Existential Psychology Weblog by Louis Hoffman

Emory Cowan: Unrecognized Humanistic Hero

This blog was original written as I was reflecting upon my years as a core faculty at the Colorado School of Professional Psychology/University of the Rockies shortly after accepting a position at a different school. It was submitted to the Heroes of Humanity Project (http://www.heroesofhumanityproject.com), but felt it also needed to be shared with a broader audience. 

Emory Cowan is one of the least known great figures in the history of humanistic and existential psychology. A Vietnam veteran and former minister, he found his way to the existential writers largely through literature. Later in his professional career, Dr. Cowan became a Marriage and Family Therapist and then attended Saybrook University where he obtained his PhD studying with Rollo May and other greats of the humanistic-existential tradition. While studying at Saybrook, he was chair of the psychology program at Chapman University’s Colorado Springs campus. When Chapman decided to shut down this campus, Dr. Cowan met with the faculty and asked, “Are you ready to quit teaching? I’m not.” Emory and these faculty then decided to build the Colorado School of Professional Psychology (COSPP).

It was not easy to build a graduate school from scratch in the late 1990s, but Emory, Sue Cooper, and other founders of the school made the seemingly impossible happen. They attained regional accreditation with many accolades on the first attempt. COSPP, within years of accepting its first student, was beginning to receive national recognition, including two nominations for Charolette Buehler Award with the Society for Humanistic Psychology.

Although not a humanistic or existential school, the school’s humanistic values and existential influence were evident to anyone blessed to walk the halls of this school. Despite the great academic success of the school and the success of its early graduates, the financial pressures of a new school were too much, leading to COSPP being sold and becoming part of the University of the Rockies (UoR). Today, much has changed from the original spirit, culture, and values of the school, but COSPP was a shooting star and credit to the humanistic and existential movement for the few years it streaked across the sky. During that time, many influential humanistic scholars (Kirk Schneider, Ed Mendelowitz, Myrtle Heery, Tom Greening, and David Elkins, to name a few) taught and spoke at COSPP/UoR. Also, many students and future leaders in the humanistic/existential movement studied at COSPP/UoR.  Through these people, COSPP and the influence of this great man continue.

As a leader, Emory had a number of characteristics that were quite influential on the success of the school. First, Emory is very inspirational, especially through his abilities as a story teller. His accounts of how the school began became mythical (in the Rollo May understanding of myth) and served to sustain the school through many difficult periods. Second, Emory was very attuned to his faculty and their needs. He seemed to know when they needed encouragement and inspiration, and he was good at delivering at these times. Third, Emory was very human. He did not hide his flaws or mistakes, he shared them with us. He trusted people with his imperfections. Emory was aware, I believe, of the risks he took in sharing his imperfections with us, but he also seemed to know that in doing so we would come together stronger, each of us drawing upon our strengths and recognizing our limitations. His faculty knew that as long as they took responsibility for their limitations and mistakes, they would receive compassion, acceptance, and support. Part of what united us as the strong team we became was that we all knew our limitations, took responsibility for them, and asked for support and help. We learned from each other and took care of each other. And no one wanted to let Emory down, not because of the fear of consequence, but because they did not want to disappoint him. This bound us like a family – one that sometimes fought, often disagreed, but we stuck together.

Emory Cowan had an enormous impact upon me, in particular. I was a young faculty member with little formal training in existential psychology, my primary professional passion, when I met Emory. He was willing to take a chance on me and hired me as a faculty member at COSPP. It was there that I was provided with the environment where I was able establish myself and my professional identity. Now, having recently accepted a position at Saybrook University, one of the top humanistic and existential schools in the world, I know that the many accomplishments and successes of my career would not be if not for Emory Cowan. I know, too, that I am one of many touched by Emory. So many faculty and students, and now their students, were impacted by what Emory and the other founders of COSPP created. Today, there are many young scholars who I have no doubts will make great contributions to the future development of existential and humanistic psychology, that owe their foundation to Emory’s school. Although Emory Cowan’s name may never find its way into the History of Psychology textbooks, or even the histories of humanistic and existential psychology, his contributions surely make him one of the greats of this movement. His influence will live on, even if unrecognized.

A Depth Psychology Perspective on the Immigration Issue

In the beginning we create the enemy. Before the weapons comes the image. We thinkothers to death and then invent the battle-axe or the ballistic missiles with which to actually kill them. Propaganda precedes technology... Instead of being hypnotized by the enemy we need to begin looking at the eyes with which we see the enemy… We need to become conscious of…“the shadow.” The heroes and leaders toward peace in our time will be those men and women who have the courage to plunge into the darkness at the bottom of the personal and corporate psyche and face the enemy within. Depth psychology has presented us with the undeniable wisdom that the enemy is constructed from denied aspects of the self. ~ Sam Keen

Since the election of Barak Obama as president of the United States, some have proclaimed that we are living in a post-racial society. Despite these claims, an abundance of evidence suggests that much latent racism still exists and now is rising to the surface. One example is the increased intensity over immigration and illegal alien issues. As a preface and to decrease the amount of ire and possibility hate directed at me that this post could stimulate, I am not saying that all who are calling for stricter immigration rules or who support the new Arizona law are racist. Yet, I think racism, conscious or unconscious, is a primary motivator for many in their support of the Arizona law. I also believe there are other reasons for these positions, too. 

The quote from Sam Keen above I believe to be one of the most important quotes for our society today. Essentially, Keen is arguing that hate, strong criticalness of others, and the labeling of other groups as bad or evil has its roots in the person voicing these positions more than in the individual or group who is the recipient of these labels and attacks. Before we condemn, we should always look inward with a close examination of ourselves. Most often, I believe, we will find that we are part of the problem, too. 

A fairly obvious example of this is illustrated through many of the homosexuality scandals within the evangelical church. Numerous times in the past several years, some of the evangelical leaders voicing the strongest condemnation of homosexuality and same-sex marriage/partnerships have been caught engaging in homosexual behavior. Depth psychology would suggest that the passion, and I would say hate, directed toward gay and lesbian individuals was likely rooted in their own inability to accept aspects of themselves, or what Jung would call the shadow and May would call the daimonic. I am not saying they are gay or lesbian, or even bisexual. Maybe these are heterosexual individuals unable to accept some same-sex directed impulses. Of course, this is impossible to know, but yet a very plausible explanation. 

Returning to the immigration/illegal alien issue, other groups of people are often the recipient of negative projections that serve as the basis for prejudice against them. For instance, the target of the immigration issue is often the Latino/a population, who are mischaracterized as criminals, lazy and trying to take advantage of the system. Ironically, the vast majority hold conservative family values, come to the United States to work, and work hard, and are very willing to contribute to the system. The evidence against these stereotypes of the Latino/a population is overwhelming, yet they exist and seem to grow stronger over time. From the depth psychology perspective, it can be maintained that many of these beliefs again begin with the self. Fears are projected upon the Latina/o population and used to justify one's position. Even the frequently used argument that "they are here illegally" has little basis. Ignoring that most individuals going through the process established by our government to get citizenship or permanent residency status will need to spend a portion of their time being here illegally in order to be here legally, we can also be thankful that those of us who are here legally do not have to face the possibility of deportation every time we break the law (speeding) or bend it (taking liberties and bending the law with our tax deductions). These are blatant double standards and double binds.

Blaming immigrants for the problems in the United States is simply a way for us to avoid taking collective responsibility for the problems we have created in this country. Some argue that the immigrants are taking "our" jobs, yet we refuse to take collective responsibility for the economic crisis which has created the greatest job crisis in recent American history. We blame illegal aliens and immigrants for health care issues, yet we too long have failed to address the problems with our own health care system. We blame illegal aliens for crime yet we cannot address the extraordinarily high rates of violent crime in the United States or the overcrowded prison system. 

If we want to solve the economic and crime problems in the United States, we need to be willing to take an honest look at ourselves and recognize that we are the problem. Neither of our political parties are showing the leadership that is needed in this vein. They are too busy pointing fingers at each other and blaming instead of looking at themselves. We need both political parties to be responsible and accountable for the corruption that exists in politics today. It is impossible, if we are to be honest, to say that one party or the other has the moral high ground. Both political parties, at their best, have good intentions with different plans about how to address problems. The difference in the parties often is more about pragmatics than morals, but we turn it into moral issues. Yet, both parties are filled with corruption, power struggles, and resistance to taking responsibility for their own problems and failures. We need political and other leaders in this country to show the type of heroism that Keen talks about -- the courage to look within and take personal responsibility instead of projecting our failures and shortcomings on others and then condemning them. 

Reflections from China: Rethinking Education

One of the presentations I was looking forward to most during my time in China was a "dialogue session" with Xuefu Wang on Nietzsche and the important Chinese scholar, LuXun. I was presenting on Nietzsche and Xuefu on LuXun. The presentation was well attended and went very well. However, one question asked during the dialogue session particularly stands out to me. A high school student from China who attended the Existential Conference stated that in high school she had been exposed to some Nietzsche quotes by her teacher to help inspire students in their education. Her question was how high school students in the United States respond to Nietzsche. In my answer, I stated that I wish high school students in the United States knew who Nietzsche was! 

I am deeply worried about many of the trends in education today in the United States from high school to college to graduate education. Although acknowledging my bias as this is my profession, I strongly believe that education is one of the most critical aspects of the future of the United States. And I believe we are failing. Education is taken much more seriously in many other countries around the world. Our standards and ways of measuring success in education are quickly deteriorating. At its best, education in the United States focuses on learning content and measures attaining knowledge as success. However, content without the ability to think about it is useless, meaningless, and potentially dangerous. Yet, this seems to be our best. We have completely lost sight, it seems, of teaching individuals how to think. I know this is an overgenralization as there are some exceptions to this; however, it seems they are fewer and fewer. 

The greatest minds in the intellectual history of the United States, such as Albert Einstein and William James, understood this problem well. They knew the limits of science, which too often focuses on the accumulation of facts, and recognized the importance of creativity and intuition in furthering science, theory, and scholarship. But today we see the arts cut from education. Fewer teachers, it seems, know how to teach critical thinking. Students often seem to think that critical thinking is just being critical. 

One of the takeaway lessons for me from the First International Conference on Existential Psychology was that we in the United States have much that we can learn about education from the international community. As many of us from the United States were, I was so taken by these young students attending the conference. Not only did they choose to attend a high level intellectual conference, but they participated with great questions and contributions. Their excitement for learning and passion for the topic was quite inspiring. 

Opening Address at the First International Conference on Existential Psychology

First, allow me to acknowledge some people and organizations that made this conference possible. Xiaozhaung University, and particularly Dr. Tao, graciously provided the facilitates for the conference and many hours of organization, as well as financial support. The China Institute of Clinical Psychology provided organizational and financial support for the conference. The Zhi Mian Institute also provided financial and organizational support over the 2-years of planning for this conference.

Reflecting back, the seeds of this conference may have begun in the words uttered in a hotel lobby about two years ago: “maybe we aren’t thinking big enough.” Mark and I were sitting in a hotel lobby, energized by the reception existential psychology was receiving on the first of our journeys across China. Soon, Xuefu joined us in the planning and the energy quickly began to build. Two years later, here we are. And this is amazing! We have most of the top existential psychology scholars in the world with us here today, in Nanjing, China.

The title “existential psychology” may have emerged in the West, but it does not belong to the West. In the West, the first use of the word “existential” was applied to a particular group of ideas well after the death of Soren Kierkegaard, who is commonly identified as the originator of existential thought. In much the same way, existentialism has had a presence in Eastern thought well before the label ever came here.

And this was our purpose from day 1, to bring Western existential thought into dialogue with Eastern existential thought. The dialogues are about encounter, mutual exchange, and mutual learning. This is now my third trip to China focused on existential psychology. We have also hosted Mark, Xuefu, Charolette, and JiaJia in Colorado as they have brought indigenous Chinese existential ideas to the United States. Although there is much commonality in Eastern and Western approaches to existential psychology, there are also challenges and the need for cultural adaptation and critique. This, too, has been central in our intentions and what we have engaged in over the past three years. What we embark on today is a continuance of this process with an invitation for all of you to be participants as we learn, create, and grow together. From this encounter, I am certain we will grow individually and collectively, and that we will push existential psychology to grow along with us.

Today, I am proud to be here beginning this awe-filled journey with so many friends. I am joined by students who have lived the Nietzsche lines that “a student repays his [or her] teacher poorly if remaining nothing but a pupil.” You more than students; you have undertaken this journey with me and you are my friends, my colleagues, and my teachers. I am honored, this trip, to be joined by many colleagues from the United States who are the foremost leaders in existential psychology as well as individuals who embody the existential spirit and are among the top psychology scholars in the United States. I am proud to be joined by many leading scholars from the East who I have been privileged to get to know and others who I hope to begin getting to know over the next three days. You have humbly taught me much. Last, it is one of the great honors of my life to be standing here with my two good friends, Mark Yang and Xuefu Wang, who have worked tirelessly promoting and developing existential psychology in China. Mark, having studied and contributed to existential psychology in the United States and China, symbolizes this east-west dialogue. Xuefu is a true scholar of Chinese culture and existential psychology. Indeed, I believe Xuefu is rightly identified as the leading scholar of indigenous Chinese existential psychology. We are all part of this very prestigious group that is making history in existential psychology. Now let us join together to begin the journey. 

Psychotherapy Outcome Debate: Rhetoric and Marketing One’s Position

Science ought to inform one’s positions and the perspective one is advocating for, not be used as a political weapon. However, it seems today that science has too often been co-opted for self-serving purposes. This, I believe, is too often the case in the outcome therapy debates in psychotherapy.

For many years I have maintained that this debate of “who’s best” is quite adolescent and not very appropriate for professional dialog. In particular, my concern is that we have been too focused on the self-serving debate of whose approach is best and not focused enough on how to work within the various approaches to make them more effective in meeting the diverse needs of our clients. This debate is a distraction that does not serve clients and does not serve the professional community.

As I have discussed in this blog series, there is plenty sufficient evidence to, at the least, cause one to seriously question the superiority of any approach to therapy. So why does the debate continue? I believe it is more about power, control, and job security than science or protecting the profession, as is often claimed. Certainly, there are some approaches to therapy, such as rebirthing and conversion therapy, that have caused harm and warrant strong suspicion. However, one is very hard-pressed to find any evidence that the majority of psychotherapy approaches cause harm. In reality, some therapists from all the different theoretical orientations cause harm. This merely suggests that any approach to therapy can be misused and cause harm.

Obviously, a personal benefit exists in being able to say that one’s approach to therapy is superior to others. To name a few, it provides better access to managed care/insurance panels, creates job security, creates openings for academic positions, and increases access to research grant money. These are strong incentives to engage in political rhetoric about the superiority of one’s approach and to wage science in an effort to bolster this position. It provides incentive to develop research to support one’s view of the superiority of their approach. Outcome research is often done by individuals with a vested interest in a particular outcome. As an example, much of the research comparing the effectiveness of medication versus psychotherapy has been supported by pharmaceutical companies. The researcher’s paycheck is part of an investment, quite literally. In other instances, individuals that practice a particular therapy orientation often are the same individuals that compare its effectiveness to other approaches. It is not surprising that the approach they advocate for often is shown to be superior.

Any time we explore a position on outcome literature, we need to take a look at the motivations, implicit and explicit. We need to consider where the funding is coming from. We need to consider other pressures that may influence how the research study is designed and how the outcomes are interpreted. This is one of the many reasons why I have more respect for the research done by individuals such as Bruce Wampold, who did not have an invested interest in how the research came out. And his research has suggested that the various therapy modalities tend to be equally effective. In the large majority of outcome research comparing the effectiveness of different modalities, there is a very clear vested interested in finding the superiority of one approach.

Even with reviews such as this blog series, one should consider the motivations and contexts. As is evident, I am invested in demonstrating that existential psychology is a valid approach to psychotherapy that produces good outcomes. Little doubt, this impacts my motivation for writing this and how I write this blog series. But I am also invested in recognizing the value of different approaches to psychotherapy. I consider myself a scientist, a philosopher, and a critical thinker. All of these identities impact the way I view the world and professional issues. I pride myself in being passionate, yet not trying to privilege my position or values over others. It is my hope that this intent, to not privilege my views, helps me take a more balanced approach to reviewing this topic. In the end, it is necessary for these ideas, too, to be critiqued.

When you look at many of the narrowly-defined scientific paradigms, they are not open to such scrutiny. They will accept critiques coming from new science, but they discount external critiques of the basis of how they understand science. I am sure that what I write in this blog series means little to them. It is simply another unscientific threat to science. I think this is unfortunate, especially in a country that produced great scientists of the likes of William James and Albert Einstein; individuals who truly engaged in a broad based approach to scholarship and science, who try to extend the limits of science, and who recognized the limitations of their own work. 

Psychotherapy Outcome Debate: Philosophical Issues

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 21^st 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. 

Psychotherapy Research

Research on psychotherapy has taken many different directions over time, as discussed in my previous blog. Although a bit of an oversimplification, most outcome research tends to fall into one of two camps: 1) Empirically Supported Treatments and 2) Common or Contextual Factors Research. I will discuss each approach briefly analyzing the strengths and weaknesses of each. 

The focus of the Empirically Supported Treatment, at its heart, is to evaluate the effectives of a narrowly defined treatment approach. This is a noble effort. First, it provides information that gives the appearance of being rather clear and straightforward. Oftentimes, it facilitates the development and improvement of very structured therapy approaches that are fairly easy to follow. These approaches often are very appealing to insurance companies and managed care, allowing psychotherapy to have an inroad in to reimbursement options. 

However, this approach has too often attempted to become something more than it is, leading to several major problems. First, this approach has often gone down the path of comparing psychotherapies trying to 'prove' which approach is best. I have concerns about the motivations, utility, and philosophy of science of such attempts. Researchers often are rooted in one of the therapy approaches reflecting a particular philosophical system and design or utilize measures that are best suited for the particular approach to therapy. Stated more clearly, different outcome measures are better suited to measure different types of therapy. 

Let me provide a brief example. The Beck Anxiety Inventory (BAI) and the State-Trait Anxiety Inventory (STAI) are two common measures of anxiety, both reflecting different theories. The BAI focuses mostly on one's perceptions of anxiety (i.e., cognitions) and little on visceral symptoms (i.e., bodily symptoms). The STAI, conversely, focuses more on visceral or bodily symptoms. The BAI is typically used in evaluating the effectiveness of cognitive behavioral therapy (CBT), which makes logical sense in that in focusing on defining anxiety primarily by cognitions and perceptions. In CBT therapy, the therapist is working on helping the individual change cognitions and the BAI evaluates this. However, it assumes that cognitions and experience will be equivalent. This creates a few problems, such as demand characteristics, in which clients are encouraged to change their cognitions in a direction with the assumption that the accompanying emotion will follow. This is not always the case. Sometimes cognitions change, the BAI results change, and the experience does not. Other forms of therapy focus on targeting the visceral symptoms more directly, without being as concerned about the cognitions. This therapy could potentially be effective by the STAI and not the BAI. In other words, as soon as an outcome measure is introduced, so is a bias. 

Studies rooted in the Empirically Supported Therapies tradition tend to emphasize a fairly controlled research setting, which also introduces limitations. This approach is biased to more structured, solution-focused therapies and against the more fluid, relational depth psychotherapy approaches. However, even many solution-focused practitioners point out that the therapy conducted in these research studies often do not reflect therapy in the real world. It takes the relationship out of even the solution focused approaches. In particular, therapists often follow structured guidelines on how to intervene at a particular point in treatment and are discouraged from following clinical judgment and experience about when adaptations are necessary. 

The controlled aspect introduces another serious limitation. First, careful screening is conducted to assure the client meets the right criteria, which often means not including individuals with complex issues or dual diagnoses. This is a large portion of the population entering therapy! Studies also have to carefully consider which factors to include and control for as potential confounding variables, but cannot include too many factors as if enough factors are controlled for, the natural co-variance across influences would reduce any unique variance to non-significant levels. Variables such as the therapeutic alliance and client motivation, which meta-analytic studies suggest are very important, are generally not included. Thus, it is very difficult to say that it is the techniques, or what is intended to be measured, that is actually being measured. These serious limitations do not suggest we should throw away this type of outcome research, but rather we need to acknowledge there are many very significant limitations. We are only getting a small bit of truth at most in these studies. 

Common Factors Research emerged from broad, critical reviews of the research, meta-analyses of previous research, and new research across therapy approaches into other factors not accounted for in the empirically supported treatment paradigm, such as empathy and therapist factors. This includes many very rigorous research approaches that are better able to take into consideration factors, such as the therapy relationship, that the empirically supported treatment paradigm frequently ignores.

The results are consistent: The two most important factors predicting therapy success are 1) client factors and 2) the therapy relationship. Both of these factors are generally not given much consideration in the empirically supported treatment paradigm! These two factors alone account for most of the therapeutic change (see Humanistic Psychology: A Clinical Manifesto, 2009, by David N. Elkins, for an in depth review of this research). 

One of the most fascinating aspects of this research is regarding technique. In the various meta-analytic studies, the role of technique generally accounts for somewhere between 1.5% to 7% of the variance in therapy outcome. However, even with this, it is not a particular technique that accounts for the variance, but that techniques are used. This means that the efficacy of any particular technique would be much less than the 1.5 to 7%! What accounts for a greater portion of the therapy effectives could be labeled as the therapist and client belief in the therapy modality used. In other words, the therapist believing in what they are doing and being able to inspire hope in their clients is more important than the type of therapy the therapist employs! The moral of this story is to make sure you believe in what you are doing and choose a therapy orientation that fits. From this perspective, we should be less interested in coercing young therapists into a particular orientation, but more interested in helping them find the orientation that is the best fit for them. 

In conclusion, outcome research is complex. Anytime you heard that it is clear and simple, be suspicious. I believe that the most rigorous and complex research on therapy outcome strongly suggests that what we should be most concerned about is 1) client factors, 2) the therapy relationship, and 3) helping therapists find a therapy modality that they believe in. This last factor, although not in the two factors identified by meta-analyses as most predictive of successful therapy outcomes, I think is related. When therapists are doing something they believe in and are passionate about, and are concerned with helping clients find the best fit (as opposed to trying to convince every client they are the best therapy for them), they will build better therapy relationships with their clients. 

Why Diversity is Therapy's Strength: What the Outcome Debate

Many believe that it would make sense to have a unified psychology with all psychologists agreeing on pivotal issues. The APS position advocates this singular position should be determined by a narrow view of science. A number of limitations to this perspective demonstrate why this 'logic' does not fit psychology. 

First, psychology is not a pure science in the narrow sense of the term. Instead, psychology is based on a broader view of science similar to what was purported by Albert Einstein and William James. The non-scientists often idealize the degree of truth that can be attained in science; however, the true nature of science is progressive, recognizing the the belief in the attainment of truth is the greatest threat to true science. This was what Einstein and James believed. 

"The most beautiful thing we can experience is the mysterious. It is the source of all true art and all true science. He to whom this emotion is a stranger, who can no longer pause to wonder and stand in rapt awe, is as good as dead: his eyes are closed." ~ Albert Einstein

Einstein believed that science, much like religion, was best rooted in an appreciation of mystery and the limits of one's way of knowing. Science which no longer questions itself is a dangerous science. Much of psychology embraces this broad view of science. The only way for all of psychology to agree is to denounce mystery and have all psychologists embrace the same worldview. If this were to occur, psychology could no longer grow or develop; it would, because it could do no other, embrace the status quo and provide a solid barrier to progressive science. To tie this back to the outcome research controversy this series of blogs is about, what some associated with APS are promoting as science is, quite frankly, bad science. This is not because of poor research methodology and, for most of them, not due to bad intentions. Rather, this is due to a severely limited philosophy of science and a deficient understanding of the role of science. This narrow view of science serves social control, not progress. 

Second, these representatives of APS do not understand that psychology's diversity is its strength. They seem to hold this idealized vision of science, and psychology, as something that is purely objective and value free. Nothing could be further from the truth! Psychology is extraordinarily value laden. In arguing for a using a narrow view of science and extremely restricted epistemology for outcome research, they are implicitly stating that this value system is superior and all must fall in line with it. If not, there is something wrong. As Nietzsche would say,

"No shepherd and one herd! Everybody wants the same, everybody is the same: whoever feels different goes voluntarily to the madhouse." ~ Nietzsche

Psychotherapy clients have a broad, divergent set of values. For a psychologist to claim one approach to psychology and psychotherapy meets the highly diverse set of needs associated with these values is more than naive, it is ignorant. Similarly, the position advocated for by these individuals assumes that all want the same thing from psychotherapy, which, too, is dangerous. When one believes this, it gives them permission to impose a particular outcome upon their client; it allows them to impose their values on the client. 

When a client comes to me for therapy, the first thing I do is not consult a research-based matrix to determine which therapy is best for my client based upon gender, culture, and diagnosis. Instead, I inquire about their values, share some about my approach to therapy and other therapy alternatives, and then together with the client make the decision about if I am the right therapist. It is not that I reject science; instead, my approach to determining therapy fit is one rooted in deep appreciation for my client's value system. After we agree to work together, I draw heavily on science to inform my moment to moment decisions in therapy, but not to determine them. In my view, science should constantly inform clinical decisions making, but not determine them. 

Some advocating the APS position would say that I use clinical judgment over science. I am not sure if this is because they are uniformed, have trouble understanding the complex model many practitioners advocate for, or are using this simply as rhetoric and political leverage. I fear the later, but hope for one of the former. Instead, what I am advocating for is to use science and clinical judgment that is informed by science. Science and research is very involved in my moment to moment decision making process, but I do not allow myself to be blinded by the science or reduced to something akin to a computer, just allowing an unempathetic science to determine what I should do each moment.

In conclusion, the diversity of opinions and approaches to psychotherapy serves two main purposes relevant to this debate. First, it promotes a progressive view of science that allows for science to develop and grow instead of becoming stagnant. Second, it better allows therapy to meet the diverse needs and respect the diverse values of clients. 

Veterans Day Tribute: Understanding PTSD

This may seem like an odd way of paying tribute to our Veterans, to focus on PTSD; however, I hope that it quickly becomes evident how this is very much in the spirit of supporting our troops. 

Since the onset of the war on terror and the war in Iraq, I have been very disappointed what the idea of "supporting our troops" has sometimes meant. Soldiers were on extended tours, often under-equipped, frequently mistreated for acknowledging psychological distress, and not given adequate care when they were injured and no longer able to serve. Many soldiers were publically humiliated for acknowledging psychological problems resultant from their military service. Yet, for many, "supporting our troops" meant supporting the war, but not necessarily taking care of our troops. 

Posttraumatic stress disorder, or PTSD, plays a big role in the politics of supporting our troops. I am not a bit fan of diagnosis and believe mental health professionals should diagnose cautiously and only when necessary. Yet, I am very disturbed when mental health professionals in the military or professionals working with our troops and veterans in other contexts say they don't believe PTSD exists. These individuals are generally not engaging in the philosophical discussion on the nature of mental illness and diagnosis; they are discounting the suffering of the soldiers and, in essence, saying their problems is because they are weak. . 

Although PTSD is called a mental illness, the symptoms can really be understood as largely adaptive behaviors that have become maladaptive patterns once not longer in a combat setting. The symptoms of PTSD include 1) hypervigalence, or being excessively aware of one's surroundings, 2) exaggerated startled response, 3) poor trauma recall, 4) Intrusive thoughts and nightmares, and 5) avoidance of thoughts, feelings, people, and places that remind them of their traumatic experience. In this partial list, it is already evident that each of these symptoms can have a positive role in responding to a traumatic situation. Hypervigalence helped the soldiers survive when in combat through being attuned to the potential dangers in their surroundings. The exaggerated startle response is partially a learned behavior, but also serves to quickly activate the flight/fight response. Poor trauma recall helps individuals block out the bad experiences until they are in a place they can face them. The avoidance of reminders of past trauma serve a similar purpose. The nightmares and intrusive thoughts illustrate the other part of the paradox. Although it may be healthy to block out bad memories at times, it is also necessary to process them. Dreams often serve to help individuals process and consolidate memories; however, for many individuals with PTSD there is too much to process and the dreams become overwhelming. Some research suggests we dream more on vacations or other times when our unconscious recognizes we are in a safe and restful place that can allow the processing of the difficult information that had been contained in the unconscious. Therefore, dreams and intrusive thoughts can be a reminder that this information needs processing.

PTSD, then, can be seen as a natural response to a difficult situation; however, most people do not understand what PTSD is like or the purpose it serves. This includes many spouses who are bewildered when their spouse comes home a different person than when they left, or when they returned home without many problems after 1 or 2 tours, but after 3 tours begin showing PTSD symptoms. 

This is why we need to be very concerned when people use this diagnosis carelessly. Following the recent shootings at Fort Hood, many mental health professionals recklessly and irresponsibly began talking about the "likelihood" that Hasan, the shooter, suffered from PTSD without even gaining information about Hasan's background or direct exposure to combat or other trauma. Even though it is now understood that PTSD would not likely fit Hasan, the damage has been done. 

The message that this irresponsible use of invoking PTSD sends is that individuals with PTSD are dangerous. For individuals who know little about PTSD, this may cause them to fear people who have this diagnosis or, quite possibly, to fear people returning from the war in general. These veterans are often desparately in need of our love, support, and compassion, but irresponsible use of the label PTSD may instead cause people to fear and keep their distance from veterans. 

In truth, irritability and anger issues are connected with PTSD. However, it is a very small percentage of people with PTSD that become violent and, when it occurs, it is very rare for it to be something like what occurred at Fort Hood. When individuals with PTSD are violent, it is often connected with other issues - their own or systemic - that contribute to the violence. For example, many do not have adequate access to treatment. Many vets have repeatedly requested more frequent therapy sessions and other service options, but are told the services are not available because of the high demand. Others are concerned that if they seek treatment, this could jeopardize a promotion, their status in the military and ability to continue to serve, or are afraid they may be mistreated by peers or supervisors for admitting problems. Although many have sought treatment without these negative consequences, there are enough examples of this occurring to justify the concern. 

What, then, does it mean to "support our troops." I believe supporting our troops mean showing them the respect and compassion they deserve for choosing a career based in serving and protecting US citizens. One can do this with or without supporting war efforts, with or without agreeing with the decisions made by our politicians about when to use military action. Our soldiers are not given the choice about which wars or in which combat situations they will participate. They enlist to protect our country, period. They must put their trust in our leaders to make good decisions about when to put their lives at risk. It is dangerous to collapse the idea of supporting our troops into the notion of supporting our political leader's decisions to go to war. From the vets I have worked with, some believed in the war efforts and some did not. Many reported they felt they had to support and believe in the war efforts when there was the possibility of being deployed; it was dangerous to be considering if it was a just war when they had to make life or death decisions involving when to pull a trigger. Yet, when the possibility of deployment was over, they began having to reconcile their beliefs and values with what occurred. I cannot imagine how difficult this must be for our troops. 

To conclude, nothing I could say would adequately express the gratitude I have to our troops. I am angry about some decisions that have been made to put their lives at risk when I didn't feel it was warranted, but I also am glad I was not the person who had to make these incredibly tough decisions about when to use our military. It is not an easy decision either way. I am also angry that our troops have not always been given the resources they needed when deployed and that they sometimes have been mistreated and neglected when they returned home. But supporting our troops is not about politicians or politics, it is about supporting the people who have enlisted in armed services because they are committed to their country and protecting all of us. This, I hope, everyone can agree upon. 

Understanding the Fort Hood Shootings: An Existential Psychology Approach

The United States has suffered another great loss with two of our citizens opening fire on fellow citizens. In the aftermath, we see the beauty of concern and compassion for those who are suffering. We also see the media frenzy trying to understand what happened and why. Striving to make meaning from tragedy is a basic existential concern; however, we also need to take a close look at the process of how we make meaning, which is the concern of this blog post. 

Withing hours, we heard psychological diagnoses being made, sometimes with appropriate caution, sometimes recklessly by mental health professionals happy to be in the national spotlight. I am glad that the media seeks to interview mental health professionals and there is nothing wrong with responding to this request. However, it bothers me when these professionals sensationalize their responses in exchange for 10 seconds of fame. It is unethical to diagnose these individuals without having known them, having access to the records, and being able to see the behavior in context. When Hasan is given the label PTSD, all of a sudden the many wounded warriors who suffer from PTSD become a threat instead of something deserving compassion. Compassion is replaced with fear for too many. I plan to write more on PTSD tomorrow in honor of veterans day. For now, I just want to highlight how this diagnosis can be used inappropriately. 

We also heard of people focusing on the shooter's last name, Hasan, and speculation that this could be because of his last name. In both the Florida and Fort Hood shootings, much was made of their ethnicity. Lost in much if this discussion is the basic reality that no cultural group in history has engaged in more mass shootings of this type than the White male. Few talk much of the role of ethnicity when the White male kills, but much seems to be made when a White person is victim. The dominant culture seems to feel safer by distancing the perpetrator from their personal identities. 

We also can use a psychological understanding of the impact of trauma and other factors to analyze what may have occurred. In doing this, the responsible mental health professional should always emphasize that this is speculation that may have nothing to do with the actual cases. Personally, I think diagnosing does not help this process most of the time, but using psychological ideas that carry less discriminatory power can be helpful. 

Most of the attempts to understand events such as the Ft. Hood shooting focus on wanting to distance ourselves from the killer. We attempt to categorize, label, and discount the individual instead of understanding him or her (almost always him in this type of event). Instead, if we truly want to understand what has occurred, we must be able to take a more sympathetic view of the individual. I understand this is not an easy idea to consider. Shouldn’t we focus our compassionate energies on the victims and their families? Yes, absolutely. However, if we want to prevent such tragedies in the future, we must take the risk of empathetically trying to understand the shooter. This does not excuse the behavior. I must stress this: empathetic understanding does not excuse the treacherous acts committed by the individual, it simply brings understanding. As James F. T. Bugental once said, he was convinced that if he had the opportunity to work with Hitler in therapy, he was confident that underneath all the anger he would find a hurt, suffering individual. This does not excuse Hitler or the holocaust; it helps understand it.

I imagine things were not easy for Hasan. To be of Middle Eastern ethnicity in the military must be difficult. I have heard many soldiers express concern about their immediate negative reactions to anyone who Middle Eastern, despite not wanting this to be the case. This is learned behavior. When deployed in Iraq or Afghanistan, they had many bad experiences with people of Middle Eastern origin shooting at them, trying to kill them, or otherwise intending harm toward them. It is basic behaviorism – learned responses. There has been some reports that Hasan did experience some blatant racism and mistreatment because of his race.

Additionally, I am sure he experienced many microaggressions. Microaggressions are unintentional, often well-intended forms of racism. A common example is when an individual of a particular skin tone or cultural group is asked to speak for everyone who shares that identification, or when an individual from a minority group is told they are articulate when a person of majority speaking the same way would be perceived as speaking quite normally. For Hasan, I’m sure he heard many stories like I have heard, of soldiers who have returned and struggled with their reactions against individuals from the Middle East. Most of the time, these soldiers cognitively realize that there is no just reason for their negative view of individuals of Middle Eastern origins. They speak of this because they do not like that they have this reaction, not because they embrace it. However, it still can be hard to hear these comments and others feel their reactions are justified.

We also need to consider the concept of vicarious trauma. Surely, in Hasan’s role, he heard many horrific stories, as do all of us mental health workers who work with soldiers and veterans. These are hard to hear; they are painful. When I hear soldiers talk of accidently killing a civilian and their guilt associated with this, or stories of being haunted by watching a friend get violently killed right next to them, it hurts. It traumatizes me.  I am sure that Hasan, as a psychiatrist, heard these stories, too. It is not as traumatic as being there, experiencing the violence and death, but it is still traumatic.

Last, I think it is important to realize that mental health professionals are people, just like everyone. There are checks to try to make sure that people entering the field meet certain standards of mental health. Yet, some individuals make it into the field that should not. Others are psychologically healthy when entering the field, but because of life experiences become unhealthy over time. However, ALL mental health professionals have their own struggles and issues. This is part of the human condition. Furthermore, some of the individuals most recognized in the history of the field as exemplar therapists were individuals who struggled deeply with their own psychological problems. Carl Jung, Harry Stack Sullivan, and R. D. Langs are just a few examples. If our expectation for mental health professionals is to have no psychological problems, then we might as well close down the professional.

In conclusion, I do not know why Hasan committed the terrible acts he did and I believe he should be held fully accountable for them. Nothing excuses his behavior. However, I do want to know why he did these things beyond discounting him as evil or acts of mental illness. He was a person who did a horrible thing. Discounting him will not help me be a better person or psychologist, but understanding him, finding ways to be compassionate toward him while holding him accountable, may just help me become a better person and professional.