Does the name Barry Marshall ring a bell?
Probably not if you are a mental health professional.
For decades, the Australian physician was persona non grata in the field of medicine — or perhaps stated more accurately, persona sciocca, a fool.
Beginning in the early 1980’s, Marshall, together with colleague Robin Warren, advanced the hypothesis that the bacteria heliobacter pylori was at root of most stomach ulcers. That idea proved exceptionally controversial flying, as it did, in the face of years of accepted practice and wisdom. Ulcers caused by something as simple and obvious as a bacterial infection? Bunk, the medical community responded, in the process lampooning the two researchers. After all, everyone knew stress was the culprit. The also knew the cure: certainly not antibiotics. Rather, antacids, sedatives, therapy and, in the more chronic and serious cases, gastrectomy–a surgical procedure involving the removal of the lower third of the stomach.
The textbook used in my Introduction to Psychology course in my first year at University boldly declared, “Emotional stress is now known to relate to … such illnesses as … peptic ulcers” (p. 343, Psychology Today: An Introduction 4th Edition [Braun and Linder, 1979]). The chapter on the subject was full of stories of people whose busy, emotionally demanding lives were clearly the cause of their stomach problems. I dutifully overlined all the relevant sections with my orange highlighter. Later, in my clinical career, whenever I saw a person with an ulcer, I told them it was caused by stress and, not surprisingly, taught them “stress-management” strategies.
The only problem is the field, my textbook, and I were wrong, seriously wrong. Stress was not responsible for stomach ulcers. And no, antacids, sedatives, and psychotherapy, were not the best treatments. The problem could be cured much more efficiently and effectively with a standard course of antibiotics, many of which had been available since the 1960’s! In other words, the cure had been within reach all along. Which begs the question, how could the field have missed it? Not only that, even after conclusively demonstrating the link between ulcers and the h.pylori bacterium, the medical community continued to reject Marshall and Warren’s papers and evidence for another 10 years (Klein, 2013)!
So what was it? Money, ignorance, hubris–even the normal process by which new scientific findings are disseminated–have all been offered as explanations. The truth is, however, the field of medicine, and mental health in particular, has a weakness–to paraphrase Mark Twain–for “knowing with certainty things that just ain’t so.”
How about these?
- Structural abnormalities in the ovaries cause neurosis in women;
- Psychopathology results from unconscious dynamics originating in childhood;
- Optimism, anger control, and the expression of emotion reduces the risk of developing cancer;
- Negative thinking, “cognitive distortions,” and/or a chemical imbalance cause depression;
- Some psychotherapeutic approaches are more effective than others.
The list is extensive and dates all the way back to the field’s founding nearly 150 years ago. All, at one point or another, deeply believed and passionately advocated. All false.
Looking back, its easy to see that we therapists are suckers for a good story–especially those that appear to offer scientific confirmation of strongly held cultural beliefs and values.
Nowadays, for example, it simply sounds better to say that our work targets, “abnormal activation patterns in dlPFC and amygdala that underlie the cognitive control and emotion regulation impairments observed in Major Depressive Disorder” than, “Hey, I listened attentively and offered some advice which seemed to help.” And while there’s a mountain of evidence confirming the effectiveness of the latter, and virtually none supporting the former, proponents tell us it’s the former that “holds the promise” (Alvarez & Icoviello, 2015).
What to do? Our present “neuroenchantment” notwithstanding, is there anything we practitioners and the field can learn from more than 150 years of theorizing?
Given our history, it’s easy to become cynical, either coming to doubt the very existence of Truth or assuming that it’s relative to a particular individual, time, or culture. The other choice, it seems to me, is humility–not the feigned ignorance believed by some to be a demonstration of respect for individual differences–but rather what results when we closely and carefully examine our actual work.
Take empathy, for example. Not only do most practitioners consider the ability to understand and share the feelings of another an “essential” clinical skill, it is one of the most frequently studied aspects of therapeutic work (Norcross, 2011). And, research shows therapists, when asked, generally give themselves high marks in this area (c.f., Orlinksky & Howard, 2005). My colleagues, Daryl Chow, Sharon Lu, Geoffrey Tan, and I encountered the same degree of confidence when working with therapists in our recent, Difficult Conversations in Therapy study. Briefly, therapists were asked to respond empathically to a series of vignettes depicting challenging moments in psychotherapy (e.g., a client expressing anger at them). Each time, their responses were rated on standardized scale and individualized feedback for improving was provided.
Now, here is the absolutely cool part. The longer therapists participated in the research, the less confident but more demonstrably empathic they became! The process is known as “The Illusion of Explanatory Depth.” Simply put, most of us feel we understand the world and our work with far greater detail, coherence, and depth than we really do. Only when we are forced ourselves to grapple with the details, does this illusion give way to reality, and the possibility of personal and professional growth become possible.
If this makes your head spin, get a cup of coffee and watch the video below in which Dr. Daryl Chow explains these intriguing results.
Until next time,
Scott
Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
P.S. Marshall and Warren were awarded the Nobel Prize for their research in 2005. Better late than never.
Thanks Scott and Daryl. My take away from this is that if we are less confident about our abilities and behave empathicly then we will achieve better results.
For me, Erickson summerised this when he said that we can always be totally confident that the client has all the resourtces they need to overcome their problem. He invited the focus on the client and their wishes [listening], putting the self of the therapist aside [lowering our self confidence] and honouring each client’s individuality [empathy].
Your work is providing evidence for what Erickson invited 50 years ago.
Bravo!
Most discussions involve developing shared definitions. The distinction between empathy and compassion and the role of empathy and/or compassion in therapy requires some understanding of how the terms are used. Edwin H Friedman would contend that empathy is over rated. Where even more recent studies suggest that compassion – an attempt to understand the point of view of the other can lead to better outcomes.
As to the process of uncertainty in therapeutic practice – “lead by following” has its weaknesses; but a co-constructed outcome would a desirable goal. There is a co-benefit when clients can become ready to give up the problem and evolve their own efficacy in therapy.
All the best with your ongoing and important research.
I always thought that empathy meant to understand the point of view of the other, but with the proviso that that understanding included the explicit and implicit dimensions of the client’s experiencing, with a strong emphasis on the latter. Before Rogers offered his convoluted understanding of empathy in ‘57 or ‘59, he offered two earlier and far more concise ones. Both, if memory serves, are from the ‘40s. The shortest one contains “as the client seems to himself.” If that’s not an exact quote, it captures the essence of it.
Really great!!!!
Thank you
At one time, if I had asked myself to rank in priority Rogers’ three necessary and sufficient conditions, I would have rated unconditional positive regard > empathy > congruence. I now see things rather differently, and would rank them in the order conventionally written; congruence > unconditional positive regard > empathy.
Upon reflection, magical and mythical empathy inevitably exist within any relationship, but can make little or no contribution to the quality of that relationship unless they are integrated with rational consciousness and then communicated between the parties. And this relies on congruence.
Similarly, whatever level of positive regard exists, if it cannot be communicated then it’s potential contribution to a healing outcome is very limited. A certain amount of communication between counsellor and client inevitably takes place automatically, non-verbally and out of the counsellor’s awareness. But it’s likely that active recognition of the client’s worth will create far more openness and honesty within the relationship.
Thus it seems that the quality of the relationship ultimately depends upon congruence, requiring of the counsellor a high level of self-awareness, mindfulness and spontaneity. And with that, a willingness to take risks.
A thought about the question posed by Scott at the top of this post. I liken the current state of psychotherapy to the state of medicine before the discovery of microorganisms and antibiotics. Psychotherapy, likewise, lacks a consensus on what causes the most typical problems and an effective treatment; i,e,, one that causes the problem/symptom to disappear or at the very least any remnant is handled in a spontaneous; i.e., without forethought, and a more productive way.
Part of the key is understanding the presenting problem, understood as a psychological. “Injury,” in the following way: It has an interpersonal origin (or is assumed to until disproven) and the effect of which cannot be significantly altered by a conscious act. The other key part is the unforced – and therefore not retraumatizing – activation of the client’s emotional experiencing; i.e., when it emerges coincident with the client receiving sufficient support for their experiencing. Such unforced activation is the facilitation condition for my concept of therapeutic catharsis. It is based on the assumption that there exists a natural healing process for psychological injuries, and as such it transforms the therapist into a midwife, someone who creates the conditions for such a process to operate. This process has two parts. The first is a sympathetic, or fight or flight response, spontaneously followed by healing emotional responses such as crying, .
Forced activation of emotional experiencing is not therapeutic. This occurs outside of session when an unexpected stimulus activates too much unresolved hurt, and when a therapist submits a client to a too intense emotional experience, which overwhelms the pain processing mechanisms.
Dr. Miller–
I’m so glad I found this blog. From reading this post, I inferred that you’re still a “sucker for stories.” At least I hope that’s the case, because I have one for you. And it’s a doozy. 😉
The minute I read “Barry Marshall,” I thought, “Why did he drop the ‘Dr. and/or M.D.’ from his name?” I knew who he is based on my readings.
“…is there anything we practitioners and the field can learn from more than 150 years of theorizing?” I’d give that rhetorical a resounding “UH yah,” because it’s been my experience that any sort of arrogance on the part of a practitioner of the healing arts leads to, at best, a concurrent pathological dynamic between patient and provider, and at worst, ineffectual outcomes.
Although the onus rests on therapists and medical doctors alike to resist that special brand of hubris when placed on the pedestal of the ultimate “authority figure,” (meaning people come to therapists and doctors alike because they are in pain, and YOU are the gatekeepers holding the keys to unlocking the source[s] of their pain, then mitigating or eradicating it), we can’t ignore the role of the patient.
Being a patient, not a clinician, I feel I can say with some certainty (ha) that the current zeitgeist demands “certainty.” The public demands unrealistic “perfect knowledge” from their professionals, and they want that knowledge to be absolute. This is a logical fallacy that needs to be addressed, but how to address it? Therapists and MDs certainly can’t say, “Look, you need to CtFD, because I’ve no clue if this treatment will work for YOU, personally. I can only tell you that I’ve had good results with other patients.”
How long do you think he or she would be in “practice,” hm? My husband, an attorney, “practices law.” His job is to eliminate as many variables as is within his purview, then reassure his clients he’s done that much, but like with anything systemic, he can’t possibly know the reaction of the judge (or in his case, the Trustee, since he practices consumer BK).
We’re a society with a toxic addiction to comfort, and a pathological aversion to discomfort. Although the human animal’s most basic instinct is survival, we’ve amplified and augmented that instinct with the drive to seek-out pleasure and avoid pain–any pain–at all costs.
Like in cases of DV, the victim can file a restraining order, or an Order of Protection, but the police can do nothing until the perpetrator does SOMETHING, yes? So, for example, medical practitioners can tell someone to change their unhealthy lifestyle habits or they’re headed for a heart attack, but only when the patient ends up in the ER does the doctor finally have the “authority” to come down, hard, on the patient, and tell him/her that they MUST change now, or the next could be the last.
I’ve rejected the CBT/ACT models’ pedestals for years. They, like every other “advance,” are riddled with publication/study/confirmation biases, and unfortunately, psychotherapists are thin-on-the-ground here in Utah. If you’re lucky enough to find one, they’re older than God, and yeah, cynical. Because in the last 30 years, their jobs, hell, YOUR job, has been made almost impossible by the medical arrogance stated above.
How to truly help a patient/client change, grow, overcome, heal, when they are on medications that don’t allow neuroplasticity? How, when their behaviors have been quantified, qualified, optimized to fit in “Check One of the Above” categories of the arbitrary “DSM” clinical dogma? And when human behavior, in all its glorious permutations, has been pathologized across the board? Try and tell someone that maybe, just MAYBE they aren’t anxious, but rather, they feel anxiety. Try it with depression, bipolar. “Oh no, I don’t have mood instability. I AM bipolar.”
It is a part of their identities, and they act, and react, accordingly, which speaks to the dynamic I wrote of earlier, between therapist and client/patient. When seen through a lens of “certainty,” there is never any room to question the very issue that plagues the patient. It’s been decided: “Yes you are, according to my handy-dandy standardize test method. Now, let’s figure out how to cognitively master those pesky issues of ‘impulse control,’ shall we?”
I love what I read somewhere on this site, I believe, when you wrote that you learn how to be a better therapist from your patients. I’d like to posit here that if more healthcare professionals believed that, well…”let the healing begin,” as they say. But more importantly, patients need to take responsibility for their health.
But if they go to the doctor and he tells them, “Look, here are tried and true ways to deal with depression,” and it doesn’t involve a pill? They find the doctor who will give them the brand-new snake oil they see on their nightly television-binge watch. I mean…the people in the commercials…they look so HAPPY! The pill must work, and if they don’t get it from one doc, they’ll go to another.
I don’t discern between the physical and mental health fields because the mind is as much part of our physiology, as our physiology is part of our consciousness and behaviors. The fissure between mental and physical health, to my mind, has been a tragedy, not waiting to happen, but happening, in the here and now, and the fruits it bears are poisoning our collective health.
Bringing back “uncertainty” into our healthcare system would take a huge movement, en masse, of clinicians and physicians, across the gamut, to admit, “WE DON’T KNOW. At least, not everything. But here’s what we’re pretty sure of, so let’s look at our options.”
I don’t see that happening any time soon, however. It’s much too comfortable for doctors and medical/healthcare providers to say, “We Know.” And it’s too uncomfortable for the general public to admit they might know more than they profess. Personal responsibility. It’s been abdicated. And clinicians have, in the past and currently, been all too happy to fill-in the blanks when asked, “What’s wrong with me!”
I’m glad I found you, and my website, above, tells a story. Specifically, who I am, how I got here, and a small part of what I’m about. I believe I have taught more MHP and doctors about my one, tiny sliver of the world of pain that they didn’t know.
My greatest hope is to educate clinicians, like you, like I have Dr. David Healy of RxISK.org and Robert Whitaker, author of “Mad in America,” and founder of the non-profit org. of the same name. I’m seeing a new therapist since the one I had, an old-school psychotherapist/neuropsychologist, is very near retirement, and… I yelled at him. I’m not proud of it, but he kind of asked for it…
Because when I told him my mission, what it is I wanted to accomplish, he scoffed at me, telling me that “no one will listen to you. ESPECIALLY doctors. Trust me, I’ve been trying for 40 years. You’re ‘little film’ isn’t going to help anyone, and it’s not gonna make you ‘famous.'” I sensed his frustration. But it was uncalled for. I don’t seek fame, nor do I wish it on anyone. I seek to only share my story in the hopes it will help others.
What did I scream, when I yelled at him? “Doctors WILL listen to me, because they swore an oath to ‘DO NO HARM!” And I stormed out.
So I’ll be directing my new therapist, a younger guy, to your site. My hope is, he’ll read, and lose some of that “certainty,” I see in his guarded, blue eyes. However, I feel the empathy from him in spades. So I remain hopeful.
For the record? I’ve never, ever screamed, nor yelled, at a therapist. But he allowed his own cynicism to cloud what he heard me say. I neither seek fame, nor do I think I will be dismissed, and since yelling at him, I’ve proved both. I’ve had the restraint not to tell him so, however. I wrote him an apology for screaming and storming, but not for my words. And, I also parted ways, aka relieved him of his therapy duties w/r/t me. 🙂
And while my words were a slight misrepresentation of the Hippocratic Oath, yes, even a reductive version, it’s the spirit of the oath itself to many patients. We put our trust in you because we want you to KNOW.
The problem? You don’t. And that’s okay. But you know more than me, than us. And that’s really what we’re counting on, when all is said and done.
I hope you read my story. I’d very much like to talk with you about the work you’re doing. It’s exciting and gives me so much heart and hope.
Thank you for your time, for sharing what you do, and it’s very nice to “meet” you. You and my husband graduated from the U the same year, BYU…well, you graduated a little earlier. It’s a passion of mine, studying human behavior. I’m a student of it. And… I’m told I tell great stories. But I always remind people:
“Fiction is the lie through which we tell the truth.” ~A. Camus.
Best–
J.A. Carter-Winward