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by Ronald B. Miller
American Psychological Association, 2004
Review by Roy Sugarman, Ph.D. on Oct 20th 2005

Facing Human Suffering

Bringing psychology into the realm of science, out of the realm of softer, philosophical origins has not been easy.  Double blind, intention to treat, random assignment, all the other trappings of scientific inquiry are difficult entities in psychology.  Many of those in practice today were trained with a knowledge base that was not subject to scientific inquiry, and often drew on theories that were little more than elegant metaphors, rather than models, paradigms, or heaven forbid, actually epistemologies or ontological in any real, testable way.  Nevertheless, they were heuristically useful, and colored our vision of the patient's complaints.

A major feature of the early training, although un-testable in a laboratory, was the need to engage in the body contact sport of therapy.  The metaphor explained the psychology; the therapy flowed from that, with transference and counter-transference examined against the theory of how both collided: therapist and 'patient', theory and fact, psychology and therapy. Diagnosis, literally 'through knowledge' was work done by engagement at the metaphysical bedside, the 'klinikos' of Greek origin. Depending on the theory, mechanisms of pathology derived from some great guru's mind were looked for, and interventions were creative and Milton Erikson or Freud-driven.

Not all were happy: early feminists immediately targeted the lack of universality of the theoretical claims, and even the seemingly more forgiving theories such as the family therapy movement provided came under attack.

More recently, and in competition for funding across the world, the need to justify what one though and did, even in apparently scientific arenas such as psychometric assessment, became pressing.

In his presidential plenary as newly elected leader of the APA, Joseph Matarazzo was forced to acknowledge that the gap between Binet and the courtroom had to be closed by psychologists justifying what they did.

Into this arena came the imperative for evidence based practice.  CBT for instance was capable of demonstrating efficacy and outcome, and so one had to apply it in various diagnostic sets in order to be funded, or answer in court when bang-for-the-buck was in question.

Psychology could thus now parade itself as a science, and many organizations such as the occupational therapists' professional bodies, and ASSBI in Australia set up websites containing the details of bits of research that scored highly on criteria such as random assignment and intention to treat.

All has not sat well though for those of us who entered the profession as a creative enterprise where there must be moments of agonizing closeness, pathos, tragedy, ecstasy, resolve, where the heavens open and magic happens: how dry, how droll, to face sadness and despair as depression, to reframe shellshock as PTSD, grief as adjustment, existential crises as mixed anxiety depression.  Engagement with the full panoply of human misery became an enterprise of nosological categorizing.

Miller, emerging from Vermont with his PhD and St Andrews in Scotland's department of Moral Philosophy, has served as associate editor for the APA's encyclopedia of psychology with responsibility for the coverage of the historical and philosophical side to the book. Now he enters the arena above with the sense that the scientific approach to psychology, while welcomed for many reasons, has drifted from the purpose of psychology, which he argues is embedded in the balanced, moral engagement with suffering and humanity that constitutes clinical psychology, rather than academic psychology.

The training in psychology thus provides two somewhat opposing positions.  On the one hand, psychology can provide helpful approaches to furthering people's ability to cope with the fabric of daily life, in all its complexity, a familiar field for the novice, but on the other hand there is a most unfamiliar body of scientific evidence and knowledge, and despite being strange, is promised to provide the most powerful and useful tools to accomplish the mission stated above in proposition one.

Miller will argue that the two positions are not complementary, but in direct opposition to one another, and that the second may deny the meaning and impact of the first.  This dawning realization that all our intuitive, life-based skills are to be set aside for the promised land of powerful and validated approaches is at first promising, but later on comes to reveal itself as a kind of "bait and switch" shell game, introducing the straw men of revised epistemology.  In this way, the sturm und drang of life's iniquities are reframed as nosological entities in a data handbook, a form of mercantile capitalism if I read Miller's intro correctly, a hijacking of humanity in the name of robust but questionable heuristic bias.  Miller refers to the reframe of problem redefinition as a subtle flim-flam game that dispatches the novice psychologist's life philosophies as mere pop-psychology.

The 'truth' offered is that it is necessary to undergo scientific training in order to be an effective therapist.  This truth however is that this necessity is created by academic psychologists committed to the scientific paradigm, but not really a truth created by the demands of the logic of clinical knowledge.  As we know, lay therapists and poorly trained social workers or GP's often make very useful therapists, without much science in their approach, and life-crises and counseling phone lines are staffed by little more than professional reflectors, with significant gains to the public apparently.

The relationship between the paradigms of clinicians and academics is thus a conflicted one, more ambivalent than helpful or motivated.  While the chairs of any university are grateful for the numbers of bushy-tailed students that dominate first year psychology courses, and of course nearly all are hired on the basis of publications and their capacity to raise funding for research, they appear to be not too keen to deliver on the promise of psychology, putting forward well grounded theories on how problems should or could be approached, but light in actual delivery of stuff that is heuristically useful.  Clinicians and academics thus remain philosophically dissociated, and the sense of moral engagement has been lost, subverted by the heuristic bias of the academics towards evidence rather than practical advice.

Internal validity would always dominate external validity, leaving students without any valuable ideas on how what they were learning would help deal with the day to day existential complaints of the sufferer, or how one could engage in their suffering in a meaningful way or with meaningful outcomes.  Miller writes:

By promoting a scientific approach to problems that are practical, contextual, highly complex and multidimensional (social, psychological, moral, political, historical, spiritual, biological, cultural, economic etc) psychology has done incalculable harm by promoting pseudoscientific solutions to complex human problems.  Students leave psychology further mystified and further away from understanding themselves better ... even worse ... leaving prematurely, taking their interest in practical psychological problems to other departments (page 13).

Academic psychology is thus failing the profession in its core job of confronting clinical reality.  Miller argues throughout the book that there is a moral dimension to this clinical reality.  Even pragmatist William James understood the difference between general laws of behavior and practical application.  Miller has clearly also been influenced by Martha Nussbaum and others in the realm of suffering and the moral imperatives which become, hopefully, surely (?) clear when we engage with those who seek our help: there is a historical and philosophical base which is lost when the endeavour becomes clearly science rather than humanistic based.

He is not alone here, as others such as the Self-Determination Theorists (see Self-Determination Theory in the Clinic: Motivating Physical and Mental Health by Kennon M Sheldon, Geoffrey Williams and Thomas Joiner for details of this) have now sought to combine humanism and science in the practice of medicine, all arguing for a more human, feeling, caring and morally engaged approach.

For in philosophy, the central assertion is of ethics, an approach common to Martin Buber's philosophy of dialogue and community, although he waits 35 and 108 pages to get to him, so densely is this book peppered with theorists, many of whom have been resurrected lately into the mainstream, theorists dear to the creative and morally engaged clinician.

The last 60 pages of the discussion are devoted to references and cross references, but at page 243 begins the recommendation section on education and training, evoking and provoking the community of trainers and clinicians to respond to the demands of morality and ethics which he argues are central to a humanistic engagement process. This of course will involve self-engagement, a self-evaluation of values and systems.  He goes into examinations of family and humanistic theories in the early second hundred pages, so this is not a long book, with protracted arguments.

He will argue throughout that it is imperative that we acknowledge that moral and ethical values are not just another set of attitudes and beliefs that can be paradigmed or modeled through the scientific method dissected, number-crunched, or teased apart. This does not tell us what our values should be, what constitutes a moral approach to engagement with suffering. This is the stuff, the arena, in which we live and die, and in which patient complaints are best evaluated, from a moral platform that can collapse into ontology rather than a scientific epistemological series of events, a far more disengaged process.  The nosology of modern diagnosis is a vocabulary of moral disengagement, and the vocabulary of suffering, compassion, choice and purpose is critically eliminated in this way, reducing any chance of moral engagement.  Society already does this; breakdowns of family and community already do this, so treatment should provide news of difference, of change, in counterpoint to the academic approach. Clinicians, Miller argues, have the potential to act as a moral refuge, a bulwark of efficiency against the need for scientific efficacy that serves more its scientific masters than its therapeutic clients.

It is thus an important book that as it size indicates does not overstate or belabor its case.  It will call for us to examine the beauty of the case study, the elegance of learning from watching and being watched, of seeing what other and wiser, not smarter, guru's can accomplish in wielding the skill and art of the clinician.  As Matarazzo argued, far from being a cold objective science, much of the practice of psychology involves a subjective component.

Miller puts forward a brave counterpoint to evidence base, not in challenge to its existence, but to its dominance in the training, to the detriment of the consumer, of mental health professionals.

His arguments, and his book, are highly recommended, and I would beg their consideration by any and every university involved in the sculpture of mental health professionals from the clay of their philosophical and moral feet.

 

 

© 2005 Roy Sugarman

 

Roy Sugarman, PhD, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia