Art and Science I: Please hold the Science

I was at a cafeteria and ordered psychotherapy without science. The waiter said, “Sorry, we’re all out of science. Is psychotherapy without art okay?”

I

When I bring up the research from clinical psychology on outcomes of psychotherapy other therapists say to me, “psychotherapy is an art and a science.” Yet I’ve had one colleague say to me, “science can’t tell us anything since it’s always changing it’s mind.” Another told me, “science cannot reveal anything about therapy because therapy is about human relationships.” These are statements of “psychotherapy without science.”

I try to spend time getting to know the scientific, empirical, naturalistic paradigm as I believe it is the best tool to predict what will happen and is thus essential for determining how to act. Fortunately, there are groups of clinicians who are interested in the difficult exploration of researching the outcomes of psychotherapy and how it might help us understand how to actually be helpful rather than just intending to be helpful.

II

In the 50s, Hans Eysenck took a hard shot across the bow of our field by publishing a paper examining the evidence of whether psychotherapy helped a group of people with (what were called at the time) neurotic disorders. He looked at the evidence he collected and concluded that psychotherapy didn’t work! This led to a wave of responses and the application of Meta Analysis to studies on psychotherapy in a seminal work by Smith and Glass, “Meta-Analysis of Psychotherapy Outcome Studies.” Their expansive study contradicted Eysenck, concluding that psychotherapy had a demonstrable and significant positive effect with about 75% of people who were treated better off than those who did not receive treatment.

Today, the American Psychological Association has a statement with references to the extensive evidence covering decades of research which recognizes the well established effectiveness of psychotherapy. I have to explain a little about how they determine this. Psychotherapy’s effectiveness in helping people is assessed in a number of ways: self report, other report, clinician assessment, or metrics such as number of hospital visits or number of suicide attempts. It is measured in “effect size,” a measure of the distance between the means of two groups measured in standard deviations. In almost any way we assess psychotherapy, the effect size comes out at around 0.8, which is considered a large effect size and corresponds to 79% of the treated being better off than the untreated. This means the outcome of psychotherapy is similar to well established medical interventions such as coronary bypass surgery, arthritis medication, and AZT for AIDS.

Psychotherapy works.

III

After graduating with my master’s degree I found myself working in a group practice in New York. A friend from my clinical supervision group turned me on to a podcast about common factors theory. In the podcast, they suggested there was good evidence that the specific things said in therapy were not what determined outcomes but rather there was something else that was common to many different styles of psychotherapy that seems to determine outcomes. This led me to the authoritative book on the matter, The Heart and Soul of Change: Delivering What Works In Therapy. The evidence was solid and my confidence was shaken… I spent so much time in graduate school learning what to say and what not to say and those ‘specific ingredients’ didn’t seem to matter! I felt as though I had been misled… as though I was misguided in my work as a clinician. My clients noticed the change in me and half of them dropped me as their therapist.

I found myself at a loss. We have many pretenses about what it means to say that science supports psychotherapy… or that psychotherapy is scientific. But the research on outcomes seems to show that the specific ingredients in what we say aren’t what makes the difference. So why do we spend so much time and effort on “Evidence Based Treatments” that teach you what to say?

IV

I’ve long felt reluctant to discuss what actually seems to account for the outcomes in psychotherapy. There’s this threat that revealing it might take its power away. If we peek behind the curtain to see the wizard, does he lose his power? Part of this is due to the initial conclusion I drew from reading The Heart and Soul of Change: if there isn’t a difference in outcomes between the wildly divergent styles of psychotherapy, could it be that it’s merely a placebo?

The different styles of psychotherapy all contain essential common factors that help people change. This is one of the areas of research that Bruce Wampold focuses on. In a recent paper he discusses his finding that common factors predicts outcomes better than the specific ingredients that evidence based treatments focus on. Because of this, Wampold proposes we think about psychotherapy through a contextual model (which focuses on the healing relationship) rather than a medical model (which focuses on providing the treatment which heals). His research shows that the better we deliver the parts of the contextual model, the better the outcomes.

This is where I get perplexed. Is this how a placebo works? Does that word fit at all at this point or is it a concept out of place?

V

A few weeks ago I got to spend some time with Scott Alexander of SlateStarCodex. While talking to him about what makes psychotherapy work, I came upon another way to think about it. Maybe different styles of psychotherapy are all good enough approximations for our underlying psychology, are not fundamentally different, and thus something like a transtheoretical interpretation is true. That is to say, the underlying similarities between therapeutic modalities in The Handbook of Psychotherapy Integration could be the right interpretation for why psychotherapy works.

I was eager for a chance to ask a researcher I really respect about this. At the Los Angeles County Psychological Association’s annual convention this year, the speaker was Scott D Miller. As one of the authors of The Heart and Soul of Change, he is a major player in the search for the answers to, “what makes psychotherapy work?” and “how can we make it work better?” After his talk, I got the chance to sit down and speak with him.

When I asked him whether psychotherapy was a placebo or whether all the styles of psychotherapy are fundamentally the same, he gave me a response I’m still working to digest. He said, “That kind of thinking continues to look at it through the medical model. I’m only interested in what better facilitates the process of healing.” We went back and forth in our discussion regarding whether psychotherapy has “lost its magick,” with him making impassioned appeals for bringing the art back into the science. He believes we’re too locked into “psychotherapy without art.”

Miller argues that we shouldn’t see ourselves in the narrow profession of ‘psychotherapy’ but in the broader profession of ‘healing.’ This makes me recall reading On Being a Therapist during my master’s program where Jeffrey Kottler romantically describes therapy as a progression of shamanism. Surely the pragmatic philosophy of William James must be driving these people... they have an incredible openness to The Varieties of Religious Experience in order to achieve their goals!

But that’s not the kind of person I am.

VI

I imagine there may be different epistemic personalities. There are people who want everything to be exacting and there are people who can go with the flow and accept ambiguity. Alan Watts has a talk where he refers to this, dividing people as either "prickles" or "goo":

The prickly people are advocates of intellectual porcupine-ism. They want a rigor, they want precise statistics, and they have a certain clipped attitude in their voices. And you know this very well in academic circles, where there are people who are always edgy like that. And they accuse other people of being disgustingly vague and miasmic and mystical. But the vague, miasmic, and mystical people accuse the prickly people of being mere skeletons with no flesh on their bones. And they say to you, You just rattle! You’re not really a human being. You know the words but you don’t know the music.”

I imagine these personalities leave us with predilections for different cultural projects like science or mysticism, analytic philosophy or continental philosophy.

I’m all prickles. I identify with debunkers like James Randi or Carl Sagan... something about them clicks with my own inner frustrations and anxieties. I am frustrated with the claims people make based on insufficient evidence because of the potential to mislead or harm others. I am anxious about being misled or deceived myself.

And yet there is something to be said for the pragmatists in philosophy for their attempts to resolve the space between prickles and goo. The pragmatist appeal to a coherentist worldview avoids the problems of skepticism we run into when we undertake the prickly Aristotelian project of deriving a foundation from first principles. I have spent a bit of time each week this year trying to better understand the pragmatic underpinnings of the philosopher of science, Willard Van Orman Quine. Quine is quite prickly, describing philosophy as continuous with science and the exploration of science as occurring from within itself with its own tools. And yet he describes science as naught more than another human project, which feels like a gooey way to describe it.

Looking out on the field of psychotherapy from within the philosophy of science I see a problem with our present Research Programme of Evidence Based Practices. Evidence Based Practices rely on conceptualizing psychotherapy with the medical model, where we try to determine which specific ingredients the client’s problem calls for. The research and writing of clinicians like Miller and Wampold directly contradict the utility of specific ingredients, a core part of that model. They show the pragmatic utility of the contextual model in research such as this recent piece by Chow which demonstrates that we can achieve better outcomes when we focus on changing ourselves as clinicians to fit the context in which healing occurs for the client.

This is the stuff scientific revolutions are made of. With such a profound shift in thinking, I still struggle to fit it into my worldview. But I know that as a prickly person, I’m committed to where the evidence leads me. And that as long as I am a clinician, I’m committed to being helpful.