Abstract
In an era of condensed treatment and managed care, three trends are gaining prevalence in some graduate training programs and in some circles of the practicing community, limiting clinicians from utilizing the therapeutic techniques needed to help a client achieve long-standing intrapsychic change, a precondition for maintaining therapeutic gains post treatment. The first trend, the equation of empathy with sympathy, hinders the therapeutic dyad from truly understanding a client’s internal experience and implicitly conveys the message that anxiety-provoking material is less welcome in the consulting room. The second trend, prizing cognition over affect, results in a primary focus on secondary thought process, discounting the affective experience that unconsciously steers behavior and thought. This trend is, in large part, due to the widespread dissemination of cognitive-behavioral therapy efficacy research and the belief by some individuals that psychodynamic forms of treatment lack empirical support. The last and most problematic trend, the rigid utilization of treatment manuals, tends to result in a reductionistic approach to treatment, limiting psychotherapy to a set of techniques while also overlooking salient aspects of treatment that can predict positive outcomes. Treatment manuals oversimplify the process of therapy; as a result, the therapeutic dyad is less likely to uncover and discover the multiple origins of one’s suffering, contributory factors that are not always readily available to conscious awareness. This paper discusses each trend and the therapeutic implications that result.
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Notes
For purposes of expressive continuity, I will use the masculine pronoun to refer to the clinician/therapist and the feminine pronoun to refer to client; the use is not intended to convey any gender significance.
Kohut also understood failures of empathy to play a large role in the development of narcissistic disorders. However, for the purposes of this paper, the definition of empathy is limited to the clinical situation as a mode of observation. For a discussion of empathy and its role in psychopathology, see Kohut (1971).
For a distinction between enactment and projective identification as understood from a relational perspective, see Stern (2010).
A clarification is needed here. I do not want this statement to be misinterpreted to suggest that I believe in the liberal use of self-disclosure. A clinician who forces his own issues into the treatment will surely disrupt the therapeutic process. Revealing one’s bodily based responses and selectively sharing these responses with a client when appropriate requires a great deal of experience and judgment, as well as active introspection on the part of the therapist (a skill that is developed in most cases only after one’s own treatment). I agree with Aron’s (1991) contention that some level of self-revelation on the part of the therapist is inevitable in treatment. However, self-revelation is not synonymous with self-disclosure, and sound clinical judgment must be used when considering whether or not to share a bodily based response with a client.
Addis and Krasnow (2000) state that there is accumulating evidence that adherence to an empirically supported, manual based treatment is associated with positive outcomes for a range of disorders; conversely, they contend that some studies suggest that manuals may have harmful effects under some conditions. In a large survey of national practitioners regarding their beliefs about treatment manuals, Addis and Krasnow (2000) found that clinicians are equally likely to have positive or negative attitudes. Those with negative attitudes believe that manuals have a dehumanizing effect on therapeutic process and emphasize rigid techniques at the expense of flexibility and a strong relationship. Those with positive attitudes see manuals as a way to use empirically supported interventions (Addis and Krasnow 2000). In a different study examining provider attitudes, Borntrager et al. (2009) found that therapists did not harbor negative attitudes toward evidence-based practice as a whole but had concerns about the use of treatment manuals.
It should be noted that psychodynamic psychotherapy is not the only model of treatment that addresses one or more of the three fallacies. Interpersonal neurobiology (see Schore 2012) is one model that also addresses the second fallacy as it focuses more on affect and right brain processing as opposed to cognition and left brain processing. Interpersonal neurobiology also overlaps with other psychodynamic principles, namely the importance of unconscious processes (which are contained in the right brain, the neurobiological core of the human unconscious) (Schore 2012). Alternative approaches address other fallacies described in this paper. For example, Duncan’s (2012) model of treatment addresses the third fallacy regarding the rigid utilization of treatment manuals as an integral part of that model includes monitoring client progress in an ongoing way and deviating from technique when needed. However, because psychodynamic psychotherapy explicitly addresses all three fallacies, I argue that it is the best approach to conduct treatment.
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Krohn, D. The Three Fallacies: Evaluating Three Problematic Trends in Clinical Practice. Clin Soc Work J 41, 192–204 (2013). https://doi.org/10.1007/s10615-013-0441-6
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DOI: https://doi.org/10.1007/s10615-013-0441-6