Verified by 
Environment
Where Psychotherapy Goes Wrong
Today's therapists have a myopic focus on what goes on inside a patient's head.
Posted November 21, 2017
In my last post, I discussed something called the fundamental attribution error. As described by Richard Nisbett and Lee Ross, this is defined as “the assumption that behavior is caused primarily by the enduring and consistent disposition of the actor, as opposed to the particular characteristics of the situation to which the actor responds.” That post discussed how this error results frequently in mistaken conclusions that are drawn from studies of people with personality disorders.
It is also the main reason why psychotherapy has not really progressed much as a science in the last 25 years or so. The 1980s and early 1990s were a period of amazing creativity in the field, during which new ways of looking at human behavior and new interventions to help change that behavior seemed to be coming out every day. In particular, family systems thinkers began to realize that the causes of behavioral problems like self-destructiveness, as well as the causes of symptoms like chronic dysphoria and anxiety, do not reside entirely within the heads of the people coming for help.
Some of it can be a normal and adaptive response to a very abnormal interpersonal environment. The "attachment" literature, which is fairly strong, shows that kin behavior has a huge effect on the psychological stability and the relationships of all human beings. Much more so, I always say, than the food pellets and electric shocks favored by behaviorists.
Family systems ideas have, unfortunately, been left behind to a significant degree, and therapists are back to looking at people as if their problems were "all in their heads." This turn of events has been spearheaded by a combination of factors that have led to the predominance of a “disease” model for all psychological problems: greedy pharmaceutical and managed care insurance companies, naïve and corrupt experts, twisted science, and desperate parents who want to believe that their children have a brain disease to avoid guilt.
Critics of family systems ideas focused disingenuously on areas about which family systems theorists were completely wrong - such as the genesis of such real brain diseases as schizophrenia (and yes, the evidence that schizophrenia is truly a brain disease is overwhelming, so spare me the "myth of mental illness" nonsense). They pulled the usual slick ploy of making arguments based on black and white thinking: if family systems theorists were wrong about some things, then they must have been wrong about everything.
Because the effectiveness of psychotherapy interventions meant to change interpersonal behavior are hard to prove in a treatment outcome study, the systems people were also accused of being unscientific. As if observation were not the first step in the scientific method! (So much for much of what we know about astronomy). "Outcome studies" were touted as definitive proof of various treatment methods, despite the fact that they are extremely limited in their overall validity because there is an almost infinite number of variables that cannot be controlled. And they cannot be double-blinded. And the therapists who are participating are not all doing exactly the same thing.
And the studies that are touted show only exceedingly modest effects in those subjects who do improve, as well as showing that a significant percentage of subjects did not get better at all.
There is also this rather big issue of what is really going on with patients, as opposed to what looks like is going on. If you do not think people have hidden ulterior motives for their behavior, secrets about themselves that they don't want to share, and lack a complete understanding of the behavior of all of those around them who affect their lives, then I am afraid you are living in an alternate universe.
But still, therapists observe their client's performance, and confuse it with their abilities, as described in a previous post. Even when therapists look at what is basically interpersonal behavior, they make this error. Therapists often label behavior and thinking as “maladaptive.” Surely, they are maladaptive in some respects, but that they serve no adaptive purpose at all is just assumed.
They also just assume that patients, particularly those with personality disorders, have mental models of their environment and other people that are distorted. This is based entirely on the way the patients respond to the others, while completely ignoring the motives and intentions on which that behavior is based. Maybe the patient wants other people to think they have distorted mental models. Why? With borderline personality disorder, it is because they are playing the role of spoiler. The therapists' incorrect assessment of the accuracy of their patient's mental models is created by the feigned actions of that patient.
Sorry, but we cannot read minds. You have to look at both the behavior and the history of patients and everyone involved with them over extended periods of time, and even then you can still get a highly distorted picture. So therapists should quit accusing their patients of what they themselves are doing: distorting. Of course, it is true that a therapist can never be absolutely certain of anything. For that, you would not only need a movie camera with sound on all participants 24 hours a day like in The Truman Show, but this equipment would have to be in place throughout the entire lifetime of the patient since birth!
Still, the more information therapists can gather on the whole picture, the more likely it will be that they will better understand what might be going on and figure out what can be done to change it.
But first, they have to stop their myopic focus on that which is going on entirely in a patient's head.
