clarke's research on the creation of meaning in psychotherapy (e.g., Clarke, 1996) shows that such a creation is a joint product of the therapeutic conversation, and that the client's active and reflective stance is fundamental to its successful outcome.
To finish up my presentation, it looks like Kelly was prophetic in the sixties when, previously to the amount of empirical findings that support the notion that the therapeutic relationship is far more important than the techniques the therapist uses, he anticipated that:
Personal construct psychotherapy is a way of getting on with the human enterprise and it may embody and mobilize all of the techniques for doing this that have been yet devised. Certainly there is no one psychotherapeutic technique and certainly no one kind of interpersonal compatibility between psychotherapist and client. The techniques employed are the techniques for living and the task of the skillful psychotherapist is the proper orchestration of all of these varieties of techniques (Kelly, 1969, p. 222).
I can think of no better, timely, and empirically supported argument against the notion of manualizing treatments and administering them to groups of diagnostically standardized patients, turning psychotherapy into the equivalent of a psychological pill.
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