Journal of Theoretical and Philosophical Psychology 2009, Vol. 29, No. 1, 34 – 46
© 2009 American Psychological Association 1068-8471/09/$12.00 DOI: 10.1037/a0015564
Psychotherapy as Applied Science or Moral Praxis: The Limitations of Empirically Supported Treatment Kevin R. Smith Pittsburgh, Pennsylvania Proponents of empirically supported treatment (EST) have argued that psychotherapists have an ethical obligation to make an EST the first choice in clinical practice. This paper challenges this idea. The EST program assumes a model of therapy as technology or applied science that poorly fits the reality of psychotherapeutic practice. The problems brought to therapy implicate fundamental questions regarding what constitutes a good life. A therapeutic response to such problems is not a technical means to change a circumscribed disorder, but an engagement with the client that has relevance to broader moral concerns. Further, the picture of therapy as technology of change implicitly proposes views of a good life, while not acknowledging that it is doing so. Keywords: empirically supported treatment, ethics, praxis, Aristotle, good life
Does therapy do any good? What good does it do? At which good(s) should it aim? One approach to such fundamental ethical questions is to recast them as questions about whether therapy works to bring about some specifiable change in symptoms or behaviors. Within such an approach, psychotherapy is understood as a technical means to bring about a predetermined end. Scientific investigation of psychological problems provides the basis for psychotherapy as a technology of change. This view of psychotherapy as applied science truncates questions about the good that therapy may do. The assumption is easily made that improvement in symptoms, functioning, or reports of distress, is all the good we need be concerned about. Ethics in this context becomes the professional obligation to provide the best means to bring about these ends. This approach to understanding psychotherapy and therapeutic benefit is clearly evident in the Empirically Supported Treatments (EST) program (Chambless & Hollon, 1998; Chambless & Ollendick, 2001; Task Force on Promotion and Dissemination of Psychological Procedures, 1995), an effort to establish a list of treatments of proven efficacy. Through a cri-
tique of this program, I will challenge the validity of the technological model of therapy upon which it relies. At the heart of the critique lies a series of interconnected ideas about psychotherapy: 1) The problems people bring to therapy cannot (or can only rarely) be understood technically, as separable components of the person that are not interconnected with who the person is. 2) These problems will be implicated in some important ways in how the person understands herself, her world, and what constitutes a good life. 3) To do psychotherapy necessarily involves engaging the person in a way that touches upon these broader concerns. 4) Since psychotherapy is a moral engagement with the client in the context of these broader concerns, ethics is fundamental to what therapy is, not simply to how it is done (the term “moral engagement” comes from Miller, 2004). 5) As a moral engagement, therapy does not fit the technological model of the EST program.
The EST Program: Its Rationale and Ethical Implications The movement to develop and disseminate empirically supported treatment (Chambless & Hollon, 1998; Chambless & Ollendick, 2001; Task Force on Promotion and Dissemination of Psychological Procedures, 1995) was prompted in part by the need to demonstrate the value of psychological treatments in an era when there are increasing demands that health care prac-
Kevin R. Smith, private practice, Pittsburgh, Pennsylvania. I thank Constance Fischer, Jane Matz, and Paul Pilkonis for helpful comments on earlier drafts of this paper. Correspondence concerning this article should be addressed to Kevin R. Smith, 552 North Neville St., Suite A, Pittsburgh, PA 15213. E-mail: email@example.com 34
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tices be supported with evidence of their efficacy. The EST program can be seen as a natural development of some prior psychotherapy research that attempted to assess the relative efficacy of different therapies. Whether a psychotherapy is effective or not can only be determined empirically, by gathering data regarding outcome in comparison to other treatment and/or placebo (see the summary of various proposals for specific EST criteria in Chambless & Ollendick, 2001). Research on efficacy can only proceed through specification: it is necessary to specify the treatment and what is being treated. Psychoanalysis is not Gestalt therapy; relaxation training is not exposure-based behavioral treatment. Likewise, obsessive– compulsive disorder (OCD) is not schizophrenia, enuresis is not alcoholism, and loneliness is not unhappiness in one’s profession. In order to determine which therapy works for which problems, the best approach is to examine the efficacy of a welldefined treatment for a well-specified problem or disorder. The operative framework here is technological. This framework proposes that psychological suffering can be analyzed into welldelineated and specifiable problems and their causes which, when carefully investigated, will yield specific methods of intervention. The descriptive differences among problems and disorders must be explainable in terms of relevant etiologic or maintaining factors that dictate different approaches to treating them. This framework comes through clearly in the comments of many who support the EST approach to evaluating treatment. For example, Chambless and Crits-Christoph (2006) claim that identification of the effective elements of successful treatment cannot be done on the basis of clinical experience alone: Can clinicians reliably assess and remember accurately what the causal factors were in their clients’ improvement? Without systematic research, it is unlikely that amid all the variability and uncontrolled factors in treatment outcome, clinicians can be confident about which of their many behaviors are consistently related to the results of treatment for a particular type of client or problem (p. 194).
According to the technological model of therapy, what the therapist does depends upon a prior assessment of the nature of the clinical problem through scientific analysis of underlying factors that cause the problem. The therapist’s
job is to apply a treatment which effectively targets those factors. Supporters of the EST program have noted the ethical implications of this conception of the therapist’s task. For example, Chambless and Crits-Christoph (2006) argue that: In the face of evidence that Treatment A works, it is not sufficient for the practitioner who prefers Treatment B to rest on the fact that no one has shown that Treatment B is ineffective. Treatment A remains the ethical choice until the success of Treatment B has been documented, unless in the process of informed consent the practitioner describes the alternatives and evidence for each, permitting the client to make an educated decision (p. 193).
One implication of the EST program is that one of the therapist’s fundamental ethical obligations is to provide a treatment of proven efficacy from a list of ESTs.
Uniform Therapeutic Efficacy: A Problem for the EST Program One argument against the EST program comes from research that reveals different psychotherapies to be generally equivalent in efficacy. Support for the thesis of uniform therapeutic efficacy (UTE) (Wampold, 2001) comes from comparisons of specific treatments (Elkin et al., 1989; Sloan, Staples, Cristol, Yorkston, & Whipple, 1975), literature reviews (Luborsky, Singer, & Luborsky, 1975), meta-analyses (Smith, Glass, & Miller, 1980; Wampold et al., 1997), and dismantling and components analysis studies (an example is discussed in Lambert & Ogles, 2004). Lambert and Ogles’ (2004) review of this and other research concludes: “In general, the results from comparative, dismantling, and components analysis studies suggest the general equivalence of treatments based on different theories and techniques” (p. 167). This has clear implications for the EST program. “These findings also argue against the current trend of identifying empirically supported therapies that purport to be uniquely effective. Decades of research have not produced support for one superior treatment or set of techniques for specific disorders” (p. 167). Supporters of the EST program do not agree with these conclusions. They can point to comparative and meta-analytic studies which do not show all therapies to be equivalent (Beutler, 2002; Huppert, Fabbro, & Barlow, 2006; Ollen-
dick & King, 2006; Shapiro & Shapiro, 1982), or dismantling studies which show that some techniques are more effective for a given problem (Woody & Ollendick, 2006). Research has repeatedly shown that relaxation training is not as effective for OCD as exposure plus response prevention (Chambless & Ollendick, 2001). Ordinary clinical experience is often in agreement. Who today would recommend psychoanalysis for someone who is spending several hours a day in elaborate ritualized washing and showering to avoid contamination? It is not just fashion or propaganda that has led clinicians to abandon certain treatments as inappropriate for some problems. Proponents of the EST program argue that it simply adds more rigor to what clinicians routinely do in making treatment decisions. Some who are generally convinced regarding research support for UTE are willing to make some concessions to those who advocate for the EST program. Treatment for OCD is the kind of case where such concessions are made. Westen, Novotny, and Thompson-Brenner (2004) make a distinction between circumscribed disorders like OCD, specific phobia, or panic symptoms, and noncircumscribed disorders like depression. Noncircumscribed disorders are woven into broader aspects of the person’s life (personality, relationship history, coping style, sense of self). One consequence is that there will be multiple points of entry into the problem that can make a difference. Hence many types of therapy and therapeutic techniques will be successful. Circumscribed disorders “involve a link between a specific stimulus or representation and a specific cognitive, affective, or behavioral response that is not densely interconnected with (or can be readily disrupted despite) other symptoms or personality characteristics” (p. 655). Not all would make this concession. Wampold (2007) maintains a more sweeping skepticism about the prospects for showing the superior efficacy of specific treatments. I am inclined to leave the door open for the possibility of a technologically conceived treatment of superior efficacy for a circumscribed disorder. It would be difficult to prove that there are no psychological problems which lend themselves to a technical intervention. However, whether a given client’s problems are circumscribed in this sense will not be decided by diagnosis alone. It is not difficult to find cases of appar-
ently circumscribed disorders which turn out not to be (for examples, see Wolfe, 2005, pp. 3– 4, on a specific phobia, and Gabbard, 2005, pp. 266 –267 on an OCD case).
Therapy as Remoralization Through Transformation of Meaning Many psychotherapy researchers have responded to the evidence for UTE with calls for further refinement of the search for efficacious treatment. If the techniques that work have not been found, perhaps they are yet to be discovered, or perhaps there are moderating factors that have confounded the research results (e.g., see Beutler, Moleiro, & Talebi, 2002; chapters on participant factors in Castonguay & Beutler, 2006; Prochaska & DiClemente, 2005; Prochaska & Norcross, 2002). Other psychotherapy researchers have been led by findings of uniform therapeutic efficacy to offer a different model of how psychotherapy works. Jerome and Julia Frank (Frank & Frank, 1991) have offered one of the best known alternatives to the technological model of therapy (see also Wampold’s, 2001, contextual model, and Slife’s, 2004, critique of naturalistic assumptions in psychotherapy theory and research). They propose that to look for the deeper roots of descriptive differences between psychological problems in specific mechanisms or causal factors is to miss the more fundamental nature of the relationship between psychotherapeutic methods and the problems they are meant to alleviate. Regardless of the particular problems that clients bring to psychotherapy, they have at their core a problem of demoralization which renders their own efforts to manage or live with their various symptoms and behaviors ineffective. Psychotherapies of various types have as a common locus of therapeutic effect the amelioration of demoralization. Remoralization can be done by various specific means, but includes a relationship with a socially recognized healer in which the patient receives some clarification or explanation of her symptoms and problems, and has some opportunities for experiences of success or mastery in a context of emotional arousal. Psychotherapy is better understood as “a form of rhetoric that relies on the methods of hermeneutics” than as applied behavioral science (Frank & Frank, 1991, p. 73).
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If psychological problems were of the circumscribed sort that could be resolved by technical means, then morale would be at most a helpful adjunct to the technical work of fixing the problem (like the optimism of a patient headed into surgery). To conceptualize remoralization this way would be to misconstrue the model proposed by the Franks as being merely an adjunct to the technological model. Theirs is in fact an alternative model which shows remoralization to be more than the enhancement of attitude or morale. It occurs through a revisioning of the problem, a shift in how it is understood and lived with that changes the problem itself. A new, more coherent picture of the client’s life course reduces anxiety and enhances the client’s sense of well-being by helping the client to make better sense of what he is experiencing.
Therapy, Praxis, Living Well Westen et al. (2004) see limits to the EST program in the complex links between a client’s noncircumscribed disorder and her other symptoms and personality traits. Jerome and Julia Frank’s (1991) rhetorical/hermeneutic model suggests that it is not just the complexity of interacting factors that needs to be considered, but the way that the client’s understanding of her problems helps to constitute and change the nature of the problem. I want to add a further consideration: the understanding of one’s psychological problems that is addressed in psychotherapy entails some notion of a good life, of what it is to live well. One way to show this is to contrast a common psychological problem with a problem that does lend itself to a technological approach. Consider someone who injures her foot so that it is difficult to walk without pain. She goes to the doctor or emergency room to find out what is wrong. She will expect a thorough examination, X-rays, or whatever other diagnostic tests are appropriate, to determine more precisely the nature of the problem (fracture, sprain) and to obtain the corresponding appropriate treatment. To say that this problem is amenable to a technological approach is not to suggest that it has no implications for anything personally important in her life. It may be extremely important. She may be an athlete who will lose an athletic scholarship if the injury is severe enough to
prevent her from returning to her sport. She may be about to embark on a walking tour of Ireland with her husband of 20 years in a last ditch effort to reconnect in a marriage that has been in trouble for some time. But the problem itself does not reveal these personal meanings: no amount of investigation of the injury to her foot, no examination, X-ray, MRI, will reveal any of these possible personal significances. One may object by varying the example. What if the patient about to travel to Ireland were to say, “Oh, I hate myself for being such a klutz that I am always injuring myself.” It is true that a personal significance appears here. But the significance concerns some skill or grace she lacks, a skill or capacity to live well that belongs to the kind of person she would like to be. The injury itself is only a sign or consequence of that lack. With psychological problems the client will often experience the problem itself as living poorly, not as the consequence of a failure to live well. Clients’ understandings (often only implicit) of what is most important to them, what they aspire to, what living well is, are partly constitutive of their psychological problems. I do not want to claim that this is necessarily the case in every instance. Nor do I mean to suggest that only psychological problems implicate notions of a good life. Many actions, choices, thoughts and feelings do that, not just those that are typical of psychological disorders. My point here is to show that fairly ordinary psychological problems are commonly interwoven into more fundamental concerns about a good life. Consider someone suffering from panic attacks. Often the problem is presented as something to be gotten rid of, as though it were a circumscribed problem. But consider how this complaint about panic attacks can shift when the person speaks of how embarrassed or ashamed she is of her panic. “I don’t have that much stress in my life. Other people manage life without panic. I feel like I’m a loser, like I can’t control myself. I guess I know that panic attacks won’t really hurt me, so why do I freak out about them? I wish I was stronger. Other people would think I was crazy if they knew about it. It’s like when I dropped out of college several years ago–I felt like everyone was looking at me like I was a loser. It doesn’t help that everyone else in my family is so successful.
They treat me like the one who’s never going to make it. Sometimes I wonder if I want to make it. Now I think maybe I just can’t.” The client believes that being afraid like this is irrational, and sees it as a failure to be the kind of person she wants to be. The therapeutic conversation that ensues will be at least in part about what the person thinks is important for herself, how she assesses her life, and whether it is on track toward some good that matters to her. The excessively harsh self-criticism of a depressed patient (one who suffers from what has been called introjective depression, Blatt, 2004), may be part of a demand to achieve some good. This person may feel that to live his life well he must succeed at achieving this good—no excuses, no shirking. To help this person change how he lives with and understands his obligations and expectations to succeed at what is important to him is to help bring about a change in his depression. But the change occurs not because one has removed the cause (harsh demands to meet obligations) of the depression. These demands are part of what the depression is. It makes less sense in this context to think of depression as something the person has (a disorder) than as a way the person is living and experiencing himself and his world. To conceptualize the depression as something apart from him with which he is inflicted is already to begin to take a technological stance toward the situation, where one is drawn to target the disorder. But if it is a way of thinking, experiencing, and living, then to respond therapeutically to the person who is depressed is to join with him in his world and look for ways to move somewhere else, or other ways to inhabit his world, other ways of living, experiencing. In doing so the person changes, not by shedding a disorder like an infection, but by taking on a different perspective, a different sense of who he is, what his world is like, or what matters most. There are problems with a cause-effect model for explaining psychological problems (harsh self-criticism constitutes, not causes depression). Further, efforts to address such problems are not technical means to bring about a separate end. Therapy engages the person in a process of reorientation, of change in her sense of who she is, of what matters to her, that constitutes a change in who she is. The fact that a cause-effect, means-end model does not fit well
what happens in therapy is at the heart of what makes the technological model of therapy problematic. It can be a difficult model to relinquish for those who see themselves as scientistpractitioners. Miller (2004) has discussed how this model of psychologists’ professional identity has created problems for developing a clearer understanding of therapy. With the expectation that therapy be an applied science often comes the idea that the only alternative is blind prejudice, ideology, or wishful thinking. One way to begin to address such concerns is to show that there are other models of knowledge, and of good practice based on that knowledge, than the technological model of applied science. Miller (2004) and Woolfolk (1998) have noted the value of Aristotle’s distinction between poiesis and praxis in this regard. Chapter 6 of the Nichomachean Ethics (Aristotle, trans. 1976) makes a distinction between human activity, poiesis (“production” or “making”), that is intended to bring about something other than itself, and an activity, praxis (“action”), which does not aim at an end separate from itself, but only aims to do well. “For production aims at an end other than itself; but this is impossible in the case of action, because the end is merely doing well” (Aristotle, trans. 1976, p. 209). Typical examples of production for Aristotle are shoe making and house construction. Shoe making aims at an end other than itself, the shoe, which in turn is a means to something else (walking, protection of the foot). Whether one has done well in production is determined by an assessment of the end product (it is a good shoe insofar as it serves well the purposes for which it was made). With praxis it is the action itself that is evaluated, not some separate product that it creates. An example of praxis is courageous action. To stand and fight despite the danger of battle, to rush into the burning building to save the child, is courageous regardless of the outcome, even if the battle ends in defeat, or the child is not saved. Likewise, to fail to be courageous, to be cowardly or foolhardy, is also not determined by outcome. One is no less cowardly for not acting to save the child because the child managed to find a way to save herself. Aristotle’s discussion of poiesis and praxis occurs in the context of a discussion of the kinds of knowledge associated with them. To production or poiesis corresponds techne, technical
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skill, “a productive state that is truly reasoned” (Aristotle, trans. 1976, p. 208). Those who have this technical skill know both what end they are seeking, and how to bring this end about. Dunne (1993) characterizes Aristotle’s techne as “the source of the maker’s mastery of his trade, and of his ability therefore not only to accomplish a successful result (which any handy person might be equally capable of) but in doing so to give a rational account of doing so” (p. 250). Psychotherapy as applied science would exhibit techne. The person who is engaged in production who has techne has knowledge of an end and works his material to bring about that end. By contrast, praxis requires not techne but phronesis (often translated as “prudence”). Someone engaged in praxis who exhibits phronesis has his interest not in an external product but in who he is or becomes through his actions. “The function of phronesis is not to maximize a ‘good’ that one already knows and can come to have, but rather—a much more difficult task—to discover a good that one must become” (Dunne, 1993, p. 270 –italics in original). Therapy as practical moral engagement is a conversation that recognizes the client’s involvement in this more difficult task. The inherently ethical nature of therapy becomes clearer when one conceptualizes therapy not as “production,” not as a technical process that treats or removes a disorder that the person has, but as an aid to the client’s praxis, to a process of discovery of a good he seeks to become. The changes that occur in therapy are in some sense a change in who the person has been. Part of what constitutes a person’s sense of who they are is where they stand in relation to some good, some notion (however vague or unarticulated) of what is a better or worse life, what makes their own life seem good or bad, worthwhile or worthless, and so forth. Who one is, is partly determined by such notions. This is an oft repeated theme of Charles Taylor’s (1985, 1989) work on human agency and personhood. The human agent “not only has some understanding (which may be also more or less misunderstanding) of himself, but is partly constituted by this understanding” (Taylor, 1985, pp. 3). Further, this self-understanding includes a moral component. Persons “only exist in a certain space of questions, through certain constitutive concerns. The questions or concerns touch on the nature of the good that I orient myself
by and on the way I am placed in relation to it” (Taylor, 1989, p. 50). Taylor is critical of the idea that one can develop a human science that ignores the constitutive role of this orientation to the good. His target is a picture of human agency as “weakly evaluative,” as simply calculating how to attain that which is desired. By contrast he speaks of people as also essentially involved in “strong evaluation,” where they are concerned not just with what they desire, but with “a qualitative characterization of desires as higher and lower, noble and base, and so on” (Taylor, 1985, p. 23). In a passage that echoes Dunne (1993) on phronesis, Taylor writes that “strong evaluation is not just a condition of articulacy about preferences, but also about the quality of life, the kind of beings we are or want to be” (1985). To refer to a way of living, of understanding oneself, in terms of one’s orientation to some notion of the good may suggest a fully articulated concept of the good, even the selfconscious endorsement of a particular philosophical school or religious belief. But the fact that the problems people bring to therapy often implicate some understanding of what constitutes a good life does not mean that therapy is a straightforward discussion of philosophical or moral positions. As the depressed person talks of situations where he is relentlessly judgmental of his failure to meet his standards, subtle shifts may occur that are not expressed in an explicit statement about self-judgment. There may be no declaration that, “I see now I shouldn’t be so harsh with myself.” Much of what people believe about what is good and bad for themselves is not explicitly articulated, but lived. Therapeutic change likewise often takes place at the level of the lived, rather than the fully articulated. But this does not make the changes in such lived beliefs any the less an alteration of some view of what the good life or human flourishing consists in. Doing therapy is an engagement with people that speaks to and creates changes in these moral notions. To refer to someone’s sense of the good as a moral concern broadens the term “moral” to include much that would not be considered moral in contemporary culture. Someone’s sense of what would constitute a good life may include holding to standard moral prescriptions (to be honest, or kind to others), but may also include other goods (to be perceptive, “cool,”
original, strong, prosperous, etc.) that are moral only in the Aristotelian sense of being part of some conception of a good life. (As the last examples suggest, the content of a contemporary list of goods will include items Aristotle would not recognize.)
Views of the Good Life in Psychotherapy The ethical import of the technological view of therapy implicit in the EST program is clear: the therapist’s obligation is to provide the most effective treatment for the client’s disorder, in order to reduce suffering and restore functioning as quickly as possible. What are the ethical implications of viewing therapy according to the alternative model of moral praxis? Are there therapists or schools of therapy that view therapy according to this model? How do these therapists describe the ethical implications of their work? It would be impossible to answer these questions with a thorough survey of the existing therapies in a paper of this length. In a sense, each type of therapy, even each instance of a given therapy’s practice, provides some nuance to types of goods, to conceptions of human flourishing that it instantiates. I consider a few representative examples below in order to show that many therapists are quite open in their acknowledgment of the relevance of therapy to these goods. Further, when such views are spelled out it becomes easier to see how the technological model of therapy also proposes its own view of the good, while not acknowledging that it is doing so. Many therapists have proposed that therapy enhances goods which go far beyond the treatment of disorders defined through their symptoms. Therapists have written of a variety of ethical aspirations: to acknowledge and affirm the uniqueness, depth, and interpersonal complexity of therapy and its participants (Bohart, O‘Hara, & Leitner, 1998); to enhance patient responsibility (Schafer, 1976); to assist clients in coming to terms with the existential givens of life (Yalom, 1980); to make possible greater creativity (Bollas, 2002), authenticity (Greifinger, 1997), or intimacy and autonomy (Holmes, 1996). Many who see therapy as providing these benefits find the focus upon the establishment of a set of efficacious treatments as at best
an ancillary enterprise, at worst as potentially undermining these other fundamental goods. Consider the response to the EST movement from Division 32 of the American Psychological Association (APA), Division of Humanistic Psychology (Task Force for the Development of Practice Recommendations for the Provision of Humanistic Psychosocial Services, 2004). In this document, psychotherapy is valued not primarily for its capacity to diminish symptoms or improve functioning, but because it can promote “psychological development.” The latter is described as including: Greater capacities for self-understanding, understanding of others, and understanding of relationships; clarification and development of values and life goals; development of a greater capacity for deep experiencing; the strengthening of relational bonds; the promotion of an environment of mutual care and empathy; development of a greater sense of personal freedom and choice while respecting rights and needs of others, as well as the limits imposed by reality; and the strengthening of individual, relational and group agency (p. 5).
There is an explicit rejection of the idea that the most important way to assess therapy is in terms of its ability to change some specific symptom or behavior. Humanistic psychotherapists. . .do not see effectiveness in terms of a method’s ability to operate on clients and change them, but rather in terms of the kinds of conditions therapists provide which allow clients to take their pain seriously, explore their lives, and find more meaningful ways of engaging in their existence (p. 11).
If there is an effort to alleviate specific symptoms, it “is done as part of the larger context of exploring broad personal issues and problems of meaning” (p. 19). Humanistic psychotherapists are not alone in refusing to focus exclusively on therapy’s power to remove symptoms or change behaviors. McWilliams (2005), a psychoanalyst, questions an exclusive focus on symptoms and functioning. She proposes that one of the benefits of psychotherapy could be to challenge the dominant individualistic, consumerist, and technocratic values of our culture with therapeutic values derived from the psychoanalytic, humanistic, and existential traditions: self-understanding, authenticity, empathy and compassion, egalitarianism, adaptation to unchangeable realities, growth in agency and personal responsi-
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bility, acceptance of normal dependency, and respect for others as subject rather than object. A therapy conceived in these terms is one which sees the client as a moral agent whose suffering is responded to with an effort to develop or strengthen certain virtues (selfunderstanding, empathy, authenticity, etc.). The effort to develop such virtues is not undertaken simply as a means to treat the symptoms of a disorder. For example, David Shapiro (1989) writes of his psychotherapy for neurotic character as attempting to address self-estrangement, an aim that distinguishes his therapy from classical analysis. It is not an estrangement of a rational adult consciousness from an intrusive, now irrational childhood wish. It is a self-estrangement of a more general kind. It is a distortion or loss of self-awareness, an estrangement of reflective or articulated consciousness from the actuality of a largely unarticulated and diffuse subjective world. To put it more simply, it is an estrangement between what one thinks he feels or believes and what he actually feels or believes (p. 28).
Shapiro describes this self-estrangement in the context of various examples of the suffering and symptoms it helps to create: recurrent interpersonal problems, depression, obsessive rumination, and so forth. The implication is clear that psychotherapy that addresses this selfestrangement will help alleviate suffering and symptoms. But if someone suggested she could alleviate distress and symptoms without changing the client’s self-estrangement, would this be acceptable? Is overcoming an estrangement between what one thinks one feels or believes and what one actually feels or believes simply a means to an end? Or is there not some sense that Shapiro’s psychotherapy is providing some good to patients in overcoming self-estrangement that goes beyond its value in overcoming depression, obsessive rumination, and so forth? In light of the discussion of praxis above, it would be more accurate to view overcoming self-estrangement not as a means to less psychopathology, but as constitutive of that change. The exploratory/expressive therapies promote an openness to nuances of meaning and subtleties of the moment. They often attend to that which is not easily pinned down or univocally identifiable, that which shifts and is transformed as it is attended to and articulated. An openness to whatever appears is valued partly
because it allows something specific to appear. For example, I have responded to a client’s fear of feeling exposed by being careful not to push him to talk about a sensitive topic. But my carefulness doesn’t seem to be reassuring to him or feel supportive. In fact, he seems more guarded, speaking less expansively, and starts focusing on some irrelevant detail. It seems that my cautiousness hasn’t come across as giving him time to come to this when he is ready, but appears to signal that I too am afraid to enter into this sensitive subject. Perhaps he’s surprised I am not pushing him and this leads him to wonder where I am, what I am not saying. But when I find some way to talk with him about my caution and its effect on him, we both recognize something we have been doing, and relax. My openness to how I am affecting this client differently than I intended leads me to see him closing down. And I address it in order to help both of us stay open. Particulars come out of this (about his shame, my hesitance to intrude). But the openness that allows the particulars to appear begins to take on a value of its own as that which helps one not to be too entangled in any particulars. This openness is not brought about by some technical intervention. It is enacted in the doing of a therapy which invites the client to join me in enacting it himself. As Miller (2004) puts it, “Whatever the therapeutic goal, therapy consists of exposing the client to small, regular doses of that end” (p. 91). Just as psychological problems implicate the client’s search for a good he seeks to become, so psychotherapy is a praxis that enacts some good. Something similar can occur in more technologically oriented therapies. What begins as a means to an end (effective techniques for the change of behavior or removal of symptoms) begins to take on a value of its own. A fundamental picture of the person is operating here as surely as in the therapies that espouse openness or authenticity. A technologically oriented therapy can claim neutrality with regard to larger issues regarding the nature of persons, human agency, or the good, only to the extent that it is directed at circumscribed disorders which do not implicate the person as a whole. Outside of this delimited range of problems, the application of this technological approach becomes the espousal of a particular philosophy of the good. It is as though the technological therapist says to
the person seeking therapy: “The best way to live is to treat yourself as a free agent whose aims can and have been freely chosen, but the pursuit of these aims is impeded by emotional or behavioral hindrances. Your interests are best served by setting about the task of removing the obstacles that interfere with the pursuit of your aims. Psychotherapy can help you to do this.” This view of a good life is not the obvious default position to which we all must subscribe. It is largely rooted in and consonant with some version of liberal individualism (see Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985; Richardson, Fowers, & Guignon, 1999; Woolfolk & Richardson, 1984). If a client raises questions about which aims are really worth pursuing, whether these aims are really her own, or considers the possibility that her distress or symptoms might be an indication that there is something amiss with the aims she finds herself pursuing, then the application of a technological approach becomes something other than a means to remove obstacles to effective functioning. It becomes an implicit proposal to understand oneself (not just one’s circumscribed disorder) technologically. Further, since liberal individualism claims to be neutral with regard to views of the good life, to only be a method to aid someone who already knows what she wants, it can wind up with nothing to say to a client who raises such questions. Worse, it may implicitly provide a model for how one answers them (it is a matter of personal preference) that can suggest that there are no standards for choosing, thereby diminishing the seriousness of such questions (Richardson et al, 1999, and Taylor, 1989, discuss this point in more detail). Perhaps a case can be made that even with noncircumscribed disorders it is sometimes better to take a technological orientation toward oneself, that to do so makes more sense and will bring one closer to a good life than the search for authenticity or self-understanding. But that case will not be made simply by showing superior efficacy in achieving symptomatic improvement. To focus the search for good therapy on efficacy is to surreptitiously propose a picture of who we are and of what the good life is for us in such a way that questions about why this picture rather than another never get raised. The EST movement
presents itself as a scientific program to address delimited problems, when it is also proposing a view of human flourishing that is not getting the open hearing, and debate, that it deserves.
Complications, Qualifications, Implications There are a number of issues related to the main argument of this paper that cannot be addressed due to limited space. Each easily requires a paper (or more) of its own. Below are some brief comments on these issues, with cursory suggestions about how they may be addressed, have been addressed by others, or relate to the argument above.
Therapy as Both Technology and Moral Praxis I have presented a contrast between two models of therapy. I have not considered the possibility that in a given instance both models may appropriately apply. For example, in the case of someone looking for help with recurrent panic attacks, some of what the therapist does may be the application of means to bring about some determinate end (behavioral methods to reduce the fear of panic attacks or agoraphobic avoidance). With the same person the therapy may at other moments also engage the client’s aspiration to be a certain kind of person, strong, in control of his feelings. My sense is that therapists’ technological work and practical moral engagement often spill over into each other, with the former serving or becoming more akin to the latter (not the other way around). In his study of the subtleties in Aristotle’s distinction between techne and phronesis, Dunne (1993) proposes that Aristotle can be read as suggesting the possibility of “phronetic techne” (p.355). He does not propose any basis for a technical phronesis.
Evidence-Based Practice Another complication concerns the superceding of the EST program by the broader program of evidence-based practice in psychology, EBPP (see APA Presidential Task Force on Evidence-Based Practice, 2006). The views put forward in the Task Force report on EBPP are
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more comprehensive and less single-mindedly focused on therapy as technology than one finds in the EST program. The report emphasizes that research should focus not just on the efficacy, but also on the applicability, usefulness, and generalizability of an intervention. This data from an expanded research focus is in turn to be integrated “with clinical expertise in the context of patient characteristics, culture and preferences” (APA Presidential Task Force on Evidence-Based Practice, p. 273). The reference to patient culture and preferences points to the limits of a technological view of therapy, for cultures always include some picture of a good life. However, the EBPP report does not acknowledge the ways in which the psychotherapies also include “cultures,” their own views of a good life. Further, much of the discussion of patient characteristics, including culture, takes them up as factors which influence choice of treatment and outcome. The implication is that improved data on these factors will enhance the efficacy of treatment. Better basic science will lead to a better applied science of psychotherapy. So while the EBPP report adds nuance to the picture of therapy, it continues to include some emphasis (if not so exclusive an emphasis) on a technological model of therapy that does not address many of the issues I have raised above.
Schools of Therapy and the Technological Model The examples given above of humanistic and psychodynamic therapists who openly espouse certain goods may suggest that within these schools of therapy one does not see a technological model of therapy. Since these therapies are often contrasted with behavioral and cognitive– behavioral therapies, the implication may be that the latter therapies are built upon the technological model. Certainly there are tendencies in this direction, especially with older versions of behavior therapy, as has been noted in the past (see Messer & Winokur, 1980; Woolfolk & Richardson, 1984). But schools of therapy do not sort neatly according to whether they subscribe to either the technological or the praxis model. Any therapy can be understood to be a method to bring about a predetermined end. Psychoanalysis has often been understood this way. Greifinger (1997) writes that when psy-
choanalysis was dominant in American psychiatry, “both analysts and analysands saw themselves as participants in a therapeutics that was based upon the application of a complex set of technical procedures to this end [the cure of neurosis]” (p. 201). And on the other side, Albert Ellis (1962), the grandfather of cognitive– behavioral therapy, is well known for taking strong stands on moral, philosophical, and religious views, and for understanding his therapy as rooted in these stands. My critique concerns the limits of a technological model of what therapy is, regardless of which school this model is applied to.
Moral Praxis and Value Conversion A further issue concerns the danger of therapists converting their clients to their own views of the good. This topic is often addressed under the heading of “value conversion,” and is sometimes seen as part of a broader concern about paternalism (see Beauchamp & Childress, 2009, chapter six). A related question concerns whether some client’s views regarding a good life (e.g., one must be in control of one’s emotions) are properly within the purview of therapeutic action, while others are off limits (e.g., a good life is one dedicated to service to the poor, or to being rich). Tjelveit (1999) has written thoughtfully about the complexity of this issue. What I can say in light of what I have written above is that one will not earn a pass on such concerns by subscribing to the technological model of therapy, for even the most symptom-focused treatment cannot be counted on to refrain from touching upon clients’ views about a good life.
The Variety of Views on a Good Life I have listed a number of goods that therapists promote through their therapies: authenticity, autonomy, intimacy, openness, creativity. Most goods are not lived in such a way that a oneword label like this does them justice. Some views of the good require an entire story in order to spell them out, or even a series of such stories and of the practices of living that go with them—that is, they require a culture. And any culture is rich with subtleties and variations on its views of the good. Each psychotherapy presents another such variation. As any school of therapy matures, it develops nuances of its core
views, which over time can come to make it appear unrecognizable as another instance of the same school. This is true of the formal theory of the school, of its practices, and of the views of human flourishing which are embodied within it. Overviews of the school with the longest history, psychoanalysis, make this clear (Greenberg & Mitchell, 1983; Sandler & Dreher, 1996). If one considers the multitude of conceptions of a good life in the many schools and orientations to doing therapy beyond psychoanalysis, the variety is astounding (even if there is also overlap). Questions arise here as to the origins of all these views of a good life. There have been many attempts to address this (Bellah et al., 1985; Cushman, 1992, 1995; Richardson et al., 1999; Reiff, 1966; Taylor, 1989, 2007). But even more important (though not unrelated to the question of origins or genealogy) is how one adjudicates between such competing views. One inclination for the psychotherapist who understands herself to be an applied scientist may be to try to find some scientific basis that assesses such views “from the outside” so to speak. McDowell (1995, 1998) argues against the attempt to find a scientific, extraethical standpoint from which to carry out such a task. Taylor’s (1989) work on practical reason in chapter three of Sources of the Self, is one attempt to show how the weighing of competing views of a good life can (and must) happen from within the picture of the good one already has. Again, what can be said in the context of this paper is that one cannot avoid this important issue by claiming to only be doing a technical therapy that avoids ideas about a good life.
Techne/Phronesis: Deeper Analysis, Wider Influences The techne/phronesis distinction can be developed in a number of directions that run beyond the scope of this paper. There are exegetical and philosophical interpretations of Aristotle’s texts regarding the nature and significance of the distinction (one example is Dunne’s, 1993, proposal of a “phronetic techne” cited above). There are also commentaries on the nature of each term in this contrast. For example, in her paper on Aristotelian rationality Nussbaum (1990) examines how the importance of context, particularity, and the incommensurability of values reveal
that phronetic deliberation is not a process of applying general rules to specific cases, nor is it an instance of scientific methodology. Similar critiques of the rules/cases model are made by McDowell (in his paper, “Virtue and reason,” in McDowell, 1998) and Wiggins (1980). Perhaps more germane to the topic of this paper is the philosophical return to Aristotle’s ethics as the basis for a critique of the modern assimilation of human science to natural science. The techne/phronesis distinction has often been an important part of this critique (see, e.g., Gadamer’s discussion of the hermeneutic relevance of Aristotle in Truth and Method, 1965/ 1975, pp. 278f). The history of this critique is long and complex. Volpi (1999) gives an overview of German neo-Aristotelianism that places Gadamer in the context of other work which reexamines the human sciences in light of practical philosophy. There are striking differences among the major figures in this field. Bernstein (1991) sees a fateful significance in the fact that Heidegger focused on the contrast between techne and episteme in his analysis of technology, while Gadamer focused on the techne/ phronesis distinction. There are further ripples out from these philosophers that return directly to psychotherapy. Both Stern’s (1997) psychoanalytic therapy and Cushman’s (1995) moral-critical therapy borrow directly from Gadamer in ways that repudiate a technological model of therapy. Bohart and Tallman (1999), who are not directly influenced by hermeneutic philosophy, put forward a model of therapy as collaborative conversation which has affinities with Stern and Cushman. Clearly, the techne/phronesis distinction has ramifications far beyond the uses to which I have put it in this paper. I have used it here for two purposes: 1) to think beyond the technological model of therapy in a language which dovetails with Taylor’s hermeneutic critique of a technological model of human science; and 2) to highlight the central role of views of a good life in both psychological problems and the therapy intended to address them.
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