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From the President
Barry Dauphin, Ph.D.
As the readers of the MSPP News might have observed, I often bring in concepts or observations from outside of the traditional psychoanalytic framework or lexicon as a means of elucidating some principle or point. I find this to be helpful, because we can otherwise get bogged down in considering some of the dilemmas facing contemporary practice as being limited to our specific work, instead of also belonging to general cultural trends. Furthermore, I believe that other disciplines use other kinds of metaphors that can help us think through knotty issues in fresh ways.
Today, I’d like to speak to issues involving longstanding attempts to remove individuality from the psychotherapeutic enterprise and to the problematic assumptions underlying this enterprise. Ever since Joseph Weizenbaum created the parody of a Rogerian therapist by means of a computer program, known as ELIZA, many researchers have hoped to find the magic formula for psychotherapy. At the present time, I suggest that the movement toward what is called Evidence Based Practice (EBT) or Empirically Supported Treatments (EST) reflects many of these cherished wishes. This represents an important trend in contemporary psychotherapy research, which I believe too few in the analytic community are paying enough attention to. The often-stated goal of these initiatives is to create psychotherapy manuals based upon concretely defined intervention packages. Adherence to the manual is essential in order for researchers to determine the possible causes of behavior change or changes in attitudes, feelings, and thinking patterns of the subjects. Once some change is purportedly demonstrated in this manner, then adherence to the manual then takes on a new urgency outside of the research facility and inside the consulting room.
In broaching discussion of this topic, I’d like to consider what I think of as the standardization principle by looking at another field and seeing if, perhaps, we could learn something important. I do this because stepping outside of one’s immediate knowledge base can sometimes illuminate issues in a manner not possible when we are caught up in our intramural differences. On the face of it, manuals and the highly concrete or tangible rule structure at their bases would seem to be a natural for fields that are number oriented. Surely, highly structured manuals are often very helpful and effective in dealing with problems or breakdowns of machines or electronic equipment. Anything that involves interchangeable parts or procedures would seem exceptionally well suited for tight regulations and repetitive procedures that could be followed to the letter (or by the number) with little, if any, deviation.
Accounting is a profession that is very much about the numbers. To the untrained eye, accounting would seem to be little more than adding, subtracting, multiplying and dividing- only with lots and lots of numbers, a kind of 4th grader’s nightmare. Moreover, anyone that does his or her own taxes with tax preparation software can quickly see how many processes can be automated. Plug in some numbers in the right place and, voila, you find out how much Uncle Sam will owe you in April (unless you haven’t paid enough taxes during the year, but that’s another story). After the scandals of recent years (e.g., Enron, WorldCom, etc.) in which accounting played a major role, it might be understandable that many would turn to the process of rule creation and standardization as a means to prevent such corruption in the future. Surely, something like accounting should be easily standardized, say we novices. Gee it’s only income and outgo, what’s the big deal?
And there are many pressures from within the field and from government to create agreed upon procedures for everything and to remove professional judgment from the equation. Sound familiar? Let’s consider this industry for a sobering look at the attempt to create overarching rules and standardized procedures that should be rigidly adhered to. Is there a price to be paid and is it worth the cost?
Following the accounting scandals of recent years Congress enacted the Sarbanes-Oxley Act. Without delving into too many details for a column such as this, we can note that this is but the latest in a series of laws and regulations designed, in part, to create uniformity in accounting. Accounting scandals of one sort or another have occurred at least since the 1930s, if not before. Each time comes the promise to create standardization. Ironically, it was Arthur Anderson & Co. back in the 1940s that championed a rules-based approach to accounting in an attempt to achieve comparability that would reduce the role of professional judgment. In other words, the very firm that has become most notorious for a never-met-a-loophole-I-didn’t-like accounting style has historically succeeded in moving the industry toward a more rule oriented approach. What has this led to?
According to Pollock (2005),
A necessary corollary is that the practice of American accounting, including the training of accountants, has focused more and more on the rule- following, as opposed to making judgments. In my experience, a principal item in corporate audit committee meetings is the external accountants explaining what new FASB standards they now have to follow. There is usually no discussion of what the rule should be. It is a compliance discussion, not a conceptual discussion.
I think that one does not have to take a great leap of imagination to change the field from accounting to psychotherapy and change the term “audit committee” to “mental health case manager” or “psychotherapy manual” and picture a clinician on the phone to an insurance company.
In certain respects, I ask readers to consider that EBT/EST, as a movement within the profession, also risks leading psychotherapists to cede intellectual and professional responsibility, save complying with the manuals. Now, in saying this, I risk being branded as against research or anti-science. Actually, nothing could be farther from the truth. I am in favor of pursuing research into psychotherapy, but believe that this research should encompass a multitude of methods and conceptual frameworks and should not be pursued on the basis of a simple philosophy of empiricism that is unable to validate its methods by using the very same needing-to-be-validated methods as the mythical “gold standard.” Furthermore, psychoanalytic psychologists should be wary about the bureaucracy mentality that arises to implement the supposedly unassailable findings of the laboratory. One would think that enough has been written, from various perspectives, about the bureaucratic mindset and the perils of unquestioning salutes to its wonders. Shouldn’t psychoanalysts be analyzing the impulses associated with manualization of the field rather than abetting them?
But even more to the point is the underlying belief that psychotherapy research will yield findings of the sort that can lead to a hyper-manualization, namely findings that result in a linear understanding of therapy. That is, it is assumed if specific procedures are applied to those with specific diagnoses, one can predict outcome in a linear fashion. Manuals exist for all forms of therapy, but most are manuals in the loosest sense of the word. They provide models with which to consider the precepts of their therapeutic schools or approaches and some examples to illustrate basic concepts. Most guides for psychotherapy, including psychoanalytic work, are not meant to be followed in some sort of lock-step fashion. Yet, the EBT/EST movement looks to create a more rigid set of procedures to be used in conjunction with specific diagnoses. Specific sets of therapeutic procedures are meant to be used with particular diagnoses. The procedure and the diagnosis, both of which are abstractions, are placed in the foreground, while the specific therapist and specific patient, both of which are human beings, are relegated to error variance.
Whatever statistically significant differences arise from a particular research study, the inflexible application of such methods to situations outside of the specific ones evident in the research assumes a relatively smooth, linear transfer. Yet, as the science of psychotherapy research labors to find replicable results that can be graphed using only straight lines, other sciences are casting off the shackles of linearity. They do so mostly because the linear models don’t do an adequate job of helping us understand and manage ourselves in a complex world. To apply the findings of a few psychotherapy research studies to specific diagnoses and then to create a bureaucratic infrastructure to force the implementation of those findings hardly seems contemporary in any sense of the word. It harkens back to the early Industrial Age type of thinking, which the more mature sciences have been questioning for quite some time. Underlying the marriage of the psychotherapy laboratory and the insurance industry is the belief that we can control nature, although in this case, it is human nature instead of mother nature. This is an old story, told and retold, and, like always, the lessons aren’t learned.
The human mind is an extremely complex system, and you don’t even need to be a psychoanalyst to say so. Complex systems are not well captured using the kinds of linear models that we psychologists are often so fond of. The initial conditions of the system at the time of observation are important to understanding what follows. Even tiny changes in the initial conditions lead to unpredictable results.
Recently the author Michael Crichton gave a paper on complexity. He said something with complex systems in mind, but something most parents would instantly recognize even without the baggage of Chaos Theory.
One complex system that most people have dealt with is a child. If so, you’ve probably experienced that when you give a child an instruction, you can never be certain what response you will get. Especially if the child is a teenager. And similarly, you can’t be certain that an identical interaction on another day won’t lead to spectacularly different results.
If you have a teenager, or if you invest in the stock market, you know very well that a complex system cannot be controlled, it can only be managed. Because responses cannot be predicted, the system can only be observed or responded to. The system may resist attempts to change its state. It may show resiliency. Or fragility. Or both.
We are often said to have a health care crisis. The United States spends something like 16% of GDP on healthcare. This leads to calls for “reform” that often emphasizes the bottom line without much consideration for how one gets there. There are numerous macroeconomic forces at play that are greatly influencing the direction psychology and psychotherapy goes. Bureaucrats are scratching their heads trying to think of the ways to save a buck. Organized psychology is promising to give them at least two ways to do so.
Second, organized psychology promises to become a less expensive dispenser of psychotropic medicine than M.D.s, especially psychiatrists. Moreover, medicine makers promise that it is cheaper than psychotherapy. Recently, the Michigan Department of Community Health (MDCH) reported that nearly two out of every five physicians in Michigan are planning to retire within the next decade, and Michigan does not yet envision a large influx of younger physicians to take their place (www.michigan.gov). Soon the State Legislature will be considering legislation to change the scope of practice for doctoral psychologists to allow prescription privileges. I assume that, in addition to pressures from the psychology lobby, many legislators will consider such legislation in light of the (linearly) predicted physician shortage, which likely includes psychiatrists.
Will Michigan actually have a physician shortage as some believe? Who knows? If the Michigan healthcare system operates solely on principles derived from linear models, it would look that way. It would be the only complex system that does, so far. However, the healthcare market might be more flexible than some imagine, if it is not overburdened with too many legislative “fixes” made in the absence of genuine predictability. But, the promise today of a cheaper medicine dispenser is quite tempting to government officials today, because for them the real crisis is today, not 10 yrs from now. Promises today mean votes tomorrow, and 10 years is a long time and who’ll remember how we got ourselves into whatever mess exists at the time. My broad point is that organized psychology stands to provide bureaucrats with something they love, namely the promise made today to save money but without anyone knowing who will be accountable later if such promises are unrealized or even foolhardy.
I believe that many versions of psychoanalysis implicitly, if not explicitly, conceive of mental functioning as a complex system that is not controllable in the way so many bottom-liners or outcome researchers hope. Psychoanalysis, as a set of theories, is generally applied in a manner that incorporates reacting to unpredictable changes in the system as well as unpredicted lack of change to the system. Acceptance of ambiguity in the absence of firm and concrete predictability is actually a strength of psychoanalysis instead of being a weakness envisioned by bean counters. Human beings practicing psychoanalysis experience an infinite variety of reactions to this ambiguity. But ambiguity in money matters spooks those invested, just witness the fluctuations in the NYSE when a new level of ambiguity appears (e.g., unclear levels of oil production, unforeseen weather problems, etc.). Yet a large part of the money worry in mental health care revolves around the fact that the consumer of the service of psychotherapy is often separated from the cost of the service by means of a third party provider. Curiously, as important as paying for service is to the field, there is a dearth of empirical double blind research protocols examining the role of money in the therapy situation. Psychotherapists made out fairly well under the third party model for many years. Live by the sword, die by the sword as the saying goes.
As what I see as an anti-therapeutic trend continues, we can consider the psychotherapy industry to also be a complex system. Will psychology be the same, but bigger and better, field with the addition of prescription privileges (like an athlete on steroids)? Will the introduction of fixed standards for diagnoses and the limitation of approved methods and procedures by payers lead to predictable changes of a linear nature? I think it is unlikely to, although I feel we can have some sense of some of the effects. I believe that these changes will be profound for the field and that there will be a substantial amount of turbulence in the field. I think that these changes to the field will also contain a powerful level of dissatisfaction for many patients or clients (maybe even for a few bean counters too). Yes, psychoanalysis has withstood the slings and arrows of various attacks before and has survived. Nonetheless, I believe that it is important for those interested in psychoanalytic psychology to be as active as possible in questioning these shifts in the profession and whether they enhance our professionalism and professional judgment. Raising questions is inherent to professionalism.
Maybe in the long run, the payers will see that the efforts to curb costs will meet a similar fate as the previous solution of Managed Care, i.e., initial success followed by a flood of spending. In the meantime it could be an even less linear ride than the introduction of the Managed Care era. So being active now, even if it means simply remaining informed and thinking actively, is vital to reinforcing our stance as professionals who are not content to cede intellectual and professional responsibility to insurance bureaucracies, psychotherapy researchers, pharmaceutical corporations or government agencies. One wants to react to the hard-to-predict shifts in the system, and stands in a better position to if actively thinking about this system as a professional. If we begin to think like technicians who are simply concerned with compliance discussions, instead of like professionals invested in conceptual and philosophical matters, then we will be technicians. _____________________________
Notes
i Stephen Zeff (2004). “Evolution of US Generally Accepted Accounting Principles”; Alex Pollock (2005). “From Making Judgments to Following Rules: The Evolution of US Accounting” AEI: American Enterprise Institute for Public Policy Research. July 2005, 1-7.
ii Pollock (2005).
iii Pollock (2005).
iv Michael Chrichton (2005). “Fear, Complexity, and Environmental Management in the 21st Century.” Presentation given to the Washington Center for Complexity & Public Policy. Washington, DC, November 8, 2005. http://www.michaelcrichton.com/speeches/complexity/complexity.html |
This
focus on the rules has an interesting momentum and ancillary side effects.
“The major accounting firms used to have serious intellectual debates
publicly in their journals about what the right accounting standards were.
No longer.” There is some gain in this approach, but the gain does not
appear to be to the profession as such. “As the conceptual and
philosophical responsibilities are taken over by this government-sponsored
standards monopoly, the accountants become subsidiary bureaucrats focused
on compliance. In one sense their lives become less demanding, with an
economic inducement to cede intellectual and professional responsibility.”
Psychotherapy
researchers are producing studies that show particular kinds of measurable
changes for particular people with particular diagnoses within a limited
time frame. They can then sell the package as