February 28, 2006

A Mind Is a Terrible Thing to Measure

Psychotherapy has to occupy the difficult middle ground , but without taking sides
By ADAM PHILLIPS The New York Times: Sunday, February 26, 2006
PSYCHOTHERAPY is having yet another identity crisis. It has manifested itself in two recent trends in the profession in America: the first involves trying to make therapy into more of a "hard science" by putting a new emphasis on measurable factors; the other is a growing belief among therapists that the standard practice of using talk therapy to discover traumas in a patient's past is not only unnecessary but can be injurious.
That psychotherapists of various orientations find themselves under pressure to prove to themselves and to society that they are doing a hard-core science — which was a leading theme of the landmark Evolution of Psychotherapy Conference in California in December — is not really surprising. Given the prestige and trust the modern world gives to scientific standards, psychotherapists, who always have to measure themselves against the medical profession, are going to want to demonstrate that they, too, deal in the predictable; that they, too, can provide evidence for the value of what they do.
And, obviously, if psychotherapy is going to attain scientific credibility, it won't do to involve such wishy-washy practices as "going back to childhood" or "reconstructing the past" — terms that when used with appropriate scorn can sound as though a person's past was akin to the past lives New Agers like to talk about.
Since at least the middle of the 19th century, Western societies have been divided between religious truth and scientific truth, but none of the new psychotherapies are trying to prove they are genuine religions. Nor is there much talk, outside of university literature departments, of psychotherapy trying to inhabit the middle ground of arts, in which truth and usefulness have traditionally been allowed a certain latitude (nobody measures Shakespeare or tries to prove his value).
It is, so to speak, symptomatic that psychotherapists are so keen to legitimize themselves as scientists: they want to fit in rather than create the taste by which they might be judged. One of the good things psychotherapy can do, like the arts, is show us the limits of what science can do for our welfare. The scientific method alone is never going to be enough, especially when we are working out how to live and who we can be.
In the so-called arts it has always been acknowledged that many of the things we value most — the gods and God, love and sexuality, mourning and amusement, character and inspiration, the past and the future — are neither measurable or predictable. Indeed, this may be one of the reasons they are so abidingly important to us. The things we value most, just like the things we most fear, tend to be those we have least control over.
This is not a reason to stop trying to control things — we should, for example, be doing everything we can to control pain — but it is a reason to work out in which areas of our lives control is both possible and beneficial. Trying to predict the unpredictable, like trying to will what cannot be willed, drives people crazy.
Just as we cannot know beforehand the effect on us of reading a book or of listening to music, every psychotherapy treatment, indeed every session, is unpredictable. Indeed, if it is not, it is a form of bullying, it is indoctrination. It is not news that most symptoms of so-called mental illness are efforts to control the environment, just like the science that claims to study them.
It would clearly be naïve for psychotherapists to turn a blind eye to science, or to be "against" scientific methodology. But the attempt to present psychotherapy as a hard science is merely an attempt to make it a convincing competitor in the marketplace. It is a sign, in other words, of a misguided wish to make psychotherapy both respectable and servile to the very consumerism it is supposed to help people deal with. (Psychotherapy turns up historically at the point at which traditional societies begin to break down and consumer capitalism begins to take hold.)
If psychotherapy has anything to offer — and this should always be in question — it should be something aside from the dominant trends in the culture. And this means now that its practitioners should not be committed either to making money or to trivializing the past or to finding a science of the soul.
If you have an eye test, if you buy a car, there are certain things you are entitled to expect. Your money buys you some minimal guarantees, some reliable results. The honest psychotherapist can provide no comparable assurances. She can promise only an informed willingness to listen, and the possibility of helpful comment.
By inviting the patient to talk, at length — and especially to talk about what really troubles him — something is opened up, but neither patient nor therapist can know beforehand what will be said by either of them, nor can they know the consequences of what they will say. Just creating a situation that has the potential to evoke previously repressed memories and thoughts and feelings and desires is an opportunity of immeasurable consequence, both good and bad. No amount of training and research, of statistics-gathering and empathy, can offset that unique uncertainty of the encounter.
As a treatment, psychotherapy is a risk, just as what actually happens in anyone's childhood is always going to be obscure and indefinite, but no less significant for being so. Psychotherapists are people whose experience tells them that certain risks are often worth taking, but more than this they cannot rightly say. There are always going to be casualties of therapy. Psychotherapy makes use of a traditional wisdom holding that the past matters and that, surprisingly, talking can make people feel better — even if at first, for good reasons, they resist it. There is an appetite to talk and to be listened to, and an appetite to make time for doing those things.
Religion has historically been the language for people to talk about the things that mattered most to them, aided and abetted by the arts. Science has become the language that has helped people to know what they wanted to know, and get what they wanted to get. Psychotherapy has to occupy the difficult middle ground between them, but without taking sides. Since it is narrow-mindedness that we most often suffer from, we need our therapists to resist the allure of the fashionable certainties. Adam Phillips is a psychoanalyst and the author, most recently, of "Going Sane: Maps of Happiness."

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