The nightmare of eclecticism.

I have had a rather idealised vision of how a clinical psychologist would go about being a therapist. Rather than just being one type of thing ("a CBT therapist" say), I would seek to possess a sort of mental toolbox that contains skills relevant to a range of issues. Prepared in this way, I would be able to adapt to different problems by drawing on a range of techniques. This is the approach that seems to be promoted by the idea of empirically supported treatments (ESTs). You meet a person with a particular sort of problem, you reach into your toolbox for the requisite tool, and you get to work. Sometimes I might engage in some necessary systematic desensitization; at others I might follow associations to understand more about the emotions a person has not yet been able to access.

This is an integrative inclincation. It seems to offer hope for my desire to incorporate the insights of psychodynamic therapies with those of cognitive-behavioral treatments. We are, I think, animals with a prediliction to act without full knowledge of our own motivations, defending ourselves from coming to know the truth about ourselves. We are also learning machines, creatures of habit who are open to some degree of rational and behavioural rejigging. Why not hold both visions in mind at once? I don't like the idea of retreating to the familiar and unattractive warring poles that we see in certain forms of therapeutic modality bashing.

But I'm coming to think that it can't easily work this way. While some different forms of therapy sit relatively easily alongside one another (many of the acronym therapies feel like they are means to the same end, with emphases on different skills) not all do. The more time I spend talking with and listening to people from different therapeutic positions, the less hopeful I feel. The difference between psychodynamic psychotherapy and CBT is not only a difference of technique, it is also a difference of aim.

For advocates of most ESTs, the overriding ethic is that the person seeking therapy should come to feel better as efficiently as possible. This sort of improvement is to be demonstrated concretely by changes in symptom scores. The sine qua non of therapy here is the rapid reduction in a symptom that can be measured in an outcome questionnaire. Some advocates of psychodynamic therapies take this to be the aim of their work too. Jonathan Shedler has repeatedly argued that psychodynamic psychotherapy can be at least as effective (and in the same way) as CBT.

But many other dynamically oriented therapists simply aren't interested in that sort of game. For these people, the overarching ethic is that the person seeking therapy should come to understand themselves as thoroughly as possible, and live in greater freedom as a result. The distinction was drawn rather nicely by Allan Young in his Harmony of Illusions:

Simply put, different doctrines can give different meanings to the same outcome. While behaviorists and cognitive therapists say that a technique is efficacious when it produces enduring changes in disvalued behavior patterns, psychodynamic therapists, particularly clincians oriented to psychoanalytic perspectives, locate the meaning of altered behaviors elsewhere - in etiologies, symbolic content, and psychological processes.  Simply reducing the intensity of symptoms can be countertherapeutic and may signal the formation of more effective psychological barriers to insight into etiological conflicts. Real efficacy means releasing a potential for inner growth and maturation and enhancing the ability to establish and sustain gratifying social relationships. In these circumstances, the behaviorist and the psychodynamic valuations would be not simply different but incommensurable: they could not be measured by a common set of standards. (p.181-182)

We can see then that therapeutic orientation is essentially an ethical question, not an empirical one. Consider the point raised by the philosopher Charlotte Blease, discussing the treatment of depression by CBT in the light of the phenomenon of depressive realism: "well-being is not synonymous with being realistic about oneself," she points out. Blease has an ethical qualm: certain sorts of therapist might value improvement in the mood in their patients over their having an accurate view of their life situation. Psychodynamic therapists might value the realism over the improvement in mood.

This is the "nightmare" of my title. Not only is there a practical difficulty entailed in deciding what sort of therapy to do (which technique is most effective in this situation? - a hard enough question); there is a basic ethical choice that needs to be made. Once the decision is taken you have to remain consistent. You could be a CBT therapist in some parts of your career, and a psychodynamic therapist in others - but it will be potentially incoherent to pursue them within the same treatment. When moving from open ended exploration to symptom relief, how would you know that it was because it was therapeutically indicated and not better understood as a countertransference enactment? How do you maintain the inevitable frustration that is required to encourage internal reflection, when the patient has come to expect active intervention from you. The move between worldviews requires a dramatic gestalt shift.

Bad news for the early career psychologist who doesn't like joining therapeutic teams. But perhaps there is one positive upshot. Psychodynamic and CBT authors could stop their often unseemly squabbling. They aren't necessarily pursuing the same goals.