All science is based upon a philosophy, whether it is implicit or explicit. The same is true for the science of psychology. However, through much of the 1980s and 1990s, and even into the 21st century, there was a movement afoot that seemed to suggest psychological science had risen above philosophy to a pure science. Many seemed to believe that we no longer needed to talk about how we know what we know (i.e., epistemology and the philosophy of science). The philosophical basis of science did not go away, it was just naively ignored and pushed to the implicit levels. The devaluing of philosophy and critical thought made it easier for narrowly defined scientific approaches to begin to gain dominance, but it did so at a great cost. Increasingly, it seemed, therapists were trained to be technicians who did not need to be able to think about therapy, just apply their techniques. There were even rumors that computer programs were being written with the belief that their ‘scripts’ could provide therapy as effectively as a highly skilled therapist.
Although it has been a while since I’ve heard rumors of the therapy computer programs, many therapists still aspire to be more like computers than genuine, healing human beings. I have many concerns about this, but will limit this post to a few. The first philosophical blunder is the belief that all means lead to the same end, so the shortest means is best. Stated differently, if all therapies tend to be equally effective in treating symptoms and diagnoses, then shouldn’t we focus on the quickest route? My answer is a resounding “No!”
The most evident example is the therapy versus medication debate. It is evident that there are differences between relying upon a psychoactive chemical to produce a mood change as compared to using an interpersonal relationship. These medications produce side effects that often are undesired. And, quite frankly, these medications have not been around long enough for us to have any conclusive evidence about their long term impact. When we apply this to psychotherapy, we can see that the various therapy approaches also have different “side effects,” or what David Elkins (personal communication) liked to refer to as “extra-therapeutic benefits.” These “side effects” or “benefits” of therapy are often positive, as compared to the negative effects of medication. As an example, cognitive-behavior and rational-emotive therapies are likely to have the extra-therapeutic benefit of promoting a rational thought process. Psychodynamic therapy is likely to have the extra-therapeutic benefit of increased insight into one’s history and relationship patterns. Existential and humanistic therapies will provide the extra-therapeutic benefit of increased insight into intrapersonal and interpersonal issues, as well as the various existential givens. I would maintain that existential and humanistic therapies would also promote deeper, healthier relationships, recognition of one’s life meaning, and an improved ability to constructively utilize a wide range of one’s emotions in personal growth. So, yes, most therapies may help alleviate symptoms equally effectively, but therapies are not all the same. We need to help clients consider what extra-therapeutic benefits they are seeking when considering the fit to a particular approach to therapy.
Let me briefly discuss one more philosophical issue: The belief that outcomes measures measure what they purport to measure. I discussed this some from a research perspective in the previous blog, but allow me to look further into the demand characteristics this time. Demand characteristics refer the idea that clients often will consciously or unconsciously attempt to understand what the researcher is looking for and then modify their behavior to conform to this. In psychotherapy research, it is pretty evident what is being investigated, but when there is a high level of congruence between the therapy measure and the approach to therapy, there is an increased susceptibility to demand characteristic. For example, when the Beck Depression Inventory (BDI) is used to measure therapy outcomes, it is pretty evident that this measure is focusing on the cognitive appraisals similar to what is being discussed in CBT. Other approaches, which may focus on encouraging a client to experience and then work though feelings, may encourage a different type of response (i.e., demand characteristic) on the BDI. Therefore, the measure is inherently biased toward CBT in this example.
Similarly, it could be argued that in CBT you are ‘teaching to the test.’ The primary focus in CBT is encouraging clients to change their thoughts with the belief this will change their emotions. If, then, the client is given a test on how well they are doing on these lessons, they may feel pressure from the therapist and internally to answer the questions in a way suggesting that they are learning what they are supposed to learn. In other words, they want to pass the test. This leads to the inherent possibility that clients will feel pressured toward self-deception instead of healing. I don’t mean these criticisms to invalidate CBT. I truly believe CBT is a valid, effective approach and believe this approach to therapy is the best fit for many clients based upon what they want from therapy. However, there are serious limitations to the outcome research often interpreted to suggest this approach is superior to other approaches to therapy.
In this blog, I only covered a few of the many serious limitations to a narrowly defined scientific approach to outcome research. Many more exist, but that would be the subject of a journal article or book, not a blog. Science without philosophy and critical thought is nothing more than rhetoric. We must understand the context of science, critically think about its findings, and understand the implicit biases in the approach to science if it is going to have any validity at all. Promoting blind science is no better than promoting blind faith; both are dangerous.
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