Monday, September 26, 2011

Inner landscape: a reflection on praxis

I am partial to decorating my office with photos and paintings of landscapes. When I was in graduate school (which seems like forever ago now), I described psychotherapy as "the process of exploring an inner landscape." At the time, the professor for whom that paper was written very much liked this description, and I believe he read it aloud to the class. (Side note: Isn't it fascinating how things can be both embarrassing and validating at the same time?)

I still think that turn of phrase is a good description for what we do in therapy. I do not think that happiness is necessarily the goal of psychotherapy--happiness is elusive and can be obtained through other means. Sometimes, happiness is a goal of therapy to be sure, but more often clients come in with concerns that start with the same interrogative pronoun: "Why." "Why do I feel sad?" "Why do I feel anxious?" "Why am I lonely?" "Why do I do things that I cannot control?" Interestingly enough, the question "Why am I not happy?" is not a question about happiness--telling for grammaticians who will notice that the subject in the sentence is not "happy," but the pronoun "I", which points accurately that the question reflects more in the person asking it than on the state of happiness.

In any case, the questions asked by a client in therapy are often resolved through introspection and questioning. The metaphor of exploring a landscape is a good one here, and I often ask clients, "Just talk about that--explore the territory." In the same sense, my job as therapist is not quite the job of being a guide--it's more the job of being an outfitter. I am prepared to cope with whatever terrain we may find, but I am not leading the expedition.

This kind of therapy is becoming less and less popular with the people who get to tell us what kind of therapy we should be practicing--HMOs are a popular target, but many academics must share the blame for the shift in focus from process-orientated psychotherapy to outcome-orientated psychotherapy. I suspect the shift from academic circles came from a desire to make psychotherapy measurable--social scientists who wanted clinical psychology and social work to stand up next to fields like biology and chemistry, in which hypotheses are measurable and testable. The ironic part is that the drive to measurablity has actually made the process of psychotherapy less measurable: The focus on outcome has overshadowed the means by which the therapist-client dyad actually reaches this outcome.

But why do we assume this is a good idea? Is the goal of therapy to provide good therapy, or is the goal of therapy to provide standardized outcomes? Why does our profession assume that the best process is that which provides easily-comparable outcomes across a wide swath of humanity? Consider two clients who both present with that most common therapeutic concern: Depression. One client is a young, successful and wealthy male who feels that he has achieved everything he has ever wanted in life, but is unhappy and does not understand why he is not pleased. The other client is a middle-aged, working-class male who has been depressed his entire life, and despite going through multiple courses of therapy, has not ever been able to reach a point in his life in which he does not feel depressed. These two people are different and present with different concerns--but likely they would be met with the "Cognitive-Behavioral therapy is an evidence-based intervention for depression" clinical disposition, and given very similar treatments.

But when it comes time to measure the outcome, what have we measured?  We measure symptoms--do you sleep better? Are you crying as much? Are you as sad as you were 3 months ago? While that may be useful information, I have to ask the question: Do you have any further grasp on why you feel depressed? Do you have a sense of whether or not this may be a life-long concern for you? And can you accept your depression, if it is? In other words, are you any closer to answering the question that brought you into therapy? Do you have an understanding of your inner landscape, or are you just more likely to answer questions about your behavior in ways that make researchers happy?

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