Trust can’t be layered on top of any method; it’s the foundation of therapy.
“Whoever is careless with the truth in small matters cannot be trusted with important matters.”
― Albert Einstein
(NOTE: This piece is to appear in Unlimited Human!, the journal of the International Medical and Dental Hypnotherapy Association)
People ascribe some of their obstacles to their minds; governments ascribe some of their obstacles to their citizens. To guide and support each other, people created community. To guide and support their communities, governments created psychotherapy.
The history of psychotherapy—or what generally falls in that ill-defined category of behavior modification—reveals its government origin. From the 19th-century management of social misfits, to the social theory behind educational psychology, to the 20th-century government importation of psychoanalysis, to the creation of psychology as a public healthcare designation by the American Psychological Association (APA), clinical psychology has worked in the service of government at every step. See the 2008 “History of the APS”, here: https://www.psychologicalscience.org/observer/the-history-of-aps See also, “Historical Perspectives on the Theories, Diagnosis, and Treatment of Mental Illness”, published in 2017, here: https://bcmj.org/mds-be/historical-perspectives-theories-diagnosis-and-treatment-mental-illness
The reversal of US government support for psychotherapy, which occurred in the 1980s when the Reagan administration replaced psychotherapy with pharmaceuticals and managed care, showed the profession’s lack of independent structure. There is no underlying theory that relies on psychotherapy for mental health in the way that anatomy provides a foundation for medicine.
Among the casualties of this policy of the 1980s was a clinical understanding of ADD/ADHD. In the largest study of the time, Cummings and Wiggins showed that 75% percent of youth diagnosed with ADD/ADHD were entirely remediated by psychotherapy, counseling, and family support. Their work was one of many lines of research buried as a result of the new government policy. (See Cummings, N.A., and Wiggins, J.G. (2001). A collaborative primary care/behavioral health model for the use of psychotropic medication with children and adolescents: A report of a national retrospective study. Issues in Interdisciplinary Care, 3, 121–128.)
Nicholas Cummings was president of the APA in 1979, Chief of Mental Health with Kaiser Permanente from 1959 to 1979, and founded the Cummings Foundation in 1994 to ensure psychotherapy’s continued inclusion in routine healthcare. Cummings was one of the “dirty dozen” at the APA who reorganized the association around psychotherapy as a clinical service. He told me that when the government pulled funding for psychotherapy, his future work not only lost funding overnight, but their past research was made unavailable and publication of their current work denied.
Psychotherapy’s medico-psychiatric approach exists by edict, as it lacks theoretical basis. When government edicts change, the field is repurposed—like a new billboard. The teaching of psychotherapy focuses entirely on popular theories whose effectiveness depends on social attitudes, norms, and support.
The field’s origin and direction as a social service institution is not explored in the training of clinicians. Focus is redirected to the field’s methodological development. This is much the same as public education whose agents, school teachers, are even more egregiously uninformed about the social purpose of their work. There has been a kind of “revolving door” between government policy and clinical, academic, educational, social, and forensic psychology.
Wayne State Psychiatric Clinic
Psychology and State
My background is in physics, neurology, sociology, anthropology, spirituality, metaphysics, philosophy, culture, management, and theory of mind. Before I studied clinical psychology, I found psychology’s pedantic curriculum to be unattractive. I made an end-run around academic psychology by following a dozen alternative approaches to self-knowledge.
I have worked among and been a member of professional psychology organizations, investigated licensure programs, and I serve as an assessing editor on an academic psychological journal. I have been the client of over a half dozen marriage, counseling, and forensic psychologists. I recall a forensic psychologist who told me to “trust the numbers” in the application of the MMPI test for psychopathology, for which the MMPI is well known to be a poor indicator. This authoritarian approach, widely shared in the profession, is misguided and ineffective.
The exceptional psychologists I’ve encountered define their role outside the realm of professional categories. I remember Michael Thompson, MD, a leader in the application of neurofeedback to children with learning disorders at Toronto’s ADD Centre (http://www.addcentre.com/), telling me his success rests on telepathy, and that he can’t say that in public. Practitioners, like Michael, build their practice on trust and understanding. They’re the exception rather than the norm.
As I continue to practice as a counselor and therapist, my clients tell me my hypnotherapeutic approach is unlike that of psychotherapists. I am reminded of this whenever I work with a client whose history has been formed by diagnoses and who identify themselves in terms of these diagnoses.
Clinically diagnosed clients tell me that I treat them as regular people and often as equals, unlike the psychotherapists they’ve seen. I find it somewhere between amusing and frightening that many of these people are either afraid to see themselves as capable of being healed, or their doctors and caregivers discourage them from believing that they can be, and press them back into a disabled self-identity. As any therapist who works with seriously dysregulated people can attest, their condition is tightly bound by the people around them and the circumstances of their lives.
In the tooth-and-claw world of public medicine, psychotherapy allies itself with academic research. Much of this work fails basic methodology, primarily to be faulted for the use of evidence to substantiate rather than to disprove. Little of this work—neuroimaging in particular—escapes indictment as correlation rather than causation. A 2015 article in Science reported that only one third of claimed results could be substantiated. See “Estimating the Reproducibility of Psychological Science”, at https://www.researchgate.net/publication/281286234_Estimating_the_Reproducibility_of_Psychological_Science. See also “Psychologists Have a Plan to Fix the Broken Science of Psychology” at https://www.livescience.com/62072-psychology-preregistration.html
The battle for professional clout and insurance dollars is led by professional organizations like the APA and the American Medical Association. I am reminded of Microsoft’s rise to dominance selling unreliable DOS and Windows operating systems by creating alliances with computer peripherals manufacturers and small businesses that subsist on the installation, repair, and maintenance of its unreliable products. So, too, has clinical psychology provided a Petri dish for cottage industries providing loosely approved licensing authority, specialization, improvement, alternatives, and snake oil.
Hypnosis has never been a “therapy” in the normative sense. Even when relegated to the medically “low-caste” functions of phobia remediation, smoking cessation, and weight loss, hypnosis serves the client. In contrast, psychotherapy’s diagnostic approach, as reflected in the Diagnostic and Statistical Manual, passes judgment based on changing social norms.
Hypnotherapy has also been a breeding ground for cottage industries, but, unlike psychotherapy, it has not relied on the Pinãta-like pretense of academic substantiation, though it has gained some. In both fields, we could draw evolutionary-like family trees with branches for such luminaries as Maslow, Erickson, Satir, and so on. The family tree of psychology would be intertwined with government, and its branching would synchronize with changes in administration. The family tree of hypnosis, like the animals of Australia, would progress along independent lines.
All this should be well known, and it largely goes unspoken in much the way that Neanderthals and Homo Sapiens had little need to list their differences. There is something primally different in acting in service to the individual versus the state, echoing the divergence between nature and nurture.
Fundamentally, mental health resides in the individual. Behavioral psychology, which became the study of manipulating people, persists in programs like public education and cognitive behavioral therapy. These treat people like gears in a social machine that serves the situation. The individual always seems to get the short end of the stick. Emotionalists, like me, are always warning that you can only press bad policies so far. It’s amazing how far bad policies can be pressed.
Building Good Methods
In this context, I was interested to read the basic manual for Feedback-Informed Therapy, FIT, co-authored by Scott Miller and others at the ICCE, the International Center for Clinical Excellence (https://www.scottdmiller.com/). The underlying idea of Feedback-Informed Therapy is that the effectiveness of psychologists and counselors is greatly impaired by clinicians’ lack of rapport with and understanding of their clients. Attempts to measure this failure are difficult, but the fact that this is being recognized substantiates what I’ve said. Embracing FIT signals a sea-change in an obdurate profession.
As a first step toward remedying this failure of respect—which I feel was fairly baked into psychotherapy from the start—Miller and others have created a method to measure a clinician’s lack of rapport. It’s done with a simple, four-question, graphical questionnaire that generates a numerical score. By working within the system, the ICCE has built both institutional support and substantiation for their claim that this provides an effective measure. From the simple suggestion that clinicians test their rapport, a small but essential crack is being made through which the light of true mental health might penetrate.
On the one hand, I feel supported. On the other hand, I feel depressed. ICCE is advocating an approach inherent in hypnotherapy from the start. Because a hypnotherapist is a guide, hypnotherapy begins with rapport. No one’s going to follow a guide they don’t trust. The premise of hypnotherapy is that the clients know their mind better than anyone else, and nothing will be accomplished without their action and consent. The premise of hypnotherapy fully embraces the subconscious to the point where the client is given the final say in both the process and the purpose of therapy.
The rating scale of Feedback-Informed Therapy focuses on rapport after the fact. I welcome it, yet it seems unlikely to succeed. There’s much controversy around whether this feedback is appropriate and where it might be retro-fitted in traditionally judgmental psychotherapy.
The image of Fantasia’s hippopotamus ballet comes to mind. I can understand and foresee that many psychotherapists will be as warm to Feedback-Informed Therapy as public school teachers are to teacher testing. We are all familiar with the meme—as in the movie, Dead Poets Society—of the best teachers being sacrificed. One need not stretch much further to reach the meme of The Matrix, where the system’s flaws reveal a larger, intentional design.
Fostering forward-thinking individuals requires forward-thinking institutions. Rather than aim to become more psychotherapy-like, hypnotherapy should recognize its leadership obligation: psychotherapy must become more hypnotherapy-like.
While the Center for Clinical Excellence’s Feedback Informed Therapy will come to loggerheads with authoritarian psychotherapy—not because it can’t prove itself, but, on the contrary, precisely because it can—hypnotherapy eschews the authoritarian model throughout. Even the most authoritarian hypnotherapy, that of suggestive hypnosis, still relies on compliance, trust, and rapport.
As hypnotherapists, we should recognize the strength of what we are. The subjectivity about which we’ve been bullied provides the emotional insight needed by the whole field of mental health. It’s not a question of which method is better, it’s a recognition that only the client’s current reality can underlie their future reality. Trust can’t be layered on top of any method; it’s the foundation of therapy.
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