Therapy Paradigms and Therapeutic Change

There are three basic paradigms of talk therapy that lead to different approaches and different outcome goals. 

Consider a hypothetical patient, AB, who comes to the therapist's office with a general sense that his life isn't working well; AB is deeply unhappy and has some clinical signs of depression (low mood, low energy, mild sleep difficulties, for example.)  His relationships are unsatisfying, his home life unhappy, and his work unrewarding.  Consider as a given that during the evaluation process we learn that AB shows patterns of behavior, established in his earliest years, that inexorably lead to his present unhappiness. 

The first paradigm of therapy, typically offered by the less well trained to those with less internal and external resources, is the pop psychology paradigm offered by such notable "therapists" as Oprah Winfrey and Dr. Phil.  In this kind of therapy the patient is essentially told that most of their problems are caused by other people or situations beyond their control.  In other words the responsibility for the patient's unhappiness is caused by others and the patient's contributions are minimized.  The patient is a victim of systems and people beyond their control and the goal of therapy may include some change in circumstances but more often involves simply making the person feel better.  The therapy often directs itself toward relieving guilt and shame. (There's nothing wrong with S & M, or bestiality, or any of the other myriad quirks that people often find shameful; in fact the problem really inheres in the straight laced, retrogressive society that doesn't understand the unfairly stigmatized patient.)  There is nothing particularly wrong with making someone feel better but the goal in treatment is quite distant from increasing the person's understanding of himself so that he can more successfully choose his own future.  The change sought is change that is approved of by the therapist.  The therapist's ideology typically dictates any change.  (For example, few such therapists would empathize with their patient's desire to discuss their conflicts with a religious leader if the religious leader were a born again Christian or Orthodox Rabbi.)

The second therapeutic approach would be to help AB identify what he is most unhappy about and find ways for him to take steps to change his condition. 

A therapist might direct AB to try his hand at on-line dating in order to find a more amenable partner.  The therapist might encourage AB to take the risk of looking for a  new job and might even recommend web sites or job counselors who could help him better identify his work goals.  In all of this, the implicit assumption would be that the patient is not a candidate for a deeper level of exploration.  This could be because the therapist has a theoretical orientation that treats the mind as a "black box" where the unconscious is assumes but ignored.  After all, the patient doesn't need to know why he becomes anxious when he goes on a job interview, but rather needs techniques to master the anxiety (and if necessary, can use medication to deal with untoward affects.)  Another possibility is that the Therapist early on recognizes that either the patient is unwilling, or unable psychologically, to do the arduous work of internal exploration.  Especially in our current climate, with a premium on rapid amelioration of distress and desires for instant gratification, more intensive work is impossible or unrealistic for many people.  In this approach, which can include Supportive Psychotherapy, CBT, and various other forms of short term therapy, there is no intention of changing deeper aspects of personality.  All the patient and therapist desire is for some improvement in current functioning and appropriate environmental manipulations.  This is perfectly adequate for most people, who often just need a therapist's help to regain their mental equilibrium after a crisis.

In the third approach, the goals are quite different.  Here the job of the therapist is to help the patient develop some curiosity about himself and the willingness to look within.  For example, beyond simply noting dysfunctional patterns, the therapist wonders with the patient how the patterns developed and, especially, how the dysfunctional patterns of behavior that have caused so much grief are maintained and sustained.  Can AB become more self aware, note his own unconscious tendencies, and begin to address the behavior that emerges from the dysfunctional patterns?  This is more difficult work and requires more time and frequency.  The most intensive treatment, Psychoanalysis, has the most ambitious goals.  During an Analytic treatment, the dysfunctional patterns become expressed in the present, directed at the therapist.  By examining the patterns (which comprise part of the transference) we hope to establish what part of the present patterns are contaminated by conflicts from the past and thereby to partially free the patient from those past traps.

In the first paradigm any action is divorced from talk, and thought.  The patient is not expected to understand why he does what he does but is to take action under the authority and guidance of the wiser therapist.   This kind of therapy risks making changes without appreciating the risks which will be the patient's alone to bear.  Further, too often the therpaist is unaware of his own biases and disserves the patient; the therapist knows he should be neutral but coicidentally, the neutral outcome is alwasy the one that conforms with the therapist's beliefs.

In the latter two paradigms there is more emphasis on the patient's responsibility to understand his troubles and take steps to ameliorate them.  In the exploratory psychotherapies (Type 3) the goal is a complex two step procedure.  One first attempts to as fully as possible understand one's options and then take action, ie make behavioral changes, while bearing the risks and rewards of responsibility.  Therapy without behavioral change risks turning into what has been derisively termed "mental masturbation" in which the patient and therapist talk and talk and talk and nothing ever changes.  Talk can never be a substitute for action; it can be necessary as a prelude to action but talk without action is a choice for passivity in the face of life's vicissitudes while action without talk risks unconsciously repeating the past patterns in disguise while surrendering one's autonomy in the process.

Yesterday, Jennifer Rubin linked to Jonathan Alter's hagiographic piece about Barack Obama in the current Newsweek and commented:

In a Newsweek cover story— half cheerleading and half-denial — Jonathan Alter lauds the president’s ability to provide the confidence and vision needed to lift us out of the recession.  “The president is well poised to bring us back from the brink,” he pronounces. It is not the policies that Alter focuses upon, but Obama’s supposed ability to provide psychological solace to us.

...

is personal testimony, a sort of political infomercial. Missing are any facts — excerpts from speeches, market reaction to presidential verbiage, or comments from supporters, elected officials, voter or critics which would examine whether Obama is indeed fulfilling expectations as “shrink in chief.”  As such, the piece has an unreality about it — as if Alter were talking about what he wishes would occur rather than any recognition of what has or is transpiring beyond Alter’s own keyboard.

There is no question that during difficult times the President's bully pulpit is of crucial importance.  If economics is to some large degree psychology, then "therapist in chief" would be a part of the President's job description, however, Alter's piece reinforces some serious concerns that have been accumulating around the Obama Presidency.  Consider:

America’s New Shrink

Chin up, everyone. This president is well poised to bring us back from the brink.

Inside the White House, the central tension so far is between speed and thought. Rahm Emanuel coauthored a book in 2006 that divided Washington into hacks and wonks. The hacks want speed—get something done ASAP. They figure any problems can be fixed later. The wonks (who recently showed up to a White House meeting wearing beanies after Obama dubbed them "propeller heads") want policy implications carefully weighed from the outset.

Confidence depends on the right balance between the two camps. If the wonks keep the hacks from moving quickly, political victories (and renewed confidence) will be delayed. But if hasty action leads to sloppy, half-baked solutions (as in the initial Geithner bank-bailout plan), confidence will erode.

Witness the speed with which the recovery package was pushed through by Obama aides who had just found out where the bathrooms were located. This raises the odds that some of the money will be spent poorly. We'll know soon if the White House's special auditor teams and new crowd sourced accountability system (run through Recovery.gov) can really work, and if Obama will be praised for identifying waste in his program, or crucified for it.

It certainly appears that Barack Obama as therapist resembles the first therapy paradigm far more than the second.  Talk (thought) and action are decoupled.  We need to trust him as he tells us how to behave without offering us any chance to look within the details of the package we are supposed to embrace.  Many people who are in trouble are eager to surrender their autonomy and be bailed out.  For them, Obama may well be an adequate therapist.  However, for the most productive members of society, people who did not succeed in life by surrendering their autonomy to others, such "therapy" is more than a little insulting.