I would like to protest the use of the word hunch in clinical psychology as vague and imprecise.  There are no clear standards or criteria for its application.  It is a throwback to a kind of pre-scientific “folk psychology,” which has the potential to interfere with the process of identifying symptoms and reaching a diagnosis based on empirical data.  Another way of expressing this is to consider a matrix of the diagnostic process.  A clinical decision a disorder is present when in fact it is absent yields a false positive (a form of Type I error).  A clinical decision a disorder is absent when in fact it is present yields a false negative (a form of Type II error).  A diagnostic technique is “sensitive” if it correctly identifies the presence of a disorder and “specific” if it correctly identifies its absence.  Serious consequences attend both false positives and false negatives.  False positives result in therapeutic interventions that not only are inefficacious but also may have adverse side-effects.  False negatives result in the underlying disorder not being identified or treated.  Hunches create an environment of uncertainty and indeterminacy in the diagnostic process.  Because of this ambiguity they are neither sensitive nor specific and potentially lead to the proliferation of false positives and false negatives.

Here are some of the things Egan has to say about hunches (p. 231 et seq.).  A hunch is a way of helping a client to “see the bigger picture.”  It enables the client to “see more clearly” what the client is “expressing indirectly or merely implying.”  The client then can “draw logical conclusions” on the basis of what the client is saying.  The client can “open up areas” that only are being hinted at.  The client may “see things” that the client “may be overlooking.”  In this way the hunch helps the client “take fuller ownership of partially owned experiences, behaviors, feelings, points of view and decisions.”  A hunch is not a “license to draw inferences from clients’ history, experiences, or behavior at will” or to “load clients with interpretations that are more deeply rooted” in one’s “favorite psychological theories than in the realities of the client’s world.”  Rather it is a “challenge” to the client that is “open to review and discussion.”

Nowhere does Egan state just how this process is supposed to work or what the hunch does to further or facilitate it.  The hunch is not a statement of empathy.  It does not “feed back” what the client says to the therapist, in a Rogerian sense.  It is not a “probe” designed to elicit information about the client’s state of mind.  Nor is it a tentative hypothesis, an interpretation or a provisional diagnosis.  It is something emergent or in-between – neither bridging these concepts, defining one in terms of the other nor offering new information.

Since all of this is unclear let’s look at some examples based on Egan’s own case histories (Exercises in Helping Skills: A Manual to Accompany the Skilled Helper, 9^th ed. 2010).  In response to each vignette Egan instructs the therapist to develop a hunch and a reason for it, then to express it to the client.  My objective is two-fold.  First, to set forth a plausible clinical diagnosis and then restate it in the format of what I think Egan is looking for as a hunch.  Second, to critique that possible formulation on the basis of what Egan actually says about hunches, what is implied by what he says, or what he should be saying in order remain consistent and for his concept to have any explanatory power.

Case #1 at p. 101

Clayton, a first-year graduate student in engineering, has been exploring his disappointment with himself and with his performance in school.  His father is a successful engineer, but has not pressured his son to follow in his footsteps.  Clayton has explored with his counselor such issues as his dislike for the school and for some of the teachers.  He says: “I just don’t have much enthusiasm.  My grades are just okay, maybe even a little below par.  I know I could do better if I wanted to.  I don’t know why my disappointment with the school and some of the faculty members can get to me so much.  It’s not like me.  Ever since I can remember – even in primary school, when I didn’t have any idea what an engineer was – I’ve wanted to be an engineer.  Theoretically, I should be as happy as a lark because I’m in a graduate school with a good reputation, but I’m not.”

Provisional clinical diagnosis: “Client is experiencing internal conflict over career choice.  Client lacks enthusiasm and motivation – client may be mildly depressed.”  Hunch: “Is it possible you’re under a lot of pressure at school?  You seem conflicted because you’re bored, but you also want to excel.”  Critique: Even under the most optimistic view of their potential usefulness hunches are semantically pliable.  Thus for Egan the phrases “Is it possible that …” or “maybe if …” or “have you ever considered that …” offer hunches whereas the phrases “I think you should try …”, “have you considered that …” or “have you considered trying …” are not hunches.  They are prescriptive recommendations, which imply a course of action the therapist thinks the client ought to adopt.  For Egan a hunch cannot be mandatory.  It cannot be phrased in terms of what the client “needs” or the operational steps the client “must” take.  Most of the time however these subtle nuances of interpretation simply are lost on the client.  Egan is bogged down in “distinctions without a difference.”  Although their semantics may be differ slightly this is superficial because each phrase expresses the same propositional content with the same emotional valency.

Case #2 at p. 102

A man, who is now 64-years-old, retired early from work – when he was 60 years old.  He and his wife wanted to take full advantage of the “golden” years.  But, his wife died a year after he retired.  At the urging of friends, he has finally come to a counselor.  He has been exploring some of the problems is retirement has created for him.  His two married sons live with their families in other cities.  In the counseling sessions he has been alternately dealing with the theme of loss and the theme of redefining his golden years.  He says: “I seldom see the kids.  I enjoy them and their families a lot when they do come.  I get along real well with their wives.  But, since my wife has been gone, I don’t make the effort I should to make it happen.  I have a standing invitation from the boys and just recently I’ve decided I’m going to get off my sofa and start living again.  I won’t kid you; it will be bittersweet.  I dread those times when I’ll want to turn to her and enjoy the moment and she won’t be there.  I don’t want my boys to see their father shattered an I sure as hell don’t want to see pity in their eyes.”

Provisional clinical diagnosis: “Client is depressed because of wife’s premature demise.  Client is in process of coping with loss, developing new interests, discerning meaning in life.  Client is afraid of appearing to be weak.”  Hunch: “Have you ever considered developing new interests, getting out and socializing more with other people?  I wonder if a fear of appearing weak or incapable in front of your sons has led you to distance yourself from them.”  Critique: For Egan a hunch must avoid implying an unequal power relationship between the therapist and the client.  Phrases such as “I have an idea that …” or “I’m wondering if …” do not express hunches because they disrupt an atmosphere of equality and collaboration between the client and the therapist.  If this is true, though, then hunches are useless.  The client wants the therapist’s interpretation of the situation and the therapist’s advice.   The client wants to know what’s wrong and what can be done about it.  The client is not looking for abstract suggestions or a watered-down version of an operationalized action plan.

Case #3 at p. 102

A 33-year-old single woman is talking to a psychiatrist about the quality of her social life.  She has a very close friend, Ruth, on whom she has become somewhat dependent.  She is exploring the ups and downs of this relationship.  This is the third session.  During the sessions, she comes on a bit loud and somewhat aggressive.  She says: “Ruth and I are on again off again with each other lately.  When we’re on, it’s great.  We have lunch together, go shopping, all that kind of stuff.  But sometimes she seems to click off.  You know, she tries to avoid me.  But that’s not easy to do  (she laughs.)  I keep after her.  She’s been pretty elusive for about two weeks now.  I don’t know why she runs away like this.  Something must be bothering her.  I know we have our differences.  But we always get over them.”

Provisional clinical diagnosis: “Client is overly dominating and controlling in the relationship.  Client has unrealistic expectations for the relationship.”  Hunch: “I have the idea you may need to restructure your relationship with Ruth and consider finding some new friends at the same time.  Is it possible that Ruth may be feeling overwhelmed by the relationship and her elusiveness is her way of dealing with it?”  Critique: Egan is committed to the concept a hunch must express uncertainty.  Even as it communicates an insight the therapist has about the client it necessarily involves a risk of possible misinterpretation.  From an ethical standpoint however this is a slippery slope.  The therapist should not say something to the client if the therapist knows it potentially is misleading.  The therapist should strive to eliminate ambiguity, not create it.

Case #4 at p. 103

A 35-year-old divorced woman, who has a 16-year-old daughter, is talking to a counselor about her current relationship with men.  She mentions that she has lied to her daughter about her sex life.  She told her that she doesn’t have sexual relations with men, but she does.  In general she seems quite protective of her daughter.  She does not know for sure if her daughter is sexually active but she has the feeling the day is not far off when she will start having sex.  She says, “I guess I’ve been afraid that if I told her I was sexually involved that I would lose my authority.  How can I tell her to wait until she’s married when I’m having sex outside of marriage?  And, if I were honest, how much would I have to tell her?  Wait.  Maybe I can be more honest with her about what I believe without needing to detail my own life.  Really this is about how much I love her, not a tell-all TV show.  I’ve wanted to connect with her on this and I think this might be the way.  Sometimes, though, it feels like such a risk.  What if it goes wrong?

Provisional clinical diagnosis: “Client is conflicted over new roles occasioned by the divorce.  Client is concerned about the structure and nature of her relationship with her daughter and issues such as sexual identity, disclosure, honesty and their consequences.”  Hunch: “I have the idea you and your daughter might want to sit down and talk this through.  She may be less naïve than you think and perhaps by airing your different perspectives you can achieve a workable compromise.  I wonder if you are feeling especially protective of your daughter because she is nearing the age that you were when you had her.”  Critique: For Egan a hunch must provoke the client’s thought process and offer a new perspective for the client to consider.  It must help the client get in touch with the client’s feelings.  This however is more like an empathetic response.  At this stage of the therapeutic process the client already is supposed to have the idea the therapist empathizes.  The therapist would not be in a position to offer even a dilute interpretation unless the therapist already had gathered sufficient data to make a provisional clinical diagnosis.  All the hunch does is present a watered-down version of an operationalized action plan.

In conclusion, for Egan, having a hunch and expressing it to a client is a little bit like talking to a bright eight-year old.  It is a guru-like pronouncement presented in an informal, folksy way.  But it is a superfluous and potentially misleading step in the process of psychological diagnosis, which readily can and should be eliminated.

Alossa & Castelli cite four studies in support of this account.  The research protocols used in them are dubious.  Furthermore they are overwhelmed by at least four confounding variables and cannot be supported absent further research.  Before I explain what they are I will briefly look at each study.

1.  Peretz (1990) used musical sequences that “were tonally structured and made up of two phrases” following principles developed by the fin de siècle Viennese composer Arnold Schoenberg.  In half of the experimental settings the first phrase was played in double-time and the second phrase in triple-time.  In the other half only the second phrase was played; it was 4 bars long, lasted 4 s and comprised from 8 to 19 tones.

2.  Zatorre et al. (1991) measured differential response to “target” tones and “comparison” tones.  All were constructed out of sawtooth waveforms.  The target tones were randomly-chosen notes between middle C and B.  The comparison tones were randomly-chosen notes from the next-higher or next-lower octave; none were repeated within any one series.  The target tones lasted for 325 ms and the comparison tones lasted for 162.5 ms.  There were 72 trials, presented in random order.  In 36 of them the comparison tone was the same as the target tone; in the other half it was different, varying by 1, 2 or 3 notes.

3.  Zatorre et al. (1994) used “melodies” and “noise bursts.”  They prepared 16 different 8-note melodies, all of which had the same rhythmic configuration and timbre, but used different notes.  The “noise bursts” were constructed so as to approximate the characteristics of the melodies (variables such as number, duration and volume of notes, and inter-stimulus presentation rate).  Each noise burst was matched to the notes of the corresponding melody by shaping its onsets and offsets to approximate the amplitude envelopes of the musical tones.  Everything was played back at the same volume.

4.  Liégeois-Chauvel et al. (1994) created a suite of different of rhythmic and melodic tests.  The first used “familiar musical excerpts,” which were taken from “pre-existing vocal and instrumental pieces.”  The rest used “novel musical sequences” that were “tonally structured,” again using the atonal principles initially devised by Schoenberg.  They “approximated familiar stimuli structures while failing to evoke a sense of familiarity.”  The melodies were slightly altered as they were presented to the experimental subjects over different trials.  Each was performed at a slightly different tempo, manipulated by “interchanging the time values of two adjacent notes” while “keeping the metre and the total number of sounds identical.”

Here are the confounding variables:

(1)  There is a profound difference between musical compositions and sound recordings.  A musical composition is the underlying song (in the case of pop music), comprising the music and lyrics.  In the case of jazz it may be the theme; in the case of chamber or orchestral music, the score.  A sound recording on the other hand is a performance of the composition in a particular instance.  It is an iteration of the composition; there could be and frequently are many others.

For example, Lennon & McCartney wrote the song “Yesterday” and it was performed by a band called “The Beatles.”  The proprietor of the master sound recording – that is, the Beatles performing “Yesterday” – is EMI Records. Rights to the underlying composition, however, are owned by the music publisher (a peculiar joint venture between Sony Music and the Estate of Michael Jackson).  Every time somebody performs the composition the music publisher collects a royalty.  Thus, when Henry Mancini’s 101 Strings cover “Yesterday,” the music publisher gets a royalty; whereas EMI Records gets nothing.  There are many different versions of “Yesterday” performed over the years, all of which earn royalties for the music publisher, but none for EMI Records.

It stands to reason that the nature, manner and style of the performance of the underlying musical composition will significantly influence the way in which the listener perceives it.  Conversely the elements of the underlying musical composition will significantly constrain the manner in which it is performed.  There potentially could be thousands of different arrangements of these variables.  This significantly challenges the experimental validity of Peretz (1990) and Liégeois-Chauvel et al. (1994), both of which peculiarly relied on already-idiosyncratic music by Schoenberg.

(2)  Zatorre et al. (1991) only studied melody.  Musical performances however comprise many elements in addition to melody, all of which the brain considers simultaneously.  At a minimum these include rhythm, tempo, the nature of the envelopes for individual notes (attack, decay, sustain and release), variations in tonal texture and timbre and other variations in performance style.  A musical performance results in a complex sound and information is scattered across the perceptual spectrum.  However they ignored all of these factors.  They also only used one kind of waveform (a “sawtooth”).  There are other waveforms, which together or in isolation form the basic elements of sounds, such as sine waves or square waves (so called because of the way they appear on an oscilloscope).  They might have gotten different results if they had used these instead.

(3)  Zatorre et al. (1994) attempted to improve on their previous experimental design by also incorporating rhythmic elements.  While they made some attempt to shape the envelope and other characteristics of the noise bursts to that of the notes, they did not consider any of the other experimental variables identified above.  In particular they only used one timbre (a “guitar” tone), failing to account for the possible influence of other tones and timbres, which may have yielded different experimental results.

(4)  It now generally is accepted that the brain is more analogous to a parallel processor of information rather than one where information is relayed serially throughout a neural network (Moors et al., 2006).  This story is completely different, though, if a behavioral response is required, such as intentional or goal-directed behavior.  Then, the brain must determine what information is relevant and signal the motor cortex to execute an appropriate action.  A mediation process most likely takes place at the basal ganglia, which acts as a gating threshold.  The signal is amplified and the motor cortex activated if the task is relevant to the objective, or inhibited if not (Szüc et al., 2009).  All four studies were backwards.  They were premised on the assumption that the experimental subjects had to act.  While this may be true e.g. in the case of a musician playing an instrument, that was not the case here.  All the experimental subjects had to do was listen.  This makes it far less likely that any hypothesis based on localization is valid.

References

Alossa, N. & Castelli, L. (2009).  “Amusia and Musical Functioning.”  Eur. Neurol., 61, 269 – 277.

Liégeois-Chauvel, C., Peretz, I., Babaï, M., Laguitton, V. & Chauvel, P. (1998).  “Contribution of different cortical areas in the temporal lobes to music processing.”  Brain, 121, 1853 – 1867.

Moors, A. & DeHouwer, J. (2006).  “Automaticity: A theoretical and conceptual analysis.”  Psychological Bulletin, 132 (2), 297 – 326.

Peretz, I. (1990).  “Processing of local and global musical information by unilateral brain-damaged patients.”  Brain, 113, 1185 – 1205.

Szücs, D., Soltész, F., Bryce, D. & Whitebread, D. (2009).  ”Activation and Response Competition in a Stroop Task in Young Children: A Lateralized Readiness Potential Study.”  J. Cognitive Neurosci., 21 (11), 2195 – 2206.

Zatorre, R. & Samson, S. (1991).  “Role of the right temporal neocortex in retention of pitch in auditory short-term memory.”  Brain, 114, 2403 – 2417.

Zatorre, R., Evans, A. & Meyer, E. (1994).  “Neural mechanisms underlying melodic perception and memory for pitch.”  J. Neurosci., 14, 1908 – 1919.

Diagnostically, “hysteria” comprised congeries of symptoms such as abnormal muscular spasms or variations of reflexes and sensory functions (Ehrenwald, p. 255).  It was applied predominantly to women and thought to be caused by disturbances of the uterus.  Charcot believed hysteria resulted from an organic neurological disorder (Hunt, p. 191).  This is significant because (according to Charcot) it means it could not have been brought about by mental factors alone.

Then something unusual happened.  Charcot began using hypnosis to induce states of hysteria, which implies pathological ideations had at least some role in its etiology.  This created a paradox, however, because if mental factors also were involved, then one pathogenic idea (the hysterical one) simply was being counteracted by another (the one induced by hypnosis).  Both ideas controlled the patient’s experience and behavior, even though the patient was aware of neither (Mitchell & Black, p. 3).

Josef Breuer exploited this anomaly in his treatment of Anna O.  Under hypnosis, she free-associated back to the point in time when her symptoms started.  Once she remembered this event (which was disturbing and stressful), then her symptoms disappeared.  This lead Breuer to conclude hysteria was caused by trapped memories and the feelings associated with them.  Once hysterical symptoms were traced to their origin, their meaning became apparent and then they resolved.  Sigmund Freud became intrigued with Breuer’s work and in 1895 they published Studies in Hysteria, which remains the defining work in the field (although now of historical interest only).  Based on the Anna O. case, Breuer and Freud hypothesized the etiology of hysteria was predominantly (if not purely) psychological, eliminating Charcot’s theory of neurological origins.

There came a time when hysteria became an unpopular diagnosis.  The Mental Disorders Diagnostic Manual (precursor of the DSM) deleted hysteria, institutionalizing its disappearance.  Hysteria also has gone almost completely missing from current psychiatric literature.  Diagnoses (such as hysteria) “disappear as time elapses or even cease existence under the influence of certain social developments, while other, new entities take their place” (Libbrecht, p. 170).

Various explanations for this have been offered.  The most popular one is that, from a post-modern standpoint, gender relations became absorbed in medical discourse; when women are the doctors and the theorizers, rather than the patients, the narratives of hysteria change (Showalter et al., 1993).  Hysteria carries a “resonance” for commentators because of its “textual tradition.”  It is a “powerful, descriptive trope” even in non-medical domains, including poetry, fiction, theater, social thought, political criticism and the arts.  In this way it sheds light on the history of disease in general (Micale, 1994).

Another explanation is the “argument from psychological literacy.”  According to this interpretation people were “relatively primitive in their psychological processes” before the 20th century and found it easier to express “acute emotional symptoms” through the formation of psychogenic physical symptoms.  However, with the coming of age of our “psychological society” and the popularization of concepts such as “unconscious motivation,” the psychodynamics of hysterical conversion systems changed.  They “failed to elicit the desired social response and subjective gratification” (Micale, 1993).

Hysteria now has been relegated to an obscure corner of DSM-IV under the headings somatoform disorder (DSM-IV 300.81) and dissociative disorders (DSM-IV 300.6, depersonalization disorder).  There is some recent work (using fMRI) attempting to restore its neurological underpinnings (Halligan et al., 2001).  This research suggests the inhibitory mechanisms originally associated with hysteria operate at a high, cognitive level of sensory-motor processing.  They originate in the right inferior parietal cortex and restrict awareness of information as to the ongoing status of sensory and motor functions.  The right inferior parietal cortex is a crucial structure in the mediation of awareness and the brain’s attentional system.  Unlike other primary sensory cortices it is independent from topological constrains and laterializes to the left side regardless of hand dominance.  This may explain the peculiar anatomical features of conversion symptoms (Sierra & Berrios, 1999).  It also supports a hypothesis that residual unconscious cognitive processing occurs even in the absence of awareness – an ironic return back to Charcot’s original theory.

In my opinion the current disapproved state of hysteria results from historical revisionism and medico-cultural imperialism.  Women around the turn of the last century who were thought to be suffering from hysteria actually were suffering from hysteria.  Even though this diagnosis now may be incomprehensible to us it defined and structured the then-prevailing symptomatology.  In this respect hysteria is like many of the other culturally-deficient aspects of the DSM (Regier et al., 2009).  In this respect I am in substantial sympathy with the views of Paul Feyerabend (1975) regarding the incommensurability of scientific theories.

To be fair, DSM-IV suggests several intriguing directions.  The main one is dissociative trance disorder, a “criteria set and axis provided for further study.”  Its primary symptom is “an involuntary state of trance that is not accepted by the person’s culture as a normal part of a collective cultural or religious practice.”  In other words, the patient is possessed, most likely by the devil, and exorcism is the only effective means of relief.

Similarly, at Appendix I, DSM-IV sets forth a list of 25 culture-bound syndromes.  These are more than just pathologies of belief.  Rather, their victims actually think they are victims of the disorder, and actually are cured by appropriate culturally-specific interventions; such as, perhaps, a voodoo spell or the services of a witch doctor.  The epidemiology, etiology, neurochemistry and treatment of these conditions can be addressed empirically, through research.  An interesting project would be to define the parameters of such studies, eliminating confounding variables to the fullest extent possible.

References

American Psychiatric Ass’n. (4th ed. 2000).  Diagnostic and Statistical Manual of Mental Disorders.  Arlington, VA: American Psychiatric Ass’n.

Breuer, J. & Freud, S. (1895).  Studies in Hysteria.

Ehrenwald, J. (1991).  The History of Psychotherapy (1991).  New York, NY: Aronson.

Feyerabend, P. (1975).  Against Method.  London, UK: Verso.

Halligan, P., Bass, C. & Marshall, J. (2001).  Contemporary Approaches to the Study of Hysteria: Clinical and Theoretical Perspectives.  New York, NY: Oxford U. Press.

Hunt, M. (2nd ed. 2007).  The Story of Psychology.  New York, NY: Anchor.

Libbrecht, K. (1995).  Hysterical Psychosis – a Historical Survey.  New Brunswick, NJ: Transaction Publishers.

Makari, G. (2008).  Revolution in Mind – the Creation of Psychoanalysis.  New York, NY: Harper.

Micale, M. (1993).  “On the ‘Disappearance’ of Hysteria: A Study in the Clinical Deconstruction of a Diagnosis.”  Isis, 84 (3), pp. 496 – 526.

Micale, M. (1994).  Approaching Hysteria.  Princeton, NJ: Princeton U. Press.

Mitchell, S. & Black, M. (1995).  Freud and Beyond – a History of Modern Psychoanalytic Thought.  New York, NY: Basic Books.

Regier, D., Narrow, W., Kuhl, E. & Kupfer, D. (2009).  ”The Conceptual Development of DSM-IV.”  Am. J. Psychiatry, 166 (6), 645 – 650.

Showalter, E., Gilman, S., King, H., Porter, R. & Rousseau, G. (1993).  Hysteria Beyond Freud.  Berkeley, California: University of California Press.

Sierra, M. & Berrios, G. (1999).  “Towards a Neuropsychiatry of Conversive Hysteria.”  Cognitive Neuropsychiatry, 4 (3), 267 – 287.

Westen et al. review the assumptions and findings of studies establishing psychotherapies as clinically valid.  They characterize these as “empirically-supported therapies” (ESTs).  The distinguishing feature of an EST is that it has been or can be corroborated using randomized controlled trial (RCT) methodology.  An example of an EST is CBT.  RCT methodology, however, imports a number of problems, such as: limited sample size, participant self-selection, iatrogenesis, attrition and the impossibility of eliminating confounding variables.  It assumes psychopathology is highly malleable, that patients are not comorbid and can be treated for a single problem or disorder, that personality is irrelevant or secondary in the treatment of psychiatric disorders and that experimental protocols are the only way to evaluate whether a therapy works. Based on these and other considerations, Westen et al. conclude most EST’s are not quite as empirically-supported as they may seem.  In fact some psychotherapies typically thought of as lacking empirical support (such as IPT or even psychotherapy) are or can be just as effective as those backed by EST claims, despite their methodological shortcomings (such as non-random assignment of patients and lack of experimental control).

Baker et al.’s paper takes the opposite point of view.  From a public policy standpoint, interventions must be efficacious, disseminable, cost-effective and scientifically plausible.  The only treatment meeting these criteria is CBT, for example, when used to treat tobacco addiction or depression.  All other treatment’s are “pre-scientific” and therefore of dubious validity.  In fact the discipline of clinical psychology itself may be conceptually suspect because as an applied science it is insufficiently grounded from an empirical standpoint.

Both Westen et al. and Baker et al. are asking the wrong question.  They assume psychology should aspire to a deductive nomological model of explanation, along the lines of physics or chemistry.  Rational accounts of human behavior, though, are not deterministic in form; that is, they are not logically deductible from a specified set of causes.

For example, I voted for Obama in last year’s Presidential election because I thought (maybe wrongly in retrospect) he would do a better job of solving problems with the economy.  Suppose there is an absolutely exceptionless universal generalization about people like me to the effect I invariably will vote for the Democratic party candidate.  This law doesn’t explain why I voted for Obama.  I just as easily could have voted for his opponent.  All it does is state a regularity, not explain anybody’s behavior.  This situation is fundamentally unlike (say) Boyle’s Law or Charles’s Law, which actually establish the causal relationships between pressure, temperature, and volume of gases.

One might consider a proposed course of action in advance, weighing the pros and cons, but doing so doesn’t transform them into “causal” factors.  Even though one has justified convictions about what to do, one easily could have acted otherwise.  One acts on the basis of reasons, but these reasons are not a “vector” of forces.

One also might argue a certain decision is “caused” by neuron firings and the neuro-chemical transmission of information along axons to dendrites, etc.  While this trivially is so, no social or psychological phenomena perfectly mirror molecular movements.  There is an indefinite range of stimulus conditions for any psychological state.  Brain anatomy doesn’t “map” onto psychological outcomes or systematically correlate with them, and there are no “bridging” principles to get from one to the other.  To continue with the Obama example, there never will be laws of elections like there are laws about gases.

More broadly, psychology has a radically different explanatory style than does physics or chemistry (best characterized as “hermeneutic,” that is, grounded in history and context).  It is not a propositional calculus or series of logical inferences and it shouldn’t aspire to be something it’s not.  For example, early psychoanalysis was unsure of its scientific standing and therefore tried to ground itself in pseudo-scientific concepts such as hypnosis.  Freud constantly was trying to defend psychoanalysis as a science because he wanted to give a supposedly scientific account of human behavior.  See, e.g., George Makari (2008), Revolution in Mind – the Creation of Psychoanalysis, p. 298.  These efforts were misconceived because of the intrinsically mental character of psychological phenomena.  Freud’s explanations were not scientific, rather, common-sensical.

This critique certainly is not original with me.  One of the best explanations of it is in John Searle’s book Minds, Brains and Science (1984), esp. chapter 5.  Searle builds on the work of Donald Davidson (“Philosophy of Psychology”) and Charles Taylor (“Interpretation and the Sciences of Man”).  Westen et al. and Baker et al. arrive at such polemical and mutually incompatible outcomes because neither of them consider this fundamental problem.

This class is about an academic discipline called philosophy of mind and its relationships to and implications for clinical psychology.  “Philosophy of Mind” studies mental phenomena such as the nature of mental events, awareness, consciousness (especially “self-consciousness”), understanding, intelligence, rationality, and even the nature of the “self”.  It seems as though it should be closely linked to clinical psychology.  After all, they both are about the “mind” and the “brain.”  The fact of the matter, though, is that despite these thematic links, there is almost a complete disconnect between the two.  Philosophers engage primarily in abstract speculation.  Psychologists, on the other hand, primarily are scientists.  They devise experiments and achieve empirical results.  One of the main objectives of this class will be to see if there is a way to validate operationally some of the theories philosophy of mind has proposed.  For example, favorite topics in the philosophy of mind are the nature of perception and processes of inferential reasoning.  Are the positions various philosophers have taken regarding these issues just hypotheses, or can evidence be developed to support them?

We will begin with a brief overview of the history of philosophy of mind, starting with Aristotle and ending with Descartes.  Most of this is pretty boring.  It deals with intractable problems that seemingly have plagued philosophers for years but that no longer really are all that interesting, such as the “problem of other minds,” the “mind/body problem,” and theories of monism and dualism.  Nonetheless it is important to have some background regarding these issues – not so much for the substantive propositional content of the material, but rather to become able to discern the ways in which it subtly inflects current discussion.

There is a huge schism in philosophy between the “Continental” philosophical tradition and the “Analytic” one.  Continental philosophy started with Descartes, then evolved through Kant, then ended up with the phenomenology of Edmund Husserl and Martin Heidegger.  Analytic philosophy started at Oxford and Cambridge in the 1930s, then moved to North America.  Most philosophy departments in the United States are strongly oriented towards the beliefs and practices of analytic philosophy.  In fact, with a few exceptions, contemporary philosophers find continental philosophy almost heretical.  We will explore the differences in attitude and outlook between the two.  These different narratives are seen as competing, when in fact they consider different questions.  For example, continental philosophy has a good story about the “emotions,” a topic about which analytic philosophy has almost nothing to say.

We will review developments in philosophy of mind in the early 20^th century, beginning with Bertrand Russell.  Due to Russell’s influence, philosophy of mind gradually got hijacked by philosophy of language.  It stayed this way for some time, really until the 1960s.  We will look at some of Russell’s interlocutors, and the alternative theories they proposed.  Interesting and important work now is being done in philosophy of mind by people like Daniel Dennett and John Searle.  We will examine their theories (and those of a few others) in some detail.  Among other topics we will consider some implications of “artificial intelligence” and recent conjectures about the relationship between mind and quantum theory.

The most interesting part of philosophy of mind is the frontier between “mind” and the brain.  We will investigate the nature, scope and extent of the relationship between the two, and whether the phenomena philosophy of mind purports to address can be explained neurologically.  How do neurological processes in the brain give rise to subjective experience?  We will review basic brain anatomy and the mechanics of neural transmission of information.  Epistemic constraints on our experience strongly imply something must be happening with these, however, the relationships are tentative and not well understood.  We will consider some interesting case histories to illustrate this juxtaposition.  These include: the neurochemistry of extreme outlying pathologies, such as schizophrenia, psychotic disorders and temporal lobe epilepsy; the mind-set of would-be suicide bombers, mass murderers and mothers who drown their children; dissociative fugue (DSM-IV 300.13); dissociative trance disorder (a DSM-IV category suggested for further study); the etiology of culture-bound syndromes (such as those defined at DSM-IV, Appendix I); and the empirical status of various (allegedly) empirically-supported therapies.  Do these involve just pathologies of belief, or can they be addressed empirically through research?

Textbook

While there are many readers and compendiums of journal articles, there is no good textbook.  Most books on the subject adopt a strident perspective of their authors, who make it sound as though theirs is the only point of view worth considering.  An added disadvantage is they have the subversive capacity to lull one into believing that’s true.  In lieu of a text, there will be reading assignments from selected journal articles, all of which are available on JSTOR.

Grading

There will be a midterm paper and a final paper, both of which will count equally.  Both should be around 10 pages in length (plus or minus) and cite to applicable literature.  You will have a choice among several different paper topics.  They will be posted at least 10 days before they are due.  Papers are expected to demonstrate clinical psychology (and philosophical) ability by showing mastery of the subject material, ability to identify premises, draw sound inferences, expose misconceptions, and use the English language with precision.

Class Attendance

As there is no text, virtually all of the topics for the midterm and final papers will be developed and discussed in class.  Attendance and participation therefore are important.  If either of your papers are on the cusp of getting a better grade then these factors will decide the issue.

Yet, there still is considerable cause for pause. Yalom speaks authoritatively, using a hyper-positivistic tone that implies he invented the concept of group psychotherapy, or that he is the font from which flows all knowledge in the field. For example, he gives only one throw-away reference (at p. 193) to the precedential work of Wilfred Bion, an important figure in the development of group theory. (1) Yalom asks no questions, pretends there are no uncertainties or confusing issues, and brooks no dissent. He ignores what I think is the most important issue about group therapy, which is: how effective is group therapy in treating psychopathology, as opposed to individual therapy?  This in turn raises an even more problematic issue, which is: what is the empirical status of group psychotherapy as an empirically-supported therapy (EST), to begin with?  Since this latter point lies at the heart of the puzzle, it is what I will address for the remainder of this essay.

One of the most engaging controversies in contemporary clinical psychology is the conflict between the paradigms of psychodynamic psychotherapy versus other forms of intervention such as RBT, the efficacy of which can be established using randomized controlled trial (RCT) methodology, Western et al. (2004). With EST methods, patients are pre-screened to minimize the possibility of differential diagnosis and confounding variables; treatments are “manualized” and a series of standardized treatment procedures is established; treatments are brief, to minimize the possibility of attrition and acclimatization; and outcome assessment focuses on symptom relief. Use of EST methods is fortified by the pragmatics of DSM-IV diagnosis and practical concerns such as insurance company reimbursement.

Defenders of psychodynamic approaches argue, on the other hand, that psychopathology is not malleable; that most patients are comorbid for any number of different Axis I disorders; that Axis I disorders typically imply Axis II issues; and that experimental, “scientific” methods cannot be generalized or extrapolated to clinical contexts where professional judgment is more important than following a pre-defined manual of standard procedures.

An example of the conflict between the two (discussed by Western et al.) is the use of CBT versus interpersonal therapy (IPT) for short-term depression. One study found that positive outcomes were associated with the extent to which the treatment was modeled on IPT. A second competing study found that the empirical prototype of CBT was more effective. More general issues include whether the elements of efficacious treatment are dissociable (and hence subject to dismantling) to begin with; and the effect of what can only be characterized as pre-selection of which treatments to test.

Western et al. conclude that in order to reconcile these competing issues, researchers (and clinicians) must “triangulate” their conclusions using “multiple methods.”  This is not particularly helpful (in the same way that “multi-modal” therapy is not a useful therapeutic modality).

Although they do not discuss it, Western et al. raise an interesting issue, which is, just exactly what is the status of group therapy as an EST?  The answer is that it depends on what one means by “group therapy.”  If the group is characterized as a “cognitive-behavioral therapy group” (GCBT), then it can be evaluated as an EST, Ingen et al. (2009). An example might be a 12-step program, which follows a specific protocol and results in outcomes that can be clearly defined and evaluated.

On the other hand, if the group is characterized as more psychodynamic in nature, then the EST schematic makes less sense. An example might be a cancer support group, Coyne et al. (2007). Such a group is “supportive-expressive” and characterized by its cathartic or confessional elements. It veers more towards personal insight rather than the cure of any specific psychopathology (or, at least, elimination or reduction of its symptoms).

There does not appear to be a clear-cut way to distinguish between the two, and group theorists nervously equivocate between them. An example is Barlow et al. (2006): “Still, some difficulties and dilemmas exist. Whether labeled empirically supported treatment (EST), or evidence-based treatment (EBT) … , or empirically validated treatments (EVT) … , it is safe to say both individual and group psychotherapy have entered the age of accountability.”  These sorts of mindless nostrums are too vague and general to be useful.

Further evidence of confusion is found in the deliberations of professional bodies. For example in 2004, a Commission on Psychotherapy by Psychiatrists requested that the American Psychiatric Association’s Council on research designate psycho-dynamic psychotherapy as an evidence-based psychotherapy. The Commission on Psychotherapy specifically included not only systematized individual psychotherapy, but also any form of group psychotherapy claiming to be psychoanalytic or psychodynamic, Gerber et al. (2006). The Council declined to do so, stating there currently is not enough evidence for such a claim and that more appropriately designed clinical trials were necessary.

Yalom does not address any of these issues, nor does he consider their implications. From a theory standpoint, though, they are fundamental. Yalom’s treatise best is regarded simply as a book about groups per se. It does not aspire to a higher level of analysis, which would involve a consideration of why group therapy is more effective in some contexts than individual therapy, or the issue of demonstrating its effectiveness, as I have outlined here. To deal properly with these issues Yalom would have to devise (and implement) specific experiments to discriminate between the two.  He also would have to consider the nature of what might count as a good explanation for any observed difference (and I assume a difference exists, otherwise there would be no call for a separate discipline called “group therapy”).

Endnote

(1) Bion held that groups have three basic emotional states: (1) “fight-or-flight,” which is characterized by sympathetic nervous system effects such as fear, hostility or aggressiveness; (2) “pairing,” which is a kind of reciprocal interaction characterized by anticipation, optimism and hope for a favorable outcome; and (3) dependence, which is characterized by a feeling of helplessness.  When a group adopts one of these stances, it interferes with the group’s purpose.  It is up to the group leader to interpret these dynamics, in order for there to be effective group work.  It would have been interesting and useful for Yalom to delve into his theories, and those of others, if only in footnotes or an appendix.  A presentation based solely on theory alone would not implement Yalom’s objectives.  It equally is true though that he may have veered slightly off the mark and become somewhat imbalanced in his exposition of practice versus theory.

References

Barlow, S. & Burlingame, G. (2006). “Essential Theory, Processes, and Procedures for Successful Group Psychotherapy: Group Cohesion as Exemplar.”  J. Contemp. Psychother. 36, 107 – 112.

Bion, W. (1991). Experiences in Groups; and other papers. New York, NY: Routledge.

Coyne, J., Stefanek, M. & Palmer, S. (2007). “Psychotherapy and Survival in Cancer: The Conflict Between Hope and Evidence.”  Psychological Bulletin, 133(3), 367 – 394.

Gerber, A., Kocsis, J., Milrod, B. & Roose, S. (2006). “Assessing the Quality of Randomized Controlled Trials of Psychodynamic Psychotherapy.”  J. American Psychoanalytic Ass’n 54, 1307 – 1312.

Ingen, D. & Novicki, D. (2009). “An Effectiveness Study of Group Therapy for Anxiety Disorders.”  Int’l J. of Group Psychotherapy, 59(2), 243 – 251.

Western, D., Novotny, C. & Thompson-Brenner, H. (2004). “The Empirical Status of Empirically Supported Psychotherapies: Assumptions, Findings, and Reporting in Controlled Clinical Trials.”  Psychological Bulletin, 130(4), 631 – 663.

Yalom, I. (2005). Theory and Practice of Group Psychotherapy. New York, NY: Basic Books.

Yalom, I. (1980). Existential Psychotherapy. New York, NY: Basic Books.

In principle communication skills are desirable. I did not find this book however to be particularly informative or useful. There is little that distinguishes it from the vast horde of other new-age self-help books. The written exercises in particular were annoying. Reading a book is a commitment to participating in the authors’ vision and bringing oneself into a condition of alignment with their goals and objectives. The authors in turn must reciprocate this commitment by writing a book that is empirically grounded, uses sound logical reasoning to move from premises to conclusions and has therapeutic usefulness. Absent a high degree of mutual attunement or resonance both the reading of the book and the writing of the book are futile exercises.

Properly understood the subject matter of the book – interpersonal communications – is a sub-branch of social psychology. The subject matter of social psychology is how individual cognitions and behavior are affected by other people and by group dynamics. The book, however, does not take into account any of the extensive research that has been done in this area. To illustrate this point I will consider two broad topics: compliance techniques and the interpretation of “body language.”

Many communications strategies in fact conceal tacit compliance techniques. Here are some examples:

1. “Foot-in-the-door,” which is the process of using a small favor to induce the respondent to accede to a larger request.

2. “Low-balling,” which is getting the respondent to make a decision based on one factor (e.g. low price) even after that factor has been changed (e.g. the price has been increased. It is based on the observation that having made a commitment, the respondent will tend to behave consistently with it, rather than attempting to modify the underlying agreement.

3. “Door-in-the-face,” which is making a large request, which the respondent turns down. The respondent then is more likely to accede to a second, more reasonable request. The respondent may feel guilty about having turned down the first request. The initial request also may set a reference point for construing the second request as being more reasonable.

4. “Bait-and-switch,” which is when a product is advertised at an artificially low price but then becomes unavailable so the respondent is directed to a higher-priced substitute.

5. “Camel’s Nose,” which occurs when the respondent is told that permitting a small, undesirable situation to occur will permit its gradual and unavoidable worsening. (1)

You would not learn anything about these tactics, discussion of which is pervasive in the social sciences literature, from reading the book. Instead the book adopts a generic “how to win friends and influence enemies” approach. It implies one can deploy persuasive techniques to convert one’s counterparts to one’s own point-of-view even if one is insincere and does not really believe in what one is saying. This ends up having vaguely Machiavellian undertones. A better policy simply is that people should say what they mean and mean what they say.

Social psychology also has done considerable research into body language, which is non-verbal communication based on pose, gestures, eye movements, flips of the hair and the like. Other paralinguistic cues are subtler, such as proximity. Much of the time body language is strongly determined by cultural conventions. For example, people from eastern cultures tend to require less overall space in elevators then people from western cultures (i.e. the latter require more “personal space” to buffer and insulate themselves). People from eastern cultures also tend to define themselves more strongly in terms of group identity, whereas people from western cultures focus more on individual autonomy. Most of the time these types of signals are transmitted (and interpreted) unconsciously. Body language projects a message as to the content of further explicit language or action. It also reveals important aspects of a person’s attitude or intention. (2)

The book makes many observations about how to use body language in social contexts, for example, to get somebody to like you or how to get your boss to give you a pay raise. However these are presented more like Jedi mind tricks, without any theoretical foundation.

In conclusion, it is disconcerting to think there are masses of readers walking around trying to “spin” their own personal circumstances, the intentions underlying their communications, and the bases for their actions. These developments also are concernful from a cultural policy standpoint. We have come to expect (for example) that politicians and celebrities basically are insincere (if not dishonest) about who they are and what they say. It corrupts the process of social discourse to think these stratagems should apply generally. Nobody would be able to trust what anybody else is saying, it all would need to be filtered for evidence of improper or inappropriate use of mental persuasion techniques. This leads to an ironic problem for the authors of the book. In the process of trying to teach people how to be better communicators, they actually teach people how to be worse communicators, or at least more disingenuous ones.

Endnotes

(1) Examples taken from Nisbett, R., Gilovich, T. & Keltner, D. (2005). Social Psychology. New York, NY: Norton & Co.

(2) Examples taken from Aronson, E. (2007). The Social Animal. New York, NY: Worth Publishers.

Criteria for a good theory include: (1) an empirical basis, that is, it is verifiable and falsifiable; (2) it results in testable hypotheses; and (3) it creates the possibility for client change. Theories are informed by perspective and experience. There are judgments and values built into any theory. Some of these are cultural; we cannot escape them and are caught in a hermeneutic circle of interpretation in which each explanation depends on others. For these reasons the best approach is pragmatic eclecticism, taking parts of each theory and applying them to different clients and situations, as appropriate.

Phases of Therapy

There are four phases of therapy. (1) Intake – determining if the client is right for analysis, if there is a felt need and the client is motivated to change. The client is introduced to the process and opened up to the possibility of self-discovery. (2) Middle Phase – identifies themes; makes connections; examines dysfunctional patterns of perceiving, thinking and relating; disentangles the past from the present; brings unconscious elements to the fore; considers the nature of transference; finds new ways to cope. Transference occurs when the client assumes the therapist responds in the same way as previous figures in the client’s life. The client projects unconscious material (such as formative childhood experiences) onto the therapist. The therapist must create a non-judgmental environment using evenly-hovering attention and not influence the process of transference. The therapist may experience counter-transference, which is a reaction to the client, and must take steps to avoid it. Catharsis is the discharge of repressed trauma. Containment is when the therapist provides a safe environment for the client and holds the client’s pain. (3) Later Phase. (4) Termination.

The core conflictual relationship theme method (“CCRT”) considers: (1) the client’s stated or implied wish (“W”); (2) the response of others (“RO”); and the response of self (“RS”). It identifies client relationship patterns and is an operationalized version of transference. The symptom-context method is when the client’s social and personal context illuminates the client’s symptoms.

Freud

Freud was a determinist in that he believed what we experience is caused by unconscious factors. Human nature is in conflict. To resolve it, or try to, we form compromises. We have various defense mechanisms we use to keep conflicts unconscious. Examples of defense mechanisms are: repression; projection; obsessions; compulsions; denials; and avoidance. These compromises and defense mechanisms in turn create neuroses. The goal of Freudian analysis is to create deep personality change by making internal conflicts and their associated defense mechanisms conscious, and therefore controllable.

There are three basic personality structures: the id, the ego and the superego. The id is the repository of drives and impulses. It is governed by the pleasure principle. The superego dictates “shoulds,” how one ought to respond morally or in society. The ego mediates the conflict between the id and the superego. It is governed by the reality principle. One goes through phases of development, which are: oral, anal and phallic. The Oedipus conflict is when a boy wants to murder his father and marry his mother. The Elektra conflict is when a girl wants to murder her mother and marry her mother.

The basic methods of psychoanalysis are free association; dream interpretation; and transference. Dreams have two types of content: manifest (on the surface) and latent (below the surface; that which requires interpretation).

Adler

Adler’s theories are called individual psychology. This really means indivisible psychology because Adler viewed people holistically, that is, they must be understood as a whole. Unlike Freud, Adler was not a determinist. Rather he believed we exercise free choice within a social environment. One’s style of life comprises the set of choices one has made about how to live one’s life, which in turn organizes future choices.

Adler believed we all start with an inferiority complex, which is creating a style of life based on the belief one is inferior. There also is another type of inferiority, which is normal inferiority or inferiority feelings. Normal inferiority in turn can be divided into primary inferiority, which is developmental and experienced during childhood; and secondary inferiority, which occurs when there is conflict between one’s self-concept and one’s self-ideal. The greater this discrepancy, the greater will be one’s feelings of inferiority, that one isn’t “good enough.”

These convictions about how one sees the world, or one’s world-view, are called the Weltbild. Together with ethical “shoulds” (akin to Freud’s superego) they are what generate inferiority. One creates a style of life to cope with and try to reconcile one’s convictions and self-concept. If one focuses solely on one’s self then one is useless. On the other hand if one focuses on social interest then one is useful. Social interest is concern with others and society. The goal of Adlerian therapy is to awaken a person’s social interest and develop a useful style of life.

The basic technique of Adlerian therapy is to understand an individual’s style of life and the choices that person has made. It starts with a life-style investigation, which is an inventory of one’s basic mistakes and one’s personality assets. Basic mistakes are conceptual errors. Examples are: are impossible goals; misperceptions; faulty values; self-denial; and over-generalization. Important aspects of the life-style investigation are one’s family constellation and early recollections. Family constellation is the circumstances into which one is born, such as gender and birth order. After articulating and examining these factors, one then modifies one’s convictions, loses one’s inferiority complex, and develops social interest. Social interest eliminates the inferiority complex.

People don’t “have” psychological symptoms in the sense of possessing them. Rather they “use” them. The therapist should ask: what would the client’s style of life be without the symptoms and what benefit there is to having them. A person with pathological symptoms is not sick, rather, simply discouraged.

Jung

Jung’s theories are called analytic (or analytical) psychology. There are two types of unconscious: the personal and the collective. The collective unconscious is a shared psychic resource. We have shared experiences we may not be conscious of. Complexes organize the personal unconscious. A complex is how the personal unconscious makes itself known; it is a part of one’s self that is disowned. Archetypes organize the collective unconscious and are a bridge to the personal unconscious. Archetypes are a recurring cultural theme or meme. Examples of archetypal patterns are: the heroic quest (exemplified by the work of Joseph Campbell); the inner child; and the wise old man.

The psyche or Self (capital “S”) is made up of opposites such as animus (male principle) versus anima (female principle); and the ego (same basic definition as Freud) versus its shadow. The shadow is those aspects of one’s ego one has disowned or repressed. One has a persona, which is the public face of the self in society; it shields the ego. There are four ways in which we experience reality: thinking, feeling, sensing and intuiting. We have two basic responses: introversion (an inward orientation) and extroversion (an outward orientation).

The goal of Jungian therapy is to obtain self-knowledge of these parts; reintegrate them; and then achieve self-individuation and self-activation. It explores the ways in which complexes connect to archetypes. The psyche is self-healing. One’s life tasks are to develop one’s ego; reclaim the lost parts of one’s self (hidden in the shadow); and then to integrate the two.

There are four stages of Jungian therapy: confession, elucidation, education and transformation. Confession is the cathartic recounting of one’s personal history and life story. Elucidation occurs through transference (same basic definition as with Freud). The therapist draws attention to the transference and provides a holding environment for the client to work it out. Examples of things that can be elucidated are: early childhood relationships; the shadow; how figures from one’s background might be archetypes; and one’s persona. Education is translating the insights one gains into responsible engagement and action. Once the client knows what is happening, the client can do things differently and break down dysfunctional patterns of behavior. Transformation is reclaiming the disowned parts of ones’ self; finding the missing pieces; reconciling opposites; and experiencing self-individuation and self-actualization.

Ellis

Ellis’ theory is called rational emotive behavior therapy (“REBT”). Our experience of the world comprises three stages: act (“A”), belief (“B”) and consequence (“C”). A does not cause C, rather, B does. The client is not upset about A, rather about B’s about A. When an undesirable C occurs it is because of an irrational B. Examples of irrational beliefs are: “I must always do well;” “things must always be easy;” “other people must always be nice to me;” “I am worthless;” “I deserve it;” “I never will be accepted.” REBT assumes people are rational and that faulty beliefs will not stand up to rational scrutiny. The client keeps subjecting herself to faulty belief structures. The way to change C is to dispute and then change B.

The goal of REBT is to modify the client’s convictions and behavior. Unlike Freudian therapy it is very interventionist. It is much less complicated than psychoanalysis. The method of REBT is to challenge the client’s belief. The therapist asks for evidence; challenges premises; questions logical inferences (such as overgeneralization, catastrophizing incidents, misattributing intent, and thinking one can control all of the events that occur in one’s life); points out counter-examples; deconstructs dysfunctional demands; and suggests alternative interpretations. Just because the client’s life isn’t perfect doesn’t mean the client is pathological. “Even supposing a worst-case scenario, would it really be that bad?”

Rogers

Rogers is a humanist. He believes people have an innate tendency to develop towards their own highest good. There are three conditions to this unfolding: (1) unconditional positive regard; (2) empathetic listening; and (3) counselor congruence. Unconditional positive regard is accepting the client the way the client is, and not judging the client. Rogerian therapy is non-interventionist and non-directional. Unlike REBT it does not take a stance of pointing out the client’s deficiencies and then “let’s fix it.” Empathetic listening is assuming that what the client says is based on the client’s reality. It’s not necessary to change anything about the client’s reality, as with REBT. The therapist must demonstrate to the client that the therapist understands what the client is saying. Counselor congruence is a warm acceptance of and interest in the client’s world. Instead of adopting an interpretive stance the therapist must be real and authentic in the moment; genuine; and not feigning or pretending interest.

When put this way the concept of transference is unintelligible. It might occur in a very small subset of cases, but hardly provides the foundation for a dominant mode of psychoanalysis. Its premise is that the client is confused about who’s who in her mental life. The client cannot distinguish between e.g. her father and the therapist. Most people who seek psychotherapy are not confused about the people who populate their mental universe. They are well able to distinguish between imaginal figures and actual individuals who exist in space and time. Wanting to talk about one’s relationships with significant people in one’s past is a mode of discussion, not some weird kind of séance, summoning ghosts or spirits from one’s previous history.

Many psychoanalytic works treat it with reverence and speak of “the transference” in awe as if it was some kind of a magical transformation. This not only is unhelpful but also is the kind of mystical mumbo-jumbo that casts all forms of psychodynamic therapy into grave doubt and suspicion.

A more sensible definition of transference is set forth by Robert Stolorow in Psychoanalytic Treatment: An Intersubjective Approach (2000). At p. 36, Stolorow writes:

“In our view, the concept of transference may be understood to refer to all the ways in which the patient’s experience of the analytic relationship is shaped by his own psychological structures – by the distinctive, archaically rooted configurations of self and object that unconsciously organize his subjective universe. Thus transference, at the most general level of abstraction, is an instance of organizing activity – the patient assimilates the analytic relationship into the thematic structures of his personal subjective world. The transference is actually a microcosm of the patient’s total psychological life, and the analysis of the transference provides a focal point around which the patterns dominating his existence as a whole can be clarified, understood, and thereby transformed.

From this perspective, transference is neither a regression to nor a displacement from the past, but rather an expression of the continuing influence of organizing principles and imagery that crystallized out of the patient’s early formative experiences. Transference in its essence is not a product of defensive projection, although defensive aims and processes (including projection) certainly can and do contribute to its vicissitudes. The concept of transference as organizing activity does not imply that the patient’s perceptions of the analytic relationship distort some more objectively true reality. Instead, it illuminates the specific shaping of these perceptions by the structures of meaning into which the analyst and his actions become assimilated.”

Stolorow’s concept of transference has so little to do with the classic Freudian definition that it really ought to be called something else. The best way to characterize it is a form of empathy as described by Carl Rogers. Two people are in congruence if they are at the same level of discourse, i.e. one isn’t pretending to be more knowledgeable, or an authority figure, or in a dominant power relationship, over the other. When the therapist is in congruence with the client, she is capable of empathetic listening and supplying unconditional positive regard. The client feels understood, and the therapist radiates this feeling of being understood back to the client.

In “Therapy Personality, and Interpersonal Relationships,” a chapter in the reference work Psychology: A Study of a Science, Rogers states that a condition of the therapeutic process is that the client perceives, at least to a minimal degree, that the therapist is experiencing unconditional positive regard toward the client; that the therapist is experiencing an empathetic understanding of the client’s internal frame of reference; and that the client perceives, at least to a minimal degree, the unconditional positive regard of the therapist for him, and the empathetic understanding of the therapist. The congruence or genuineness of the therapist in the relationship means that the therapist’s symbolization of his own experience in the relationship must be accurate. The therapist must accurately “be herself” in the relationship and express or communicate to the client the accurate symbolization of her own experience. The greater the communicated congruence of experience, awareness and behavior, the more the ensuing relationship will involve a tendency toward reciprocal communication with the same qualities, mutually accurate understanding of the communications, improved psychological adjustment and functioning in both parties, and mutual satisfaction in the relationship.

This last component is crucial. Without it the client lacks evidence her communication to the therapist has been successfully received. In supplying this evidence it is appropriate for the therapist to draw analogies from her own experience. Thus, the therapist might say something like: “I understand what you are saying. You are saying (briefly reparse what client said). The reason why I understand it is because (brief self-disclosure by therapist).” This is a good definition of transference in the sense Stolorow uses it, and vastly improves on Freud’s puzzling initial formulation.

The condition of being useless is not pathological. A person doesn’t “have” (possess) a defined set of psychological symptoms. Rather, she “uses” them in her dealings with others and lives within their parameters, confines and restraints. She believes there must be some benefit to deploying them and that her life would change for the worse if she wasn’t able to do so. In this sense neurosis is a form of reality-evasion. The useless person is not sick, rather just “discouraged” because the dysfunctional relationships she has developed result in loss of social functioning and subjective mental distress.

Adler’s process of analysis begins with the evaluation of one’s “family constellation,” which is the set of circumstances into which one is born such as gender and birth order. It continues through one’s “early recollections,” which are formative events that dynamically influence the growth and development of one’s personality. At the conclusion of this process one will be able to ascertain one’s “basic mistakes,” which are conceptual errors and adverse modalities or ways of being. One habitually enacts them, or uses them as a basis for action, as part of one’s style of life. One also will be able to identify and inventory one’s “assets,” which are accomplishments or successful instances of orientation towards people and projects that are not self-centered.

Adler identifies the source of basic mistakes as an “inferiority complex,” which is behaving “as if” one was of lesser stature (emotional, physical, intellectual) than others, and then creating a style of life based on this belief. The inferiority complex is more than just a cognition or an attitude. It is a form of self-centeredness and is self-defeating. If one solely pursues self-originated objectives then one tends to self-isolate and to avoid risk. People have a self-concept, which is one’s belief about who one is. People also have a self-ideal, which is a belief about how one should be. One experiences dissonance between these two ideations. The greater the tension between them, the greater one’s feelings of inferiority, because one is acting primarily to preserve one’s concept of self.

Feelings of inferiority in turn lead to self-aggrandizement and the pursuit of a useless style of life. They result in the promotion of self-interest over social interest. Social interest is more important than individual interest; put slightly differently, the best expression of individual interest is to veer towards social interest. Only after recognizing one’s basic mistakes and taking prophylactic action to mitigate against them can one then segue to a useful style of life. Undeveloped or underdeveloped social interest is evidenced by poor performance of basic life tasks. Reorienting oneself to pursue one’s social interest in turn reorganizes one’s style of life and enables one to avoid committing further basic mistakes. In this way the goal of Adlerian therapy is to eradicate one’s “inferiority complex” and to awaken ones undeveloped or underdeveloped social interest.

“Social interest” presents the following issues.

1. Adler says social interest is an attitude or outlook towards furthering the welfare of others. It comprises then a set of beliefs about the relationship between actions and outcomes. Actions evidencing social interest cause a certain set of outcomes to occur, which are welfare-enhancing; those that do not are welfare-reducing. This bifurcation however ignores the possibility that concerted group action may not be in the interests of all members of the group, or in the interests of members of other groups. In a democratic society there are many interpretations of what might be welfare-enhancing. A totalitarian society might have only one interpretation, with which many covertly disagree. Different cultures per se will have different points of view. Since Adler is committed to a theory of mass action he would be unable to draw these distinctions. He confuses a set of propositional beliefs about what comprises social interest with the dynamic of how social interest is created and then orients itself within a society towards different results.

2. Evaluating one’s style of life in terms of its “usefulness” is a form of utilitarianism. As classically defined by John Stuart Mill, “utilitarianism” is the greatest good for the greatest number of people. This formulation ignores however the dilemma of what a society should do for those of its members who are the least advantaged (as argued by, among others, John Rawls). Adler is committed to the former definition.

3. Unless an individual is a person of influence it is unlikely her actions will result in an overall augmentation of social welfare or that they will implement or achieve any socially-desirable objective at all. In some cases individuals who are purporting to advance it simply may be gratifying their own desire to implement an outcome in response to their activity, which is not evidencing or enacting social interest. In most cases individuals simply do what they do without thinking about whether it advances or retards social interest. They are enmeshed within the structure of their own lives. They undertake tasks and pursue goals and objectives without giving the slightest thought to abstract notions like social interest.

4. Adler is committed to a theory of motivation. If one pursues social interest then one has a motive for doing so. An example of a motive implementing social interest is altruism. Altruism may be commendable but is not necessarily efficacious. It may even be counter-evolutionary. People are motivated to do things for a variety of reasons, only a small subset of which are altruistic. By evaluating everybody who isn’t altruistic as “useless” Adler dramatically overstates his case. People may advance social interest without necessarily being altruistic, just as many altruistic people may act in a way that does not advance social interest.

5. The way Adler defines it, “social interest” is a utopian ideal. It depends on a Marxist concept of society evolving to a utopian state of fraternity and brotherhood. Etymologically, social interest immediately suggests the possibility Adler is advancing a form of “socialism.”  At the same time, “social interest” is inherently conservative. The way to enact social interest is by complaisantly and compliantly fulfilling one’s designated social role. Stepping outside its confines means one is pursuing an individual objective rather than a social one. This kind of mindless conformity is antithetical to the development of authentic personality.

6. This also is puzzling because Adler called his approach, “individual psychology.”  One’s style of life comprises the set of one’s “choices” and what one chooses in turn depends on one’s style of life. It follows that a person cannot be biologically or environmentally predisposed or determined. Adler for example would say one “chooses” to be gay, which implies one can choose not to be gay. One is ego-dystonically homosexual. This is an outmoded view that was discarded two decades ago (among others it creates a problem of what the “default” conditions are before one can exercise freedom of choice). Properly understood Adler is committing a type of fundamental attribution error, in that one’s ability to choose freely is constrained by the very elements Adler eschews, such as biology and environment. People can make individual choices only within the context of a well-developed social milieu. If it is “individual,” then how come Adler is so concerned with a cultural (inter-individual) outcome such as “social interest”?