Contemporary Issues and Future Dilemmas
Department of Clinical Psychology
Ramon Llull University
This paper focuses on a prospective approach to the future of clinical psychology and psychotherapy from the personal perspective of its author. First, the basic dilemma confronting a psychotherapy for the future is presented in terms of the alternative discourses of objectivism and constructivism. Secondly, the ontological status of the object of psychological science is discussed. A central part of the paper is devoted to the implications of the aforementioned developments for psychotherapy research, practice, and teaching/training. Finally, a series of items for the future agenda of psychotherapy and clinical psychology are proposed.
Clinical Psychology, Psychotherapy, and Mental Health:
Contemporary Issues and Future Dilemmas
This paper focuses on some selected contemporary issues and future dilemmas that clinical psychology and psychotherapy will face in the context of their present status and foreseeable development. So as to structure this prospective presentation, the paper is divided into six parts. First, an introductory characterisation of the main dilemmas that clinical psychology and psychotherapy will face in the next decades. Second, a brief but necessary discussion of the ontological status of the object of psychological science. Next, three sections on the implications of the aforementioned issues for research, practice, and training in clinical psychology and psychotherapy. Finally, a summary of selected conclusions.
The historical development of the span of psychological thought in the past led to what nowadays constitute two alternative and hardly compatible discourses: objectivism and constructivism. Before briefly characterising these two psychological discourses, however, I would like to clarify some basic concepts.
First, I use the term "discourse" to refer, according to the social constructionist tradition, to "a set of statements that constitute an object" (Burr, 1995, p. 184). In this sense, objects (or, at least, their meaning) do not precede discourse, but are created by discourse.. Thus, psychology’s basic question can no longer be, "what is a human being?", but "what kind of human being is constructed by our theoretical discourse?" As can be seen, this is a clearly anti-essentialist position. Having said that, it would then be clear that the ultimate criteria of the "quality" of a given discourse cannot be its truthfulness assessed via a contrast with reality, because reality is co-created by that very discourse. Certainly there are other quality criteria left, but so far what I would like to highlight is that, even if I present objectivism as opposed to constructivism, I think that neither one nor the other can be defended as more truthful, but that will be dealt with in more detail in the rest of my presentation by these other criteria I mentioned before.
On the other hand, I use the term "discourse" almost as a synonym of "metatheory", i.e., a series of assumptions of a high conceptual level common to different psychological theories. It would not be correct, then, to equate a given discourse with just one theory, since there are more theories than discourses. In the field of contemporary psychology, it is obvious that different theories share the same deep assumptions on such basic issues as the nature of human beings, knowledge, science, or psychological disorders and their cure.
What I refer to in this paper as the "discourse of objectivism" has been referred to differently in other authors’ works (e.g., positivism, naïve realism, received view) and has been widely characterised in terms of its basic assumptions in a growing body of recent publications (see Botella, 1995). To synthesise these characterisations, the core assumption that identifies the discourse of objectivism is that Reality exists independently of the observer, and can be known with objective certainty if the right means are used. This objectivist view has its roots in Newtonian physics and in the worldview of Modernism, which influenced psychology in its historical origins (see Anderson, 1990; Botella and Figueras, 1995; Gergen, 1991). When applied to clinical psychology and psychotherapy, this discourse carries not only epistemological implications, but also methodological, technical, and ethical ones.
The discourse of constructivism has also been referred to (and it still is) differently according to different authors (e.g., constructionist, hermeneutic, post-modern, discursive, post-rationalist, narrative). Even if each of these terms has slightly different meanings, what is common to all forms of constructivism is the assumption that reality cannot be conceived of as independent of the observer, and that our knowledge is a product of the contrast between our constructions and reality as we experience it (see Botella, 1995). The historical roots of constructivist thought date back to pre-Socratic philosophy, and can be traced along the whole history of human ideas (see, e.g., Mahoney, 1991). Also in this case, the implications of construing the object of psychology from this discourse are not only epistemological.
As for the nature of knowledge, constructivism assumes that knowledge is a hypothetical (i.e., anticipatory) "construction". Thus, it departs from the traditional objectivist conception of knowledge as an internalised representation of reality. This constructivist assumption can be traced back to Kant's philosophy and to Popper's notion that no knowledge originates in pure observation, since every act of observation is theory laden (see Popper, 1974).
Epistemic values, according to Howard (1986), are "those criteria employed by scientists to choose among competing theoretical explanations" (p. 135). Questions on epistemic values rarely arise in objectivism, since knowledge is viewed as a representation of reality and, consequently, explanations are chosen according to their truth value (i.e., their correspondence with the external reality they represent). The objectivist conception of knowledge and truth are thus closely linked and, as noted by Mahoney (1991), imbued science with "justificationism"; the reliance on the authority of facts to justify a given knowledge claim.
Constructivism cannot rely on the original/copy correspondence metaphor, since it departs from a representational conception of knowledge. Justification by means of the authority of truth is then regarded as an illusion, a "never achieved ideal or horizon concept" (Howard, 1986, p. 134). This non-justificationist position leaves constructivism facing the task of articulating an alternative set of epistemic values, taking into account that values are, by definition, subjective preferences. Constructivist epistemic values vary according to different constructivist theories, whereas all of them can be viewed as alternatives to the justificationist position. Two of the most pervasive sets of epistemic values in constructivism metatheory, however, correspond to (a) the pragmatic value of knowledge claims (i.e., their predictive efficiency, viability, and fertility), and (b) the coherence of knowledge claims (i.e., their internal and external consistency, and unifying power).
As I said before, construing psychology from one discourse or the other depends ultimately on the ontological status attributed to the object of psychological theories, a point I would like to focus on now.
The decision of focusing the study of psychological processes from an objectivist or constructivist standpoint is related to a previous and inevitable ontological assumption. The researcher, theorist or practitioner needs to ask him or herself about the ontological status of the object he or she is working with. This need is common to all science, and not posing it explicitly leads only to the hidden assumption of an implicit answer. To sum up, the key question in respect of this point is what is the level of existence of the phenomena to which psychological knowledge is applied.
Traditionally, this question has received two answers in the course of the history of psychology. The first one, closely aligned with objectivism, is inspired, as I said before, in a partial understanding of Newtonian physics, and asserts the objective existence of psychological phenomena. In fact, this perspective rather proscribes (i.e., forbids) that anything not measurable and observable, or without a clear biological/material referent, becomes an object of psychological study. The best example of this position applied to psychology is orthodox behaviourism, with its traditional emphasis on the study of observable behaviour.
Nevertheless, the historical blind alley to which behaviourism was led (visible in clinical psychology in the evolution from behaviour therapy to cognitive-behaviour therapy) reflects the infertility of a psychology that begins by excluding as an object of study everything that is most essentially human, such as language, consciousness, memory, or emotions. Driven to this point, we face the key question of what is the ontological status of the "phenomena" just mentioned.
In my opinion, two options are opened again in front of us (particularly as clinical psychologists and psychotherapists). The first one consists of a rebirth of the discourse of objectivism, even though far from the rigours of behaviourism, and can be seen in the attempt to reduce all psychological processes to their biological components. Thus, we can equate psychology to the study of the biological (i.e., physiological, genetical, neurological…) manifestations of psychological processes. Certainly, we are currently witnessing an impressive growth of the popularity of such an approach (called the medico/biological model by some authors) evident in some best-selling books on the supposed genetical origin of intelligence, gender or ethnic differences, etc. However, this critique would be an inadequate and somewhat caricature view of the researches of the ‘neural Darwinians’, represented in the Anglo-Saxon world philosophically and scientifically by such authors as Dawkins, Dennett, Edelman, Pinker, Gazzaniga, Sachs, and many others, most of whom are as anti-crude geneticism as we would like to be; e.g., the genetic model of the single origin of language, of which Pinker’s is a good popular account, emphasises its universality transcending any specific racial origin.
The medico/biological model applied to clinical psychology has been nicely sketched by Vallejo (1985) in a series of related assumptions regarding the nature of "mental diseases" and their cure:
(a) Mental diseases have an aetiology or cause; (b) Aetiology is organic; (c) Organic aetiology 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).
The medico/biological model in psychology, as a manifestation of an objectivist discourse, has its own logic of justification, research programmes, forms of practice, ethical principles, and even professional and academic communities. Nevertheless, those who present it as the only possible way to construe clinical psychology 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 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.
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 one of the most recent and detailed formulations of this constructivist 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 behavioural)? 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 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. Of course, we should not oversimplify the epistemic issues here, for ultimately the moon also is constructed within our discourses. For example, in contrast with an objectivist approach to the study of intelligence--such as the ones mentioned before concerning its genetical components--Robert Sternberg’s triadic theory of intelligence (see Sternberg, Conway, Ketron, and Bernstein, 1981) derives from a methodology based on asking people what they mean by intelligence and reducing the inter-individual variability of their answers to their shared components. Even if Robert Sternberg is not an author particularly close to a constructivist perspective, in this case his approach illustrates nicely the point I was referring to.
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 one of the worst misunderstandings of constructivism. Stating that the objects of psychology are products of a social or individual discursive construction does not mean that their effects are not "real" or that they cannot be approached with scientific quality. 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 trait with an objective existence, while constructivism would locate it in the domain of socially shared forms of construing human experience.
Having said that as a form of framing the dilemma that in my opinion will face psychology in the future, I would like to focus the next sections of this paper on an analysis of the implications of both discursive alternatives (objectivism and constructivism) to the construction of clinical psychology and psychotherapy in three interrelated domains; psychological research, clinical practice, and training. The dilemma between objectivism and constructivism is visible in these three domains through its maybe most obvious consequence: the call for multiplicity embodied by constructivism versus the orthodox dogmatism (methodological, theoretical, and clinical) of objectivism. In some previous works related to this issue (e.g., Botella, 1995; Botella and Figueras, 1995), my colleagues and I have highlighted the connections between these opposite positions and the broader cultural scenarios of Modernism (in the case of objectivism) and Post-modernism (in the case of constructivism).
Even if research, practice, and training in clinical psychology and psychotherapy are inextricably intertwined, I will begin by focusing on the future of research since, in my opinion, research should guide practice and training.
Objectivism in psychological research has traditionally made a strong call to adopt a single methodology (positivistic and quantitative) as the only safe way to access reality and scientific truth. Key concepts in classical methodologies of psychological research, as well as assessment devices such as psychometric tests, are implicitly or explicitly inspired in an objectivist view of knowledge. Even if this approach has proven to be fruitful and useful in some domains, it has also proven its insensitivity to some others. Ultimately, when one reviews the research literature on, for example, personality traits that correlate with a given pathology, one is invaded by a feeling of clinical and applied irrelevance. It seems as if the most significant point in psychotherapy research (the client’s own experience) had been lost under layers of constructs belonging to the experimenter instead. It is probably this feeling of irrelevance what fosters the alarming disinterest of most practitioners concerning basic research (see, e.g., Mahoney, 1991).
In psychotherapy research, a first historical stage can be distinguished (see Botella and Feixas, 1994); it was a stage in which most efforts were addressed to proving what theoretical model of treatment was better than the others. Outcome research, as it has been called, arrived finally to the paradox of outcome equivalence (see Luborsky, Singer, and Luborsky, 1975). Apparently, as far as outcome is concerned, no theoretical model of psychotherapy is clearly better than all the rest. This result is only paradoxical, however, when considered from an objectivist standpoint that anticipates that there can only be one form of effective psychotherapy—the one addressed to the real cause of the disorder.
Outcome equivalence should make us reflect on the possibility that the ontological status of the object of our research as psychologists (in this case, psychological disorders and their treatments) may be a form of construing experience and, thus, may respond equally well to different forms of treatment according to client, therapy and relationship variables.
In this domain, thus, a call should be made for a multiplicity of methods and research approaches. Psychotherapy outcome research is no longer as interesting as psychotherapy process research. Knowing what sort of therapy works (even if it is still necessary in some cases) seems to be a first step in a process that leads naturally to the question of what makes it work, i.e., what are the variables of the client, therapist, and therapeutic relationship that can account for psychotherapeutic change? For this kind of research, traditional methods and instruments appear insufficient. What is being studied is an interpersonal activity, socially constructed, markedly inter-subjective, unique, and conversational. The best methodologies to approach such a complex domain seem to come from disciplines such as anthropology (e.g., conversation analysis), sociology (e.g., grounded theory methodology), and even literature (e.g., narrative analysis). In most cases, they are qualitative methodologies that depart from the rigours of positivism. Despite the occasional critique of some radical positivists, qualitative methodologies are increasingly accepted due to their scientific quality (see, e.g., Denzin and Lincoln, 1994). Obviously, the use of qualitative methodologies in psychotherapy process research does not exclude the use of quantitative methods as well.
Ideally, research and practice should be closely related, and one should dialectically inform the other. Actually, this is not always the case. Nevertheless, this dialectical relationship becomes evident in some cases in dysfunctional ways. For example, during 1997 we witnessed a heated argument on the effectiveness of psychoanalysis, not in the pages of a scientific journal or during a congress, but in a widely read Spanish newspaper instead. Once again, the calls to dogmatism of some of the participants in the debate were evident in their war-like form of speech. In the article that initiated the debate (Ferrer, 1979), the author accused psychoanalysis of being a "pseudoscience" characterised by its "lack of logic, methodological flaws and thesis incompatible with the empirical data we currently have " (p.7). The basis for such daring accusations was a misunderstanding between psychoanalysis and psychoanalytic psychotherapy, and a review of outcome research that only covered data previous to 1978, including the controversial study by Eysenck (1952), widely criticised nowadays because of its methodological biases. Again, it is obvious that the calls to dogmatism are not capable of accommodating the increasing complexity of our post-modern world in a permanent state of change.
If we are coherent with the results of psychotherapy research, leaving interested short-sightedness behind, we will have to admit that the future of clinical and psychotherapeutic practice will be one of increasing eclecticism (see Mahoney, 1991). Among other factors influencing the increasing popularity of psychotherapeutic eclecticism, the research result on the equivalence of outcomes is one of them.
Having said that, the term "eclecticism" certainly has some negative implications, since in some cases it means a random combination of techniques that are theoretically incompatible among them. My position regarding this issue coincides with the constructivist proposal of a theoretically progressive integration in psychotherapy (Neimeyer, 1992). Basically, this model proposes to analyse the relative compatibility between pairs of theoretical models, and to integrate them at different hierarchical levels (metatheory, basic theory, clinical theory, techniques) according to their consistency. For example, the congruence or compatibility between some forms of cognitive, systemic, and constructivist approaches has been repeatedly highlighted, and informs my own clinical practice at the Centre for Cognitive Therapy in Barcelona, as well as the clinical training of the students at the Master’s Degree in Clinical Psychology and Psychotherapy that I co-ordinate at my University.
The development of knowledge in the domains of clinical psychology and psychotherapy renders a general under-graduate training insufficient. Thus, post-graduate degrees in psychotherapy are being offered all over Europe, most of them in the form of Master’s degrees. Training criteria for European psychotherapists are being standardised by the European Association for Psychotherapy. However, I would like to focus on some issues other than training standards.
We must admit the manifold nature of psychotherapy. Thus, I regard the inclusion of contents from "health sciences" in psychotherapy training curricula as fundamental. However, I believe it is equally important to include contents from human and social sciences (such as anthropology, sociology and social psychology, and literature). Psychotherapy cannot be alien to the rest of human enterprises, particularly to the social, cultural or even political ones. The practice of clinical psychology and psychotherapy (at least from my constructivist perspective) does not only consist of "healing patients", but of understanding and relating to human beings who are experiencing the consequences of socially shared (or not shared) constructions.
On the other hand, the training of future psychotherapists calls for an attitude of informed critique, overcoming the traditional isolation of different therapeutic schools. Contemporary psychotherapy is no longer a question of theoretical persuasions, and advanced training requires an awareness that some contents are beyond controversies among therapeutic schools.
Training in clinical psychology and psychotherapy should also provide the therapist with experiences of personal growth and development. Even though some therapeutic schools (particularly psychoanalysis) have always advocated the need of a personal therapy as part of professional training, I think that all of them should foster a serious reflection on the therapist’s own processes. My experience as a clinical supervisor makes me think that the therapist’s developmental level is often more important than his or her level of knowledge or experience--particularly during difficult moments in the course of psychotherapy.
To end this paper, and as a renewal of and invitation to an enthusiastic exploration of a challenging but rewarding profession, I would like to use the words of someone I admire and respect. He has the strange virtue of always finding the words one needs to hear so as to take the next step in life. Maybe that is what defines a good psychotherapist:
Like those they intend to serve, scientists and practitioners alike are wise to recognise both the limits and the potential of their understanding. Those of us who seek to understand, comfort, and counsel human lives in progress must therefore be vigilant in the responsible nurturance of our own hopes as well as in learning the lessons of our fears and failures. Our counsel must also be more than rational or strategic rhetoric; rather, our reason must be guided by an informed heart. To most valuably serve those who seek our counsel, we must also invite and affirm their courage to be. Without such courage there will be diminished engagement and exploration, which constitute the experiential pulse of human life (Mahoney, 1991, pp. 374-375).
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