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The Troubled Marriage of Science and Art in the Practice of Psychotherapy – Cynthia Ezell

by | Oct 12, 2009

The Troubled Marriage of Science and Art in the Practice of Psychotherapy
Written by Cynthia Ezell, LCSW

In a recent issue of Newsweek, (Ignoring the Evidence. Why do psychologists reject science? October 12, 2009), Sharon Begley opined about the analysis published in the November 2009 Perspectives on Psychological Science concerning the disparity between what science can prove about psychotherapy and what psychotherapists actually do. She was basing her article on a report that actually first appeared in 2008 in Psychological Science in the Public Interest, the journal of theAssociation for Psychological Science (APS), co-authored by Timothy Baker of the University of Wisconsin, accompanied by an editorial written by Walter Mischel. [Editor’s Note: For the extremely curious, the 145-page pre-publication draft is available HERE.] In the original report, Baker states that many clinicians “fail to use the interventions for which there is the strongest evidence of efficacy.” (Begley, 2009) Baker’s report and the attendant responses have set off a firestorm in the media about psychotherapy and psychotherapy training programs.

Two years ago, the APS established an accreditation system for graduate psychology programs that would stand in opposition to the current credentialing system maintained by the American Psychological Association (APA). Begley states that “if public shaming doesn’t help” (Begley, 2009) then perhaps the new credentialing system proposed by APS will “stigmatize ascientific training programs and practitioners.” (Baker, 2008) The intention seems clear—to draw a firm line between those who are deemed scientifically trained, and those who aren’t. Don’t stop reading here just because you are a master’s level psychotherapist and aren’t really concerned about doctoral training programs. This debate affects all of us.

Baker believes that psychologists spin the facts to cover up what they must surely fear—that their profession is a “charade.” He says that psychologists are “deeply ambivalent about the role of science” and “lack solid science training”. A particular target of both Baker’s report and Begley’s article are Psy.D. programs, which focus more on the practice of psychotherapy than on clinical research. Begley deems these programs as “science-lite”. Might she deem a LSCW or a LMFT training program as “science-zero”?

There was an interesting discussion of the tension between science and practice in December onNPR’s Talk of the Nation, which I did not hear. Fortunately, Melinda Borthick, Ph.D., did hear it, and forwarded me the transcript. The host is Joe Palca, and the guests that day were Bruce Wampold from the University of Wisconsin, Richard McFall, executive director of the Psychological Clinical Science Association System, and Dianne Chambless from the University of Pennsylvania. Wampold made a comment which seemed to me to be obvious and central to this debate, but which seemed to have little impact on the other guests. Wampold said, “So becoming a therapist involves clearly being knowledgeable about what the science is, about the disorders and about treatment, but it also takes a great amount of effort and supervision to learn how to deliver these treatments. And so it may well be that the graduates of these (strictly scientific) programs actually have less therapy training and maybe wouldn’t be as qualified or as effective as therapists in other programs” (Wampold, 2009). Richard Almond likens the relationship of researchers to clinicians to “two populations living on continents that have drifted apart.” He writes that researchers and clinicians now live in different social “ecosystems,” having little in common organically besides their shared heritage. (Almond, 2006)

This is not a new debate. We have been talking about “evidence-based” therapies in the field for years, each of us having to make decisions about what treatment methods we use and why, whether or not we will participate in managed care networks, and how we will evaluate the effectiveness of the treatments we choose. Not all treatments are equal, just as not all therapists are competent. There is a good bit of “new-age” treatment being passed off as psychotherapy in our community. And sadly, a few of us have just tripped along doing whatever “feels right” to us, without putting ourselves or our theories under the microscope of science or clinical supervision. This cavalier approach to treating clients (who often aren’t informed enough to know the difference between good therapy and bad) frightens and concerns me deeply, both for the damage done to the reputation of psychotherapy and the potential damage done to the public.

If we prejudice the art of psychotherapy over the science of psychotherapy we often end up serving our own ego needs instead of the real needs of our patients. And, if we prejudice the science over the art, we might end up being automatons, dispensing something to the patient, as opposed to engaging in a healing relational process with our patients. It’s finding the right balance that intrigues me.

The desire for some empirically proven way to work with those in distress is understandable. We all want to believe that there is A WAY to prevent suicide, to heal suffering, to redeem the past. The problem with Begley’s argument is that psychotherapy is NOT just an application of a scientific technique. It is an intricate, complicated exchange between two humans, influenced by their personal histories, affected by their character adaptations and infused with their own particular vulnerabilities.

After reading Begley’s article, Jordan Lee straight away denounced what she called the “false dichotomy” of science and clinical experience. She says,

“Sharon Begley’s assertion that the clinical and research realms of psychology are polarized, is simply outdated. While so–called evidence-based therapy has been heavily researched in the past, mostly because symptom reduction is so easy to measure, the most recent research has focused on ‘therapeutic process’ – meaning researchers are less concerned with determining which specific orientation is most effective and more concerned with the discovery of why and how and for whom these treatment modalities are working. To date, therapeutic alliance, client involvement in treatment, and therapist flexibility, (just to name a few variables), have been shown to consistently predict positive treatment outcomes across all modalities. (For additional details, see the work of Stephen Shirk, Mark Karver, Phillip Kendall, Brian Chu, Bryce McLeod, John Weitz, Kristin Hawly, Ann Garland, and Alan Kazdin). It’s important to note here that this research is not phenomenological in nature (the so-called ‘soft’ sciences,) but achieves the seemingly impossible task of quantifying the interactions between therapist and client and subjecting this complex relationship to the same rigorous research trials that Begley supports. The centrality of the relationship between therapist and patient is not new to those of us in the clinical trenches. We have known all along that the quality of the relationship we develop with our patient is the key healing component, and we now have the science to prove it. It is very troubling, though, that this science has been available to the public for over a decade but that people like Begley persist in advancing the myth that psychodynamic psychologists are hapless, or worse, irresponsible. I have to wonder if a more reasoned article that actually looks at the research it claims to report would sell as many magazines. Perhaps it is journalists, and not psychologists who are ignoring the science” (Lee, 2009)

A new study has just been published in the American Psychologist that offers an empirical demonstration of the efficacy of psychodynamic psychotherapy, thereby refuting the claim that only symptom-focused or medication focused treatments have scientific credibility. Jonathan Shedler, PhD, of the Colorado School of Medicine has studied the efficacy of psychodynamic psychotherapy, providing scientific evidence that it is highly effective, and that the benefits are “at least as large as those of other psychotherapies, and they last”. (Shedler, 2010). Shedler reviewed analyses of 160 studies of psychodynamic psychotherapy, plus analyses of other psychological treatments as well as treatment with antidepressant medications. These analyses, representing the most up to date scientific evidence on psychodynamic psychotherapy all showed statistically relevant treatment benefits. “The consistent trend toward larger effect sizes at follow-up suggests that psychodynamic psychotherapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended. In contrast, the benefits of other ‘empirically supported’ therapies tend to diminish over time for the most common conditions, like depression and generalized anxiety.” (Shedler, 2010)

[Editor’s Note]: Shedler’s article is available for free HERE. Some other publications have covered his recent article. Check out these links for articles in Science Daily and the Huffington Post (by Wendy Jacobson).

Karl Jannasch, Ph.D., also reviewed the Begley article for us, and what follows is a portion of his thoughtful response:

“I reply as a psychologist who practices psychotherapy. In this role I’m not aware of ‘rejecting science’ or maintaining an anti-science basis. I certainly have nothing against clinical trials- if done well, this approach to the generation of knowledge is a great way to learn about the efficacy of treatments with real patients and their problems. This holds as long as the trials have the usual controls in place and then test varied treatments that are delivered with fidelity.

Outside the work of well conducted randomized clinical trials, which is most of the world, I must admit bewilderment at times upon being told by a colleague that some new approach to psychotherapy, mostly untested as far as I can tell, is now at the cutting edge. Further, I become worried when neuroscience terms and expensive training as well as equipment get thrown into the discussion when there appears to be thin evidence one way or the other. No matter how sincere, testimonials are, well, testimonials. And it is becoming increasingly clear that placebo effects can be powerful, perhaps often more powerful than the treatments under investigation.” (Jannasch, 2010).

(Let me interrupt Karl’s thoughts to suggest that we all look at the latest research on the placebo effect of antidepressants. Look at the latest Journal of the American Medical Association article, Antidepressant Drug Effects and Depression Severity by J.C. Fournier, et al.)

Karl goes on to say that:

“I believe that personal experience ought to count for something in this discussion- it is after all what each of us wakes up with in the morning before we march off to our respective clinical settings. We each depend on clinical common sense to get through the day. So without adopting an anti-science attitude I wonder how claims, based on experience in appropriately controlled studies actually translate into practice where everyday clinical work gets done. When Begley puts down anything that doesn’t meet her definition of ‘science’ I worry that she has become “scientistic”. Simply because wisdom traditions and newly emerging approaches to psychotherapy don’t have the clinical trial stamp of approval is not reason to throw then all out. For example, she lumps ‘mediation therapy… and eye movement desensitization’ into the chaos of ‘1,000 forms of psychotherapy in use’ when both MBCT and EMDR have been, and are being, studied rigorously in the field, To me, she overstates her case here in a way that only adds to public confusion and fear about psychotherapy. As a clinical psychologist I find myself, often, sort of muddling along, trying to be a good enough psychotherapist, never really ‘scientifically’ knowing as much as I might like, but hardly harboring a desire to ‘reject science”. I don’t find the sort of black and white thinking and argument in Begley‘s discussion to be very helpful. I’d like a little more civility and a little less bombast”. (Jannasch, 2010).

Amen, Karl. More civility, less bombast, please. I appreciate both Karl’s and Jordan’s thoughts, as well as Melinda’s catch on the NPR segment. In Part II of this article, we’ll discuss how this science/art—research/practice dilemma gets resolved in our own work, and how NPI as a community might engage in a conversation about what constitutes good psychotherapy. Please feel free to post a comment here on the NPI website [Editor’s Note: You must be logged into your account to post a comment or view comments by others.], or write to me at cynthiaezellblair@gmail.com.

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