Consumer knowledge of psychotherapy's value system

[ChineseRoom]

I am in no postion to tell anyone how to live, but I just think that due to the nature of this profession, we all should value the importance of being human...as well as living healthy lifestyles. And, if all that you wrote was true, I wondered about professional burnout, sleep hygiene/health, aerobic/physical health, interpersonal relationships, outside interests/hobbies.

And, yes, the Lord did indeed say to rest on the Sabbath, PSYDR.

First post here but I'm gonna bump this thread for several reasons. One that I find it quite interesting and like to hear more about what people do once they are done with their studies. Specifically, I'm considering becoming a therapist (one of my options), so this kind of information is very helpful to me.

Secondly, and sorry for the digression, I want to comment on people who criticized the person who is working 60-100 hours. This goes to one of my pet peeves about clinical psychology. I see it everywhere, on TV shows, books, internet sites, psychology support forums. It's about psychologists, and psychology as a field, judging other people but keep framing things in "health" language or "functional" language or recently in "humanistic" language. It's Dr Phil type "how's that WORKING for you?" Or it's not "healthy" to work this many hours. Or like the above post talking about "importance of being human."

I certainly don't want to become a therapist if it means telling a person who is working so hard and contributing so much to helping others, how to live or even worse, to call them sick or ill (if you're not healthy, what are you?!). Even worse, are they NOT a human being or are they not BEING a human the way they're supposed to? Who are we to judge? Hundreds of years ago people worked differently, different hours, different ways, whatever. Were they not human? What about other cultures, even at present time, are they not "healthy"? And what if they're not, is "healthy" more importance than doing what you want or contributing or helping others or...other values and goals that define and shape our activities?

The worst part in all of this is how psychology tries to deny having any values. It pretends to accept people, no matter who they are, but it does not. There are expectations of what healthy people are or do, and how one should live. Yet how many of you therapists, at the beginning of a session, come out and mention your values, and rank your value priorities in a specific and precise manner, before starting therapy? I bet very few of you do.

But it's just me, this is my pet peeve, and I know many people don't see things this way, and I see many people in psychology support forums and on TV shows slowly learn and use and accept the language of psychology, calling things "healthy" and "functional" and "human." Perhaps as someone who has only taken a few psychology courses and has not had therapy, I am paranoid about it and see it slightly as cult-like.

In fact, before coming here I was searching Amazon to see if there was a book about philosophical underpinnings of psychology, specifically psychotherapy, to see what philosophical views shaped psychotherapy. I know Freud's views played a big part in all of it. His secular views, his views on importance of functioning in society (defense mechanisms are all about practical concerns, like sublimation in sports, not that hitting someone against the board in a hockey game is exactly "healthy" either), his focus on sexuality (probably rebelling against the society), his denial of truth of spiritual phenomenon (God as merely a father figure), they did shape psychotherapy.

But I have also read about Carl Rogers. That humanistic values have also shaped therapy is also puzzling. Why? Was there a double blind study done on humanistic values that showed they are "good" or "right" or "helpful" for patients? A lot of research has gone into behavioral methods but humanistic therapy just came out of nowhere. Those values were added...perhaps because it was just a sign of the times? The way suddenly being gay was not seen as mental illness in the 1970s, after political action by homosexuals? Or consider Maslov's hierarchy. It has barely any research support and yet it's used and referred to constantly.

I am sorry if my critiques sound like the drunken political grumblings of a foreigner, but in reality what I am really asking is help to get a grip on all of this, to make sense of it. If psychology and psychotherapy is a science, then I want to see the science. If it's a religion, who is its prophet, Freud or Carl Rogers or someone else? If it's a mix, with different views, different research methods, some values just smuggled in, a variety of therapies and therapy ideologies, where is the ultimate book that explains it all, the history, the philosophy, the ideology, the value system, what are the seminal books that will answer my questions?

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[WisNeuro]

The worst part in all of this is how psychology tries to deny having any values. It pretends to accept people, no matter who they are, but it does not. There are expectations of what healthy people are or do, and how one should live. Yet how many of you therapists, at the beginning of a session, come out and mention your values, and rank your value priorities in a specific and precise manner, before starting therapy? I bet very few of you do.

Of course I don't do this, it'd be a terrible way to begin therapy. Therapy isn't about us as a therapist. It's about the patient. This would be a great way to alienate a client/patient with different values and torpedo the therapeutic alliance before it even starts. What purpose would this serve therapeutically?

 

[Pragma]

I am sorry if my critiques sound like the drunken political grumblings of a foreigner, but in reality what I am really asking is help to get a grip on all of this, to make sense of it. If psychology and psychotherapy is a science, then I want to see the science. If it's a religion, who is its prophet, Freud or Carl Rogers or someone else?

They do a little bit. They also are a little misguided. But, you are seeking information in order to make more informed decisions, and that is a good thing.

A lot of the new guard that are out there are concerned about the evidence base - producing research, understanding research, using therapies that have research support, etc. It is a science, it is just sad that there are a lot of practitioners out there that don't use science. So if we think something has potential, we study it and add to the evidence base.

Unfortunately, in the field we have to deal with people who have their own theories and clinical anecdotes and who ignore evidence-based practice to just "do their own thing", and entire programs that are oriented in this direction. These programs are parasites and the students who come out lack perspective and adequate training to practice competently.

You sound like a smart person, I hope you make a smart decision about where to pursue your studies.

 

[JonEC]

"But I have also read about Carl Rogers. That humanistic values have also shaped therapy is also puzzling. Why? Was there a double blind study done on humanistic values that showed they are "good" or "right" or "helpful" for patients? A lot of research has gone into behavioral methods but humanistic therapy just came out of nowhere"

-Rogers actually conducted quite a bit of treatment outcome research focusing on qualities of effective psychotherapists before promoting them widely. His contribution is important, as dominant theoretical orientations stipulated that the therapist should assume a neutral and/or expert stance. We now know that the quality and strength of the relationship between therapist and client is one of the most important factors in determine whether therapy will be successful.

For example:
Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review.
Authors
Martin DJ, et al. Show all
Journal
J Consult Clin Psychol. 2000 Jun;68(3):438-50.

Affiliation
Abstract
To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from 79 studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability. Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study.

PMID
10883561 [PubMed - indexed for MEDLINE]

 

[ChineseRoom]

Of course I don't do this, it'd be a terrible way to begin therapy. Therapy isn't about us as a therapist. It's about the patient. This would be a great way to alienate a client/patient with different values and torpedo the therapeutic alliance before it even starts. What purpose would this serve therapeutically?

I'm sorry, I must have not explained myself well. I did not mean YOUR values, as in your real life. For instance in real life you might value work above family or be religious or be a feminist or have bias against minorities or be an anarchist or whatever. I mean THERAPY's values. Since you are representing a particular form of therapy, then they will be the values that will be guiding your work with a particular patient and so in your professional role, they will be your values in the setting. These values are not always obvious to the patient, I assume. For instance as a therapist you may value individual responsibility highly. Perhaps if you're a Freudian you may hold the person less responsible for certain actions or thoughts or feelings (because of role unconscious plays). I'm just making these up, but the point I'm trying to get at is that therapy is not value-free and different therapies view people differently and also have different goals and values, and most importantly, patients are not quite aware of these. Why do I think that? It's just based on some informal conversations I've had with people in psychotherapy support forums. I am particularly peeved whenever I see someone describe a behavior and another person says that's not "healthy." Or "functional":

You did not spend time with my family? You did not act assertively? You ignored how you felt? Well that's not "functional" and it's not "healthy." Every thread there, I tell you!

 

[ChineseRoom]

They do a little bit. They also are a little misguided. But, you are seeking information in order to make more informed decisions, and that is a good thing.

A lot of the new guard that are out there are concerned about the evidence base - producing research, understanding research, using therapies that have research support, etc. It is a science, it is just sad that there are a lot of practitioners out there that don't use science. So if we think something has potential, we study it and add to the evidence base.

Unfortunately, in the field we have to deal with people who have their own theories and clinical anecdotes and who ignore evidence-based practice to just "do their own thing", and entire programs that are oriented in this direction. These programs are parasites and the students who come out lack perspective and adequate training to practice competently.

You sound like a smart person, I hope you make a smart decision about where to pursue your studies.

I would appreciate some readings suggestions. Are there books that can help me gain clarity? I don't want to get into a program (after doing all the work) but then realize that it's not a good fit for my kind of thinking (I'm a little bit of rebel 😉 ) or personality. Perhaps a good book on philosophy and history of psychotherapy would be most helpful to me. Thanks.

 

[Pragma]

I'm sorry, I must have not explained myself well. I did not mean YOUR values, as in your real life. For instance in real life you might value work above family or be religious or be a feminist or have bias against minorities or be an anarchist or whatever. I mean THERAPY's values. Since you are representing a particular form of therapy, then they will be the values that will be guiding your work with a particular patient and so in your professional role, they will be your values in the setting. These values are not always obvious to the patient, I assume. For instance as a therapist you may value individual responsibility highly. Perhaps if you're a Freudian you may hold the person less responsible for certain actions or thoughts or feelings (because of role unconscious plays). I'm just making these up, but the point I'm trying to get at is that therapy is not value-free and different therapies view people differently and also have different goals and values, and most importantly, patients are not quite aware of these. Why do I think that? It's just based on some informal conversations I've had with people in psychotherapy support forums. I am particularly peeved whenever I see someone describe a behavior and another person says that's not "healthy." Or "functional":

You did not spend time with my family? You did not act assertively? You ignored how you felt? Well that's not "functional" and it's not "healthy." Every thread there, I tell you!

It is not value free at all, but I would hope that any good therapist has a strong understanding of how their values interact with their client. sticking to EBTs for specific issues is always best. Otherwise you risk therapists ruining things because they suck at therapy (because they don't pay attention to evidence).

 

[JonEC]

I mean THERAPY's values. Since you are representing a particular form of therapy, then they will be the values that will be guiding your work with a particular patient and so in your professional role, they will be your values in the setting.

You might be interested in learning about intersubjective psychoanalysis, an approach that is very careful not to impose a value system:
http://integral-options.blogspot.com/2012/05/intersubjective-systems-theory-in.html?m=1

 

[Pragma]

I was quoted but you were quoting someone else. Just wanted to be sure that was clear.

 

[Marissa4usa]

I mean THERAPY's values. Since you are representing a particular form of therapy, then they will be the values that will be guiding your work with a particular patient and so in your professional role, they will be your values in the setting. These values are not always obvious to the patient, I assume. For instance as a therapist you may value individual responsibility highly. Perhaps if you're a Freudian you may hold the person less responsible for certain actions or thoughts or feelings (because of role unconscious plays). I'm just making these up, but the point I'm trying to get at is that therapy is not value-free and different therapies view people differently and also have different goals and values, and most importantly, patients are not quite aware of these. Why do I think that? It's just based on some informal conversations I've had with people in psychotherapy support forums. I am particularly peeved whenever I see someone describe a behavior and another person says that's not "healthy." Or "functional"

You did not spend time with my family? You did not act assertively? You ignored how you felt? Well that's not "functional" and it's not "healthy." Every thread there, I tell you!

I may be misunderstanding what you're trying to say but to me it seems like you're talking about a therapist's theoretical orientation - plain and simple; I am not sure to what extent I would conceptualize that as a "value". To be an effective therapist, you work within a certain theoretical framework and if you're a good at upur job, you don't go and switch back and forth between theoretical approaches to treatment (i.e. you don't interpret someone's dream one day to get to the root of a problem and do a functional analysis of behavior the next) . As you read more in this forum, you'll find that most people here are proponents of theoretical orientations that have a strong empirical foundation and that have very little to do with "values".

In terms of patients not being aware, I agree with you - however, that's part of the problem of this profession as a whole. Most people don't understand/know that therapy is more than just talking to someone for 50 minutes. Consequently, so-called therapist get paid to deliver and implement treatments when they have no business of doing so. If the public was more informed about what effective treatments for various psychological conditions constitutes (including the fact that it is more than "just talking"), this array of various values and goals you're referring to wouldn't exist.

 

[ChineseRoom]

Thank you so much for that explanation about theoretical orientation, I must have assumed that too was value based, as if a therapist merely chooses a particular orientation (behavioral vs cognitive vs humanistic) based on own personality or values (e.g. a therapist who loves abstract ideas might be a bigger fan of Freudian views, as opposed to one who is a bigger fan of concrete evidence and would choose behaviorist methods), the way a chef might mix and match a recipe to satisfy his desires or personal taste. Although maybe that's not the best analogy because for one thing I think some chefs make use of principles of molecular gastronomy and so their choices are somewhat science based.

I realize I have derailed this thread enough, thank you all for engaging the musings of a newbie, but I will bow out before we go too far off topic. I would appreciate any PMs about reading material though. The End.

 

[WisNeuro]

Well, I do actually explain my approach (CBT, PE, CPT) before we ever begin the therapy process. I'm not sure if that's what you mean by values or not. Regardless, it was what I was trained to do in my program. The client/patient is a consumer and I want the to be fully informed about what I'm doing. And, if they want further information, I provide it. As for choosing the orientation. I was actually trained pretty broadly, dynamic and CBT, I merely chose what I feel is best based on the empirical evidence (best outcomes for what I treat in a timely manner).

 

[Therapist4Chnge]

Can you take this discussion elsewhere? I would like to keep this thread on topic since it is a frequently asked about topic.

 

[ChineseRoom]

Is it possible for the mod to cut out the last few posts, starting with my original, and put them in a new thread, called something like "consumer knowledge of psychotherapy's value system"? I did want to revive this thread and learn more about what people do, so maybe I can then make a quick post here about that but minus the digression?

 

[AcronymAllergy]

Mod Note: Broke these posts out from the "typical day in practice" thread to allow for further (separate) discussion of these issues.

 

[cara susanna]

Therapy isn't really about telling someone else how to live or what's healthy vs. unhealthy, it's more about helping them realize the motivations and consequences of their behavior. If the person didn't want to change something, they probably wouldn't be in therapy. If they don't want to change it, they don't have to--they just have to live with the consequences. Of course there are exceptions to this such as dangerous behavior (like suicide attempts or eating pathology) or illegal issues arising from the behavior.

For instance, let's say a client has anxiety about elevators so instead always takes the stairs. This isn't really an issue unless 1) The client is having impairment as a result, such as always being late and getting into trouble for it, and/or 2) The client would like to be able to not take the stairs and instead take the elevator. If someone always takes the stairs instead of the elevator, I wouldn't really do that myself but it's not exactly hurting me any.

As for the question about humanistic therapy and the "nonspecific" factors, the fact is that you aren't going to get a lot done in therapy if you don't have a solid relationship with the client. Most of the use of nonspecifics that I've seen is more for building rapport and building the relationship so you have a solid foundation for the techniques and evidence-based stuff later on. Therapy can be scary and difficult. If the client doesn't feel like you care about him or her, they're probably not going to be very compliant and will probably stop showing up.

 

[JustNoticing]

http://psycnet.apa.org/index.cfm?fa=search.displayRecord&uid=1997-04451-002

 

[LivingOffLoans]

Positivism is still a (very Western) value. I don't think anyone else has mentioned that yet. It is very worshiped inside and outside of academia, and so you won't find many fish who know they're swimming in water.

I also feel the need to mention that just because one endorses EBT's does not mean they are more likely to be value-free in psychotherapy, or produce better results. I have known a couple of incredibly cruel and unethical 'behaviorists' who did more damage than good; but because they used 'science', they rationalized their own behavior.

There is a lot of research which suggests that the therapist's and client's personalities are large determinants in therapy process/outcome. You can apply the same interventions and techniques across a population of well-trained therapists and get very different results. It seems to me then that being effective as a clinician may actually be more about who you are than what interventions you use, though what interventions you use are critically important. My concern is that, as a profession, we promulgate so much of the latter that we forget about the actual people sitting in the consultation room (the therapist and the client) and how they affect each other.

I do believe in the vast benefits that empirical research affords to clinical practice, and that therapists have a responsibility to consume the literature regularly; but I don't believe that it's the be-all end-all, or always the #1 angle toward applied practice, that many of us are implicitly trained to take it as. It's really just a small part of the full range in the spectrum of human inquiry that can help us better understand/help people. However, because empirical investigation is often the quickest, most viable method toward 'certainty' (let alone things like academic tenure, promotion, and generating revenue), it gets touted as though anything outside of it is not worth considering.

 

[WisNeuro]

I do believe in the vast benefits that empirical research affords to clinical practice, and that therapists have a responsibility to consume the literature regularly; but I don't believe that it's the be-all end-all, or always the #1 angle toward applied practice, that many of us are implicitly trained to take it as. It's really just a small part of the full range in the spectrum of human inquiry that can help us better understand/help people. However, because empirical investigation is often the quickest, most viable method toward 'certainty' (let alone things like academic tenure, promotion, and generating revenue), it gets touted as though anything outside of it is not worth considering.

After you get past common factors, you have to rely on empirical support for efficacy. Otherwise we get people doing "primal scream" and conversion therapy because those practitioners "know in their hearts" that they're doing good. Empiricism is what helps us make ethical and helpful decisions for our patients. There are mounds of research out there about clinicians who "do their own thing" and feel that their practice is more of an "art" than a science. The literature strongly suggests that patients within that approach do not do as well on a variety of outcomes.

 

[Therapist4Chnge]

There are mounds of research out there about clinicians who "do their own thing" and feel that their practice is more of an "art" than a science. The literature strongly suggests that patients within that approach do not do as well on a variety of outcomes.

Do you mean that severe pathology cannot be cure with moonbeams and pixy dust?!!

How dare you doubt my methods!

 

[sockit]

Thank you so much for that explanation about theoretical orientation, I must have assumed that too was value based, as if a therapist merely chooses a particular orientation (behavioral vs cognitive vs humanistic) based on own personality or values (e.g. a therapist who loves abstract ideas might be a bigger fan of Freudian views, as opposed to one who is a bigger fan of concrete evidence and would choose behaviorist methods), the way a chef might mix and match a recipe to satisfy his desires or personal taste. Although maybe that's not the best analogy because for one thing I think some chefs make use of principles of molecular gastronomy and so their choices are somewhat science based.

I realize I have derailed this thread enough, thank you all for engaging the musings of a newbie, but I will bow out before we go too far off topic. I would appreciate any PMs about reading material though. The End.

I think there definitely are therapists out there who claim (or intend) to use evidence-based therapies, but wind up going off track, maybe because they're out on their own, they get burnt out, whatever. Speaking as someone who's benefitted from therapy (but has also not), my best experience was with a therapist based at a group practice where therapists regularly discussed cases with each other (I think biweekly, if I remember -- this was shared with me, I had to consent to it), and explicitly invited discussion (with me, the client) around both progress and the process, formally, at particular points in time (e.g. at the 6th session) and informally, on an ongoing basis, as things came up. In addition: if I felt it wasn't working, I could freely discuss it with another therapist, or switch therapists. (There was a lot of effort expended towards explaining that and making it an easy thing to do.) The theoretical orientation and overall process were laid out at the first session in plain English. I think their commitment to being genuinely 'client-centred' and their organizational structure -- the fact that they checked in with each other as a matter of course -- probably helped them stay on track. Pretty amazing place.

Point being: I think there are organizational processes that can mitigate the worst of the tendencies you describe, OP.

 

[WisNeuro]

Do you mean that severe pathology cannot be cure with moonbeams and pixy dust?!!

How dare you doubt my methods!

No, it cannot. It can, however, allow you to fly. But only if you really believe with all of your heart.

 

[futureapppsy2]

After you get past common factors, you have to rely on empirical support for efficacy. Otherwise we get people doing "primal scream" and conversion therapy because those practitioners "know in their hearts" that they're doing good. Empiricism is what helps us make ethical and helpful decisions for our patients. There are mounds of research out there about clinicians who "do their own thing" and feel that their practice is more of an "art" than a science. The literature strongly suggests that patients within that approach do not do as well on a variety of outcomes.

I honestly wonder if a lot of this comes from the tendency at the undergrad and masters level to present all theories/theoretical orientations as "equally true" and then tell students to pick the one that "resonates with them the most."

 

[WisNeuro]

I honestly wonder if a lot of this comes from the tendency at the undergrad and masters level to present all theories/theoretical orientations as "equally true" and then tell students to pick the one that "resonates with them the most."

Mayhaps, this tendency is why I am skeptical of non scientist-practitioner programs.