Editor’s Column
How Psychotherapy Works – The Sociopath Who Changed
Ed Lundeen
(In memoriam to my father who died of Cancer while this issue was going to press. He would be angry with me that I would mention him in this context, but as he is now in the eternal night, I risk his disapproval. He taught me to seek the truth at all costs and to not flinch in the face of that which was not readily understood or known. To his eternal embarrassment and pride - as so many men of his generation would feel at being so lovingly spoken of - I profess my utter gratitude to him and commend him to the ages.)
“Who is John Galt?” So opens Ayn Rand’s “Atlas Shrugged”, with the eternal question, the meaning of which the reader eventually comes to understand signifies the answer to questions that are unanswerable. That is, “Who is John Galt?” means “you have asked a question for which no answer exists, and my reply is equally without answer.” Rand ultimately does reveal who John Galt is: I am less sanguine about my chances of completing this piece with such a revelation. Also, in respect to my Dad, I make no claims to originality in this piece, nor scholarly understanding of what others may have said long before.
"If we don’t accept that our actions forever change the future we are not a true discipline
On the Div 42 email group not long ago, one of our own dearest members posed a clinical conundrum. In short sum, a patient talked too much in therapy and life and was ruining her chance at relationships with others because of it. Our brave colleague had seen this behavior and wondered aloud to the group what course of action he might take to help this patient understand her problematic talking and perhaps modify it. A number of sage responses were forwarded, from a few theoretical orientations, all quite different, but reaching for the same ends by different names, e.g. behavior modification or insight.
As I read the replies it occurred to me that our colleague would pick one of the options, create one of his own or perhaps try a hodge-podge. But one thing was clear to me. There were a number of choices he could NOT blend together, that were mutually exclusive. And having picked one of those choices would make others options for intervention no longer available. For example, if he opted to use interpretive tactics with the patient and they failed (or perhaps even if they worked), he would not be able to use behavior modification tactics in the same, de novo, way others had suggested. I am convinced of the truth of that statement, and here’s where Heisenberg comes in. Werner Heisenberg offered the famous eponymous “Uncertainty Principle” of physics, which has earth-shattering meaning to all attempts at observation and manipulation. It states (summarily), “The more precisely the position is determined the less precisely the momentum is known.” This means, very over-simplified, that when one tries to measure the position of any subatomic particle, i.e. its current physical location in space, the less able one will be to determine where the particle is going or will be next. And, if I could just beg your indulgence, this in essence means that any effort at manipulating or measuring any subatomic system will lead to changes that are inexorable and cannot be measured a priori.
Here’s where my editor says “Whatever Ed, can you ha‘ina ‘ia mai ana ka puana” (in homage to Pat DeLeon, the only man I know who might translate that – it is Hawaiian slang for “get to the point”). I’m trying, honest. I believe that Heisenberg informs all psychological intervention with his amazing postulate. That is, we can infer from Heisenberg that once having intervened with a patient, we have forever changed the nature of our interaction with them in some meaningful, albeit unpredictable way. Hopefully often for the good, perhaps frequently for the neutral, but surely at times for the worse. We can’t just keep trying every different intervention until we find one that works. What we do matters right from the start (OK. I know that’s totally unoriginal!) and each choice we make will take things down a different path from any other choice.
Maybe you simply nod your head at this quasi-profundity and say, “Duh, I knew that.” But the few replies I got on the email group to my attempt to explicate this point did not suggest a universal agreement on this – at least a few told me they didn’t think my point was necessarily true at all, and that indeed many things we might do as psychological interventions were not only not mutually exclusive, but might even be equivocal in terms of their ability to be helpful. And it was that, which I’ve heard from more than just Div. 42 colleagues, that concerned me.
Now there are dozens of debated points in psychology, so another one should not cause me that much consternation. But this one does. I can’t feel comfortable with a profession that won’t (or refuses to out of pure independent-minded cussedness) accept certain fundamental truths as a cornerstone for our knowledge base. True disciplines (note how I have deftly tried to avoid the “are we a science or art” dichotomy with this word) are disciplines because they accept a set of fundamental principles. Granted, these principles might and do change, but it is their existence and foundational driving forces that determine the general action plan of the profession (note: I have in one simple sentence likely offended and alienated all the post-modernists out there. Tempted as I am to apologize, I won’t).
If we don’t accept that our actions forever change at some micro level the future, that each interaction with a patient takes some course that meaningfully alters all other future options, then I would suggest we are not a true discipline, and we lack the fundamental ability to communicate at the finest of levels. Maybe that is why we are so fragmented and why many of us can maintain such iconoclastic world views and ways of practicing (present writer pleads nolo contendre) as psychologists.
I told you I wasn’t optimistic about some useful conclusion to all this. I wish I were in a position to make some kind of clarion call for action and unifying principles secondary to my flash of insight (delusion?). I will ask the following however. As psychologists all in name and trade, there are some truths which we must all accept as fundamental and not subject to interpretation or individual judgment. Perhaps others will articulate those others that are needed. My contribution is that we must agree that having acted as psychologists with our patients, we can never undo our actions with our patients, predict exactly how that action will change the future, know how the future would have been different had we not acted in that way, nor take any other action without the prior action serving as influence. I would also proffer that we cannot consider the prior statements as mere sophistry without meaningful clinical implications, and cannot each determine if we personally believe the statement to be true or false (it’s either a profession-dependent decision or we all agree it isn’t true). I would also say we cannot use as excuse a disinterest in philosophy (our direct forefather after all), a distaste for or neglect of professional questions where the initial answer is “Who is John Galt” (with an understanding that Rand’s device applies here – John Galt can be known), nor abandon this question because it’s asker does not do an optimal job of explicating it in the space allowed. I say this without hesitation: our future does not rest on these dilemmas, but our chance at growth beyond our current bounds surely does. We can’t expand our knowledge of what truly works in therapy, and here I’m talking about getting beyond the at best 70% mark of the common curative factors research (see Bruce Wampold “The Great Psychotherapy Debate”), without acknowledging this principle, our concern is best consumed by trying to define how to address more accurately and consistently the 30% of change we either can’t account for or can’t currently consistently promise to our patients. And we need Heisenberg to be seen as a fundamental truth. Now I invoke the Muses to help me make better sense of this all at some later column.
