Rough Draft--not for publication or citation
© 2000 by Arthur Warmoth, Ph.D.

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The Three Pillars of Licensed Psychotherapy:
Science, Law, and Empathy

Arthur Warmoth
Sonoma State University

It is useful to look at the profession of psychotherapy as composed of three elements: prescription, case management, and empathic communication:

1) Prescription (Prediction). Based on expert knowledge, the therapist is able to prescribe behavioral and pharmacological interventions that relieve the client's symptoms or helps solve the client's problem in a way that is recognized as valuable by the client.

2) Case Management (Control). Based on expert knowledge the therapist is authorized by society to restrain the behavior of the client, up to the point of incarceration, for the protection of him/herself and others

3) Empathy & Empowerment (Interpretation & Facilitation). Based on the richness of the therapist's life experience, the therapist is able to enter the client's "life space" (Lewin) and help the client discover new options.

The first two functions fit into the science-practitioner model and place psychology on a par with psychiatry within the medical model. These are certainly legitimate social functions. Their exercise should be guided by research on the reliability and validity of the interventions involved. However, the third element of psychotherapy, empathic understanding, needs to be given equal recognition, for, in combination with science-based knowledge, it is the key to opening up broad horizons of practice for psychologically educated professionals.

Prescription and Prediction. The ability to "prescribe" interventions and behavior change strategies for the benefit of the client presumes a level of knowledge and expertise that is substantially beyond the client's own resources. The ability to prescribe behavioral interventions requires knowledge in the areas as diverse as developmental psychology, cognitive psychology and learning theory, social psychology, and neuroscience. The ability to prescribe medication requires even more specialized knowledge of neurophysiology an psychopharmacology. All of these represent areas of objective, experimentally validated scientific knowledge. Their findings are subject to the canons of scientific method, including statistically significant measures of validity and reliability. Since they involve comparative judgments of alternative treatment strategies they are also subject to the cost-benefit analyses of economic science. Since the expertise involved requires high levels of specialized knowledge that are beyond the ability of the client to effectively evaluate, licensing procedures that assess the practitioner's mastery of an appropriate scientific knowledge base are appropriate.

Case management and control. In some circumstances, psychotherapists are called upon to intervene not only for the welfare of the client but also for the welfare of society at large. A therapist may order a client restrained for the protection of self or others. Psychologists participate in a wide variety of judicial proceedings. They also make decisions about client's access to social and medical services and other public resources. The judicious exercise of this authority requires not only a sound foundation of psychological expertise, but perhaps more importantly a solid grasp of the relevant principles of law, public policy, and ethics. It also requires the character and temperament to be able to apply these principles in a fair and constructive manner. Again, we are looking at a set of characteristics of which professional assessment is justified for the protection of the public interest.

Empathy and empowerment; interpretation and facilitation. The third element of effective practice mentioned above has also been shown to be an essential element in successful psychotherapeutic practice. However, its premises and characteristics are very different from those of the other two functions. Rather than requiring a level of expertise that is beyond the capacities of the client, empathy requires the ability to enter as fully as possible into the client's "lifeworld" of knowledge, feelings, attitudes, and values. (Bohart & Greenberg, 1997). It requires the ability to establish rapport and trust. And it requires the ability to identify horizons of possibility (to survey Vygotsky's, 19??, "zone of proximal development") into which the client can imagine moving.

All three of these elements are equally important to the successful practice of licensed psychotherapy and clinical psychology within the medical model. Recognition of their complementarity, rather than their antagonism, is essential to the future of the profession. Advocates of the scientist-practitioner model should recognize that self-knowledge, empathy, and effective communications skills have theoretical, and not just pragmatic, significance in defining the parameters of successful practice. Proponents of interpretive practice should strive for a clearer understanding of the epistemological foundations of their contribution to practice. This includes recognizing that their foundations are different from those of the natural sciences, and are in fact closer to the disciplines of the arts and humanities. They would do well to abandon the project, initiated by the founders of psychoanalysis, including both Freud and Jung, to establish a science on the natural science model. Instead, interpretive practitioners need to recognize that the emerging social constructionist understanding of knowledge, which recognizes psychoanalysis as a significant weaver of the narrative webs of modern culture, offers a more accurate and socially useful account of their intellectual contribution to psychology and society.

Licensed practitioners should be familiar with the findings of natural science-based psychologies, including neuroscience, cognitive science, and evolutionary psychology. Neuroscience informs us about our material nature, while cognitive science institutionalizes our ability to reflect upon our own mental processes and to project those processes into the physical world of electronic machines. Evolutionary psychology informs us about our animal nature by placing our cognitive and emotional life in the dramatic context of patterns of adaptation by random variation and natural selection. They should also be familiar with the theory and practice of the law.

However, to find the moral insight necessary to live a good life in the context of our material and animal natures, and of a universe in which spiritual intuition has been cut loose from theological certainty, I prefer Shakespeare. His metaphor of life as a cosmic stage is apt. We are always either in rehearsal or on stage in our own life drama. We turn to psychotherapists as personal coaches in this drama (indeed, the profession of "personal coaching" is gaining status in its own right), but psychotherapists do well to study philosophy and art, as well as science, in the interest of perfecting their craft.

Education-Based Practice

A solid knowledge of the findings of psychological research and a judicious grasp of the law, public policy, and ethical principles are critical for the successful practice of licensed clinical psychology. So are self-knowledge and a capacity for empathy and effective communication.

However, clinical psychology and psychotherapy are not the only fields where self-knowledge and communicative competence are important. A wholehearted acceptance of this dimension of the practice of psychotherapy opens the possibility that this aspect of the effective education of psychologists could be incorporated in a variety of other multicultural practice models that would greatly extend the usefulness of this aspect of psychological training into a variety of fields that can respond to pressing social needs.

The postwar era of the ascendancy of professional psychology in modern American life could be described as the period of the full flowering of modern industrial society. This was a society that made resources for the fulfillment of desires available to the middle class on a scale unprecedented in history. However, we are now entering a new era whose forms are being shaped by the revolutionary impact of electronic communication and information processing technology. While this technology greatly expands the horizons of opportunity, it also destabilizes many parameters of the social and economic order. Combine this with an increasing awareness of the negative ecological side effects of the industrial revolution and increased tensions between the "haves" and "have nots" of the world, and we have a world in which the challenge to the middle class is no longer primarily adapting to the present, but rather to participate constructively in the co-creation of the future.

Psychological Practice as Facilitating Personal and Organizational Learning and Development. Psychologists have been carving out their role as healers and practitioners within the scientific/medical paradigm for most of the past century. They have also played a major role in education, both the psychologists' role and the public understanding of the educational nature of the enterprise has been limited by psychologists' ideological focus on behavioral learning and their practical focus on specific instrumental achievements such as intelligence testing and therapeutic techniques.

However, the unifying theme of all psychological practice is the basic process of learning, including knowing, understanding, interpreting, skill-building, and creating. The best term might be "epistemology," except that the word is too long and belongs to the philosophers. (I remember in graduate school someone calling psychology "empirical epistemology.") Every human endeavor is dependent on the human capacity to learn. Therefore every discipline and every social institution, especially in the information age, offers opportunities for psychologists. At the same time, the diversity of the ways in which psychologists approach perception, cognition, and insight argue against any form of ideological hegemony and for a pluralistic epistemology that recognizes the diversity of our theoretical and research agendas.

Health care is only one complex of social institutions, only one sector of a diversified political economy. Another is social context for psychological practice is education. An examination of institutional and political economic alternatives could greatly expand our horizons for thinking about practical action and therefore for thinking more creatively about career opportunities. An understanding of education as a social process (when taken beyond our thinking about traditional educational institutions) can suggest a cornucopia of opportunities, particularly in the new social and economic order that is being created by the imperatives of electronic communications and information processing technology.

This view of education-based practice would come close to the view of humanistic practice articulated by the group at the recent Old Saybrook 2 Conference (2000) that was addressing the question: Who should our clients/customers be?. As articulated in the Conference Proceedings , this group identified the following characteristics of humanistic practitioners as having a broad rage of potential applications:

The tasks facing the education-based practice model are different from those facing the medical model practitioner. Although there is considerable overlap in the actual practice of psychology in the medical and educational paradigms, they differ fundamentally in their philosophical foundations, in their assumptions about the role of the practitioner, in the appropriate strategies for evaluating outcomes, and in the economic models appropriate to their funding. They also differ in the degree to which they are currently clearly defined in public consciousness.

Educational practice requires the more ambitious task of expanding society's assumptions about the nature of economic institutions and creating new institutional forms that are appropriate to the needs and dynamics of an information rich society. The latter task requires an approaches in psychology and the social sciences that are rooted as much in the arts and humanities as they are in the natural sciences. And they require approaches to evaluation that are political in nature, rather than expert-based. Therefore, the larger challenge of education-based practice is to take a practice model that now exists primarily on the fringes of APA (Division 32, etc.) and to articulate a basis for practice that would realize the practice potential of facilitated personal and group learning in the postmodern/postindustrial society. Psychology has already developed several sub-disciplines and practice models that fit nicely into a personal and interpersonal learning model of practice including: Emotional Intelligence, Somatics, Phenomenology & Hermeneutics, Depth & Imaginal Psychology, Narrative/Creative/Expressive Arts Psychologies.

Undergraduate Curriculum. In the new environment, deep self-knowledge and self-discipline are needed for the effective application of knowledge (particularly of capitalized information) to a wide range of areas of social life. But in addition to self-knowledge, a broad knowledge of how the world works is also needed. This discipline-based knowledge need not be focused in psychology a traditionally defined. It may include the disciplinary knowledge bases of the other social sciences, or even of the humanities, knowledge which is rapidly being capitalized through the application of technology. Indeed, one of the consequences of the information revolution is to make discipline-based knowledge bases more widely n cheaply accessible.

However, if psychology is taught as a broad liberal arts major, the combination of self-knowledge, literacy, numeracy, and basic research philosophy and methods, combined with a deep historical perspective on the field, can lay the foundation for work or further study in a wide range of interdisciplinary fields.

The proposal for a curriculum that expands the historical and cultural contextualizing of the field resembles Anthony J. Marsella's (1998) proposal for a "global-community psychology." However, Marsella's analysis focuses primarily on conceptualizing a new field of psychology designed to address pressing global concerns. The present analysis suggests that there is a historical continuity with the metapsychological theorizing of personality theory and depth psychology. It also suggests that, from a systems perspective, there is a continuum of issues of identity and values spanning a spectrum of scales ranging from the individual personality through communities, organizations, and ethnic groups, to the national system that have dominated the modern world and the global systems characteristic of the "postmodern" era.

Graduate Curriculum. At the graduate level, this analysis suggests the value of a balanced emphasis on quantitative and qualitative methods, along with an increased emphasis on the study of the history and cultural context of psychology. This does not invalidate the necessity of specialized training for specialized areas of research. But it does suggest that a broader and more open educational model is appropriate for the "general practitioners" of applied social science who will be using social science knowledge and methods to address specific social issues.

This analysis also suggests that there is room for practitioners to develop useful knowledge and practical skills at the master's level, and that the services of these practitioners, which are more likely to be used by organizations and agencies than by individuals, can be left to the free play of the market, rather than being restricted by licensing laws.

Ethics & Licensing. In the context of the medical practice model, where the client is assumed to be vulnerable and in need of expertise which s/he is not in a position to evaluate, the protection of a licensing establishment is rational. But in the facilitator model (which includes the skills of creative interpretation an leadership) the relationship is seen as one of equality, or at least mutuality. It is precisely the ability of the practitioner to enter into the client's lifeworld and make his/her expertise accessible and useful in that world that is at issue. It is the client's willingness and ability to take responsibility for her/his decisions that is critical. Therefore, the relationship required a legal and ethical framework that makes it clear that the client is in charge of defining and evaluating outcomes. However, and intelligent, healthy client should need no legal protections beyond those offered by good contract law. A separate licensing bureaucracy placed between the practitioner and the client can interfere with the spontaneity and creativity that is essential to an effective relationship.

Conclusion

Psychology in general and humanistic psychology in particular have spent considerable energy and resources over the course of the twentieth century carving out a position in the larger context of the medical model health care system. The principle tool in this effort has been the psychologist's license. The justification for this license has been research-based expertise justifying prescriptive authority. If we focus on the uniquely psychological skills of empathy and creative empowerment, it is clear that there are abundant opportunities in 21st century society for skilled practitioners in a variety of areas.

However, developing these skills requires complementing the traditional science-based curriculum with extensive exploration in the humanities--art, literature, and philosophy. It also requires democratic power relationships based on negotiation, agreement, and accountability, rather than on bureaucratic authority and control.

 

 

References

Bohart, A. C., & Greenberg, L. S., Eds. (1997) Empathy reconsidered: New directions in psychotherapy. Washington, DC: American Psychological Assn.

Marsella, A. J. (1998) Toward a "global community psychology": Meeting the needs of a changing world. American Psychologist, 53, 1282-1291.

Old Saybrook 2 Conference Proceedings. (2000, May 11-14). http://www.sonoma.edu/psychology/os2db/proceedings.html

Szasz, T. S. (1961). The myth of mental illness. New York: Hoeber-Harper.

Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes (Ed. M. Cole, V. John-Steiner, S. Scribner. & E. Souberman). Cambridge: Harvard University Press.