Abstract
Robert Woolfolk’s history and critique of clinical trials of psychotherapy illustrates how scientific investigations transform psychotherapy into technological procedure. This creates a place for psychotherapy in the healthcare economy but misses the value of psychotherapy not indexed by money or numbers.
As Woolfolk states, “This book is intended as a step toward an answer, an intellectually sound blueprint for how psychotherapy should be evaluated at this point in its history” (p. 113). He emphasizes the importance of understanding the lifeworld of psychotherapy and states that “there is no explanatory framework outside of human experience itself that could produce a scientifically sound, purely objective characterization of human action” (p. 120).
In response to pressures from managed care to medicalize psychotherapy, double-blind crossover studies are used to measure its worth. This is a pharmaceutical model of research requiring manualized treatment protocols, delimiting characteristics of the patient sample to demonstrate treatment effects. When psychological problems become decontextualized from the social-cultural situations in which people live, methods of natural science research can be used to investigate topics objectively. The lifeworld of a patient’s problem cannot be included without a radically idiographic approach that precludes the development of reliable generalizations.
Clinical trials seek to legitimize a method of evaluation, hoping to make procedures of psychotherapy determinate, reliable, and definite across lived experience, establishing psychotherapy’s place in the economy of knowledge. And this has been successful. Psychotherapy, in commercial and ideological competition with biomedical psychiatry and the pharmaceutical industry, has broken through “Big Pharma’s stranglehold on mental health interventions” (p. 158). Clinical trials provide significant evidence that psychotherapy is superior to pharmacotherapy, with drugs being more likely to generate a biochemical imbalance rather than correcting an existing one (p. 169).
But not all of psychotherapy’s value is located in the extreme distance of objectification. Psychotherapy is a conversational space for inquiry, generating insight and motivation regarding unspoken assumptions that underlie social relationships; such insight typically being difficult to access because one’s view is embedded in one’s social-historical context. To perceive psychologically is to empathize with the other, and know this as another self. This knowing occurs in relationship, so it is constantly changing; it has a fluid, living quality. If we require an Archimedean point outside of psychotherapy to evaluate it, then the psychotherapy is removed from the relationships in which it arises. As such we come across a limit for measuring and generalizing psychotherapeutic value.
Woolfolk’s book shows clearly how psychotherapy becomes non-psychological when translated into measurable variables. It is a subject so relational that when objectified it recedes from itself until reasserting itself as an object of inquiry. The research of clinical psychology shapes a non-psychological phenomenon. The truly psychotherapeutic does not permit a point of relation to itself because it brings into being what it itself is.
The book goes on to demonstrate how the study of psychotherapy seems to be a study of the logical form of clinical practice. Psychotherapy exists to the extent that the notion of psychology has its ground within itself. Although there is room for positivist notions, psychotherapy requires accessing the world that it reflects, within the confines of the investigation that it mirrors, existing in mind as a process of thought and understanding, extinguished fully into life, dialectically related to insight. Constantly changing, psychotherapy’s fluid, living, subjective, and relational quality is missed in measurement. As Woolfolk says, “capturing and assessing mental life is sometimes like nailing Jell-O to a wall” (p. 75).
One of the major points made by Woolfolk is that the value of psychotherapy is not an objective claim, but more of a way of life. Schools of psychological thought are like cultural islands, with their own customs and practices of interpretation, explanation, and understanding. Although they have the same subject of interest and generally agreed-upon definitions of therapeutic relationship, psychotherapy research has not determined scientific laws of clinical practice or underlying mechanisms, so differing approaches are not being integrated. Woolfolk explains how the DSMs do not provide an intellectually sound basis for scientific research or public health policy; following extremely expensive and unsuccessful efforts to develop new drugs that target specific brain pathways, some pharmaceutical companies are shutting down their psychiatric drug discovery programs.
One puzzling weakness of the book is that Woolfolk’s American perspective ignores the history of psychotherapy in the rest of the world. He writes of the importance of sociology, anthropology, and history for understanding current notions of psychotherapy. Counter to Woolfolk’s claim, psychotherapy is not a principal export of the United States. Watershed developments in psychotherapy in the 20th century occurred throughout the world. Once the reader accepts the book as primarily a review of U.S. English-language literature and a study of the value of psychotherapy in the U.S., it is of interest to see how managed care in the U.S. has impacted methods of research and definitions of value shaping the meaning of psychotherapy. With this focus, Woolfolk provides a good review pointing to the limitations of using the scientific method to predict and control psychotherapy outcomes and understand the psychotherapy process.
Second, although for the most part the book highlights our limited understanding of psychotherapy, at times Woolfolk seems intent on progress, and he borders on writing a Whig history of psychotherapy wherein there is an inevitable progression towards greater enlightenment rather than staying with the cultural-historical determinants of any understanding.
Courses in clinical or counselling psychology could use this book to foster a critical perspective on clinical research. The critique of psychotherapy as psychotechnology and the implication for theories of human nature is longstanding, yet it is valuable to review the history of this development as Woolfolk does. What he adds to this discussion is the observation that “no important fundamentally new developments or techniques or schools of therapy have arisen since the 1970s” (p. 12). This observation is incentive for a new form of investigation and evaluation of psychotherapy.