Mistakes Were Made - Carol Tavris [51]
Moreover, by its very nature, psychotherapy is a private transaction between the therapist and the client. No one is looking over the therapist’s shoulder in the intimacy of the consulting room, eager to pounce if he or she does something wrong. Yet the inherent privacy of the transaction means that therapists who lack training in science and skepticism have no internal corrections to the self-protecting cognitive biases that afflict us all. What these therapists see confirms what they believe, and what they believe shapes what they see. It’s a closed loop. Did my client improve? Excellent; what I did was effective. Did my client remain unchanged or get worse? That’s unfortunate, but she is resistant to therapy and deeply troubled; besides, sometimes the client has to get worse before she can get better. Do I believe that repressed rage causes sexual difficulties? My client’s erection problem must reflect his repressed rage at his mother or his wife. Do I believe that sexual abuse causes eating disorders? My client’s bulimia must mean she was molested as a child.
We want to be clear that most therapists are effective, and that some clients are resistant to therapy and are deeply troubled. This chapter is not an indictment of therapy, any more than writing about the mistakes of memory means that all memory is unreliable or that writing about the conflicts of interest among scientists means that all scientists do tainted research. Our intention is to examine the kinds of mistakes that can result from the closed loop of clinical practice, and show how self-justification perpetuates them.
For anyone in private practice, skepticism and science are ways out of the closed loop. Skepticism, for example, teaches therapists to be cautious about taking what their clients tell them at face value. If a woman says her mother put spiders in her vagina when she was three, the skeptical therapist can be empathic without believing that this event literally happened. If a child says his teachers took him flying in a plane full of clowns and frogs, the skeptical therapist might be charmed by the story without believing that teachers actually chartered a private jet (on their salary, no less). Scientific research provides therapists with ways of improving their clinical practice and of avoiding mistakes. If you are going to use hypnosis, for example, you had better know that while hypnosis can help clients learn to relax, manage pain, and quit smoking, you should never use it to help your client retrieve memories, because your willing, vulnerable client will often make up a memory that is unreliable. 8
Yet today there are many thousands of psychiatrists, social workers, counselors, and psychotherapists who go into private practice with neither skepticism nor evidence to guide them. Paul Meehl, who achieved great distinction as both a clinician and a scientific researcher, once observed that when he was a student, the common factor in the training of all psychologists was “the general scientific commitment not to be fooled and not to fool anyone else. Some things have happened in the world of clinical practice that worry me in this respect. That skepsis, that passion not to be fooled and not to fool anyone else, does not seem to be as fundamental a part of all psychologists’ mental equipment as it was a half century ago…. I have heard of some psychological testimony in courtrooms locally in which this critical mentality appears to be largely absent.”9
An example of the problem Meehl feared can be seen in the deposition of a prominent psychiatrist, Bessel van der Kolk, who has testified frequently on behalf of plaintiffs in repressed-memory cases. Van der Kolk explained that as a psychiatrist, he had had medical training and a psychiatric residency, but had never taken a course in experimental psychology.
Q: Are you aware of any research on the reliability or the validity of clinical judgment or clinical