Synthesis behaviour therapies: an evidence base without a premise

Claire Baxter May 2023

About

Dialectics, since before the time of Socrates1 refers to a method of enquiry between two people of opposing points of view. It ends with either a synthesis of the two ideas, or a refutation of a proposition which is consequently exposed as false. The dialectic method is distinguished from the didactic method, where one side teaches the other.

In his 2023 seminar on negativity, Psychologist and Psychoanalyst, David Ferraro, posed the rhetorical question, 'What is dialectical about dialectical behaviour therapy?'

My rhetorical answer is that Marsha Linehan, psychologist and founder of dialectical behaviour therapy, known as DBT, liked the idea of 'synthesis.' She describes her reasoning below:

'The overarching dialectical worldview... emphasises the synthesis of opposites... The term dialectical is also meant to convey both the multiple tensions that co-occur in therapy with suicidal clients … as well as the emphasis in DBT of enhancing dialectical thinking patterns to replace rigid dichotomous thinking. The fundamental dialectic in DBT is between validation and acceptance of the client as they are within the context of simultaneously helping them change.' (Linehan, Dimeff, 2001)

As I read further, I began to think that DBT, which arose out of 'failed attempts to apply the standard cognitive and behavioural therapies of the late 70's' (Linehan, Dimeff, 2001) was a 'synthesis' on the part of, not the clients, but the therapist, who came to a 'radical acceptance of clients' current capabilities and behavioural functioning.' Like David, I could not see what was dialectical about this.2 In fact, DBT could perhaps be thought of as dialectical reasoning in reverse: it began with an antithesis around clients needing to ‘change’, and proceeded to a thesis of 'radical acceptance of the client'. The apparent ‘synthesis’ of ‘change’ and ‘radical acceptance’ possibly reflect a development in Linehan’s understanding of her own work as a psychologist, however, it is hard to see how the patient and therapist are involved in a dialectical process if the outcome is predetermined. Being ‘taught’ what to accept and what to change is a process more akin to didactics than it is to dialectics.

Linehan, like all psychologists, is a product of her times and training, and the theoretical vagaries of her therapy point not to any shortcoming on her behalf - indeed, she has done everything right, and DBT is now an ‘evidence-based treatment’ (DeCou, Comtois, Landes, 2019). The requirement for ‘evidence-base’ however, perhaps reflects the ‘criteria’ for an approach to psychological therapy that is shortsighted. Something may be ‘evidenced-based’, but according to what framework?

The thesis I want to propose is not that DBT is wrong in the outcomes it achieves - I have respect for a therapy that arose from attempts to keep suicidal patients alive, and respect for the depth and breadth of Marsha Linehan’s research and application.3 My thesis is that psychology generally has no theory to understand what, when psychological methods like DBT do work, is actually working and why.

Psychologists face pressure to deliver ‘evidence-based’ psychological treatment. If someone commences therapy, everyone - especially the people funding it - wants to know that it will ‘work’. Ironically, the evidence consistently shows that the type of therapy matters far less to patient outcomes than the relationship between the patient and the therapist (Flückiger, Del Re, Wampold et al., 2018; Norcross & Lambert, 2018; Karver, De Nadai, Monahan et al., 2018). It boils down to the relationship between two people, rather than the cognitive or behavioural skill taught. Yet, psychology has no theory of relationships, and why people heal within relationships: psychology doesn’t understand what it is about psychology that actually works.

The irony is that there has been a comprehensive theory about the relationship between therapist and patient - and how and why healing can occur within such a relationship - since the early twentieth century. Psychoanalyst, Sigmund Freud, coined the term ‘transference’ to describe the phenomena that he observed happening in his work with patients. He observed that his patients behaved towards him as if he were someone else. Freud theorised that a revival of the patients’ earlier fantasies were playing out onto the analyst (Freud, 1912). Freud’s concept of transference requires a theory of the unconscious mind.

Transference is not a case of confusion at the level of the consciousness: Freud’s patients were not idiots, and they were well aware that Sigmund Freud was their treating doctor, not their father or their mother. The confusion occurs at the level of the unconscious, and the transferential relationship that emerges occurs at both the conscious and the unconscious level of the patient. In fact, transference occurs in many relationships, not just therapeutic ones. What is unique to psychoanalysis is that the psychoanalyst works within the transference and with a theoretical understanding that enables them to enquire into what may be happening for the patient at a level other than the patient’s consciousness.

The theory gained so much attention that Freud received several nominations for a Nobel prize; an achievement that is arguably more significant (no pun intended) than gaining the ‘evidence-based’ status on a treatment package. And yet by some huge hiccup in the history of science, this Nobel prize contending theory was shunned by psychology. Why?

Because of a corruption of the word ‘evidence’, and because of a fear of implications of the theory of the unconscious. Both this misunderstanding of ‘evidence’, and the fear that the ‘ego is not the master of his house’ (Freud, 1917)4 are pertinent to the state of psychology today.

Most of the people I have met who suffered from suicidal thoughts haven’t gone wrong at the level of reasoning. As a freshly graduated psychologist with limited practical experience and no comprehensive theory to draw on, I worked for a brief time with a young adult who presented with depression, ennui, suicidal thoughts and formidable intelligence. Every session I was drawn into a harrowing debate where they argued for their right to kill themselves. I attempted to argue that life was a better choice than death, however their argument was more sophisticated than mine - they’d spent far more time thinking about life and death than I had. Their desire to die was not a failure of their ability to reason. While there might have been evidence of so-called ‘distorted thinking’, the ‘distortion’ clearly wasn’t caused at the level of their conscious mind.

In fact, a knowledge of reason entails an acknowledgement of the existence of something before the reasoning process. The outcome that the process of reasoning might reach depends on the premises, or the set of assumptions taken by the reasoning agent to be true. Without assuming some kind value for one’s own life, then there is no way of guaranteeing that a reasoned argument is going to arrive at the conclusion that life is worth living. The premise for an argument must come from somewhere. Looking back on the case now, my highly intelligent patient’s inability to value life possibly came from something that had occurred for them at the level of the drive. Their drive was towards Thanatos, or death, a theory which Freud expands in his famous work, Beyond the Pleasure Principle (Freud, 1920b).

The intelligent, young adult did not kill themselves during their work with me. They took an abrupt about turn, and discovered or rediscovered an area of interest, and commenced study with a view to employment in a related area. Whatever changed for the young adult, it probably had little to do with the treatment, which was inconsistent at best. It certainly had nothing to do with cognitive skills, distress tolerance or mindfulness: I was never able to ‘teach’ these things without the patient turning the session into an eristic proof of their right to die. What I know about the treatment is two things: i) that I lost every debate and ii) that despite my anxiety, I had a strong desire to see them come back to the next session. If only I had a psychoanalytic understanding to draw upon back then, I might have been a better therapist. Psychoanalysis seeks not to engage in the didactics of teaching cognitive or behavioural skills because such an approach seeks to engage the client at the level of consciousness thought, which is to overlook what is happening at the level of the unconscious.

Jacques Lacan conceived of psychoanalysis as a process of dialectics (Lacan, 2007) that reveals the truth beneath the patient’s own knowledge of themselves. This kind of dialectics is not the kind of intellectual death-role that I was drawn into with my young patient, but rather, a means in which the analyst listens to the words of the patient, rather than the narrative. Analysing Freud’s case study of Dora, Lacan argues that Freud’s treatment of Dora can be understood as a series of dialectical reversals.5 The method involves a scansion of language structures in which truth is transmuted for the patient: structures that affect not only their comprehension of things, but their very position as a subject (Lacan, 2007). With respect to my young patient, a more useful approach might have entailed shaping the question not towards their right to die, which simply saw them re-enact their symptom without gaining any clarity into what was happening for them, but towards an understanding of their dual need to defeat both me - manifest in their need for relentless triumph over me - and also themselves - manifest in their demand for their own demise. If only we might have found some way of understanding what was happening at the level of the unconscious. Freud theorized that the inclination towards suicide is a manifestation of the patient’s wish to punish someone diverted into hostility towards the self (Freud, 1920). It is possible that something of this order was occurring in my intelligent patient, but I didn’t have the theoretical background back then to ponder the pertinent question, that being, who was I in the patient’s transference? Alas, we will never know.

Lacanian dialectics rejects the idea of a synthesis, which would result in a position of absolute knowledge, because, Lacan argues, the presence of the unconscious makes absolute knowledge an impossibility. The Lacanian theory of dialectics in psychoanalysis is one of uncovering truth rather than reaching a compromise between two positions of knowledge. The process of analysis means that the truth of the symptom becomes apparent via the process of speaking: the patient begins to understand the logic of their own suffering.

In 1909, when little Hans presented with a phobia of horses, Freud saw that the phobia was a displaced fear (Freud, 1926). The phobia was a construction that Little Hans came up with to deal with his fear of his father’s (symbolic) castration. This fear brought about two repressions: an aggressiveness towards the father, which became an aggressiveness from the father, and his over-fondness for his mother (Freud, 1926). The idea of being bitten by a horse was, according to Freud, a substitute, via distortion, of the symbolic castrating role of the father. Under Freud, the therapeutic intervention addressed the displacement itself. Having found a means of naming what it was that was occurring, Little Hans no longer needed to displace his unspoken fear onto horses.

The case study stands in stark contrast to approaches like exposure therapy or cognitive reality testing, where the aim is to eliminate the symptom. The elimination of a symptom without addressing the underlying cause risks the patient developing another symptom in place of the one just abolished. Freud understood that there is always a reason for the development of a symptom, and, for this reason, a symptom must be treated with the respect of enquiry rather than an attempt at erasure. The incredulous thing is not that exposure therapy and cognitive therapies are taught, but that Freud and the theory of the unconscious are not. Generations psychology graduates from Australian universities have never read Freud. Luckily, for the psychologists who become aware of their lack, psychoanalytic schools welcome the curious.

The theory of the unconscious has long attracted criticism: people do not like the idea that there are processes occurring in their own minds of which are not conscious. It’s a humbling idea to think that while you may not be in control of all that you do and think, since Freud, you are, however, responsible for your symptoms, for if not you, then who? The departure is from Freud6 is also partly due to a desperate obsession with 'evidence-based’ treatment. In 1934, philosopher of science, Karl Popper published The Logic of Scientific Discovery7 in which he argued that it was no good to move from observation to theory: a hypothesis must be proven to not be wrong. Popper championed the deductive theory of falsifiability, and it became the standard of evaluation of scientific theories and hypotheses. Popper's falsifiability has led to a peculiar interpretation of ‘evidence’ that has led Psychology too far down the wrong path. Falsifiability means that a true generalisation must apply with unlimited precision to an unlimited domain. Physicist, David Harriman, argues that such a position commits the fallacy of dropping context and is ultimately unsustainable for scientific enquiry generally. ‘The meaning of our generalisations is determined by the context that gives rise to them; to claim that a generalisation is true is to claim that it applies within a specific context. The data subsumed by that context are necessarily limited in both range and precision 8’ (Harriman, 1979, p189). Falsifiability seems to have replaced any other consideration of what may constitute ‘evidence’ in psychology.

An alternative method of gaining scientific knowledge is the inductive method: observe phenomena and then create a theory to explain what you observe. Freud worked in such a manner. He had some noteworthy companions, such as Issac Newton, whose laws of physics ‘have not been contradicted by any discoveries made since the publication of the Principia’ (Harriman, 1979, p145). The emphasis on falsifiability and reproducibility means that case studies like Little Hans rank poorly on the hierarchy of evidence 9 in favour of experiments with large sample sizes, control groups and reproducible results. By this standard, Freud’s case study has low credibility: you can’t reproduce the study to find a universal relationship between little boys and their fear of horses.

Psychology has ventured too far down the wrong pathway: it cannot see the person for the population. In the hype about falsifiability and hypothesis testing, one thing must be remembered, and that is that inferences about the nature of individuals cannot be deduced from inferences about the group to which those individuals belong. This is known as the ecological fallacy (King, 1997)10. As a psychologist, I don’t treat groups: I work with individuals.

Psychoanalyst, Leonardo Rodriguez recasts the problem of evidence as residing squarely within the individual.

'What is evident is only evident for someone: for a subject of evidence…the evidence accumulated in one hundred and twenty years of psychoanalysis will not be sufficient as a response to the human being who asks the question: ‘Is psychoanalysis going to work for me?’ His psychoanalysis will produce the evidence, and no guarantee can be given beforehand as to how it is going to work for him, if it does. Nobody has found a formula to guarantee that a

particular psychoanalysis is going to be efficacious. Our ethics separates us from the clinician whose practice is supposedly based on evidence and who thinks that he knows what the result of the experience will be.’ (Rodríguez, 2014)

As an undergraduate psychology student I was utterly amazed to learn that the question ‘can you teach a little boy to fear a white rabbit?’ was a legitimate behavioural investigation in the 1920’s. Little Albert was involved in an experiment pairing a non-fearful stimulus (a white rabbit) with a fearful stimulus (loud noises and maternal panic). The experimenters, John Watson and Rosalie Rayner, acted, watched, and made notes as little Albert exhibited a fear response whenever he saw a white rabbit (Watson, 1920). Little Albert was undoubtably worse off with his encounter with behavioural interventions than little Hans was with his encounter with psychoanalysis.

The ethical position of psychology has improved since the perverse experiments of yesterday, and we now see experiments that have passed rigorous ethical standards. We see experiments investigating the relationship between risk taking, sex and age in Sprague- Dawley rats trained to make nose-pokes in exchange for food pellets (Westbrook, Hankosky, Dwyer, et al 2018). Findings show that both adolescent and adult rats choose the button that releases large food pellets less often as the probability of reward decreases. Such statistically-backed ‘knowledge’, has not yet proven to be as clinically useful to me as case studies such as little Hans. It’s not that the answers provided by the ‘rats and stats’ approach are wrong. It’s just that humans - when their fundamental human rights aren’t being violated - won’t stay in a cage and spend their time pushing buttons to get pellets of food. It's not that the behavioralists' experiments aren’t ‘true’, it's just that they are limited.

Psychology, despite its claim to study how people think, feel and behave, and never managed to come up with a theory of the human psyche with which to interpret the plethora of statistical inferences they keep trying to make, The thesis that I want to make is that what we have in psychology is the synthesis of experiments based on mistaken need for universals, falsifiability and reproducibility. In psychology there is a lack of theory. Psychology simply does not have a useful way to contemplate humans.

Psychoanalysis has an integrated theory that understands the nature of relationships, and it offers a theoretical framework to understand how the relational experience might uniquely influence the development of an individual psyche, as well as the ethical position of the psychoanalyst.

To restate my thesis, when DBT ‘works,’ it is less to do with a synthesis of cognitive skills, and more to do with the relationship that the patient forms with their therapist. My rhetorical exploration of what is lacking in psychology further advances my thesis so that it becomes, not a criticism of DBT, which I respect as a therapy that arose from attempts to keep suicidal patients on the side of life, but a criticism of psychology’s departure from Freud. No doubt I have made problematic statements in my argument. I would welcome an antithesis in the hope that what I write here might open up a dialectical discussion.

Claire Baxter May 2023

Footnotes

1. According to Plato, (Plato, Parmenides) Zeno the philosopher refined dialectics as a process of thesis, antithesis and synthesis. See also ‘dialektike’ in the Ancient Greek Lexicon by Liddell, Scott, Jones.

2 I have never practiced DBT, nor received DBT, so there is much of what I write about DBT which could - and should - be read critically.

3 To see YouTube footage of Marsha Linehan speaking about DBT, see Ratner, Rebbei, Borderliner Notes.

4 Freud’s remark is reminiscent of Seneca's ten tragedies. Seneca makes a comparison between an emperor commanding an empire and the ego commanding the self. Seneca, in turn, possibly draws upon Aeschyus’ Oresteia trilogy.

5 Lacan reviews Freud’s case of Dora and conceives of it as a series of dialectical reversals (Lacan, Ecrits) Dora described complex dynamics between her own family and a neighboring family which sanctioned her father’s illicit love affair with Frau K. The dialectical relationship between Dora and Freud revealed a layer of truth below the narrative.

In the first dialectical reversal, Freud notes that Dora is the object of an odious exchange.," and asks her about her own involvement. In the second dialectical reversal, Freud notes Dora’s jealousy of Frau K actually masks an extreme interest in what Frau K means for her father, albeit in inverted form. The third dialectical reversal reveals that Dora’s fascination with Frau K has to do with what Frau K represents: the mystery of Dora’s own femininity’, thus answering more fully the first dialectical reversal: Dora involvement is due to an interest in the mystery of her own femininity, hence her complicity in the affair.

The truth of Dora’s suffering was not known to her at the start of the treatment, but it emerged from her articulations as a result of the dialectical process. That Dora rejected Freud’s interpretation and discontinued the treatment points to the patient’s lack of desire to know (Dora was commanded into treatment by her family, not by her own desire). For the dialectical process to be of benefit the patient must first perceive a problem.

References

DeCou C.R., Comtois K.A., Landes S.J. (2019) Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior: A Meta-Analysis. Behav Ther. Jan;50(1):60-72.

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4)

Freud, Sigmund (1912). The Dynamics of Transference. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud . (Vol 7) London: Hogarth Press, c. (1958)

Freud, S. The Psychogenesis of a Case of Homosexuality in a Woman. 1920. The Standard Edition of the Complete Psychological Works of Sigmund Freud. Ed. James Strachey, Anna Freud, Alix Strachey, Alan Tyson, Angela Richards. Trans. James Strachey et. al. Vol. 17.

London: Hogarth Press, c. 1953-1974

Freud, Sigmund. Beyond the Pleasure Principle. 1920b. In J. Strachey, A. Freud, A. Strachey,

A. Tyson, A. Richards (Ed. & Trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol. 18. London: Hogarth Press, c. 1953-1974.

Freud, S (1926.) “Inhibitions, Symptoms and Anxiety.” In J. Strachey, A. Freud, A. Strachey,

A. Tyson, A. Richards (Ed. & Trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol. 20. London: Hogarth Press, c. 1953-1974.

Freud, S.. “Fragment of an Analysis of a Case of Hysteria.” 1905 (1901).In J. Strachey, A. Freud, A. Strachey, A. Tyson, A. Richards (Ed. & Trans.) The Standard Edition of the

Complete Psychological Works of Sigmund Freud. Vol. 7. London: Hogarth Press. c. (1958)

Freud, S. (1925) Negation. The Standard Edition of the Complete Psychological Works of Sigmund Freud In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol 19). London: Hogarth Press.

Greenhalgh T. How to read a paper. Getting your bearings (deciding what the paper is about). BMJ. 1997 Jul 26;315(7102):243-6.

Harriman, D. (2010) The Logical Leap Induction in Physics, New American Library, New York

Karver, M. S., De Nadai, A. S., Monahan, M., & Shirk, S. R. (2018). Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy, 55(4).

King, G. (1997). A Solution to the Ecological Inference Problem. Princeton University Press. ISBN 978-0-691-01240-7.

Lacan, Jacques, Écrits: The First Complete Edition in English (Bruce Fink Trans.) 2007, New York, NY.

Liddell, Scott, Jones, dialectike, Ancient Greek Lexicon (LSJ) https://archive.org/details/Lsj--LiddellScott

Linehan, M. M.; Dimeff, L. (2001). "Dialectical Behavior Therapy in a nutshell" (PDF). The California Psychologist. 34: 10-13. https://www.researchgate.net/publication/ 239279018_Dialectical_Behavior_Therapy_in_a_Nutshell

Mental Health Treatment (2022, July, 4) Historical: Child Psychology, Psychiatry, Pediatric Illness [Video] YouTube

https://www.youtube.com/playlist?list=PLfZFeqnCUQDrKCI81GmGlfUB33cX9j_51 News Dog Virals, (2017, Sept 5) The Little Albert Experiment [Video] YouTube,

https://www.youtube.com/watch?v=5duLMjaTL0U

Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III.

Psychotherapy, 55(4)

Plato, Parmenides. (Benjamin Jowett, Trans.)

Project Gutenberg, January 16, 2013 https://www.gutenberg.org/cache/epub/1687/pg1687- images.html

Popper, K.R., Objective Knowledge, revised edition (Oxford: Clarendon Press, 1979) Internet Archive, 17 April 2020 https://archive.org/details/The_Logic_Of_Scientific_Discovery_Karl_Popper.pdf

Ratner, Rebbie, Borderliner Notes, (2017, Apr 14), Marsha Linehan - How She Came to Develop Dialectical Behavior Therapy (DBT) [Video] YouTube. https://www.youtube.com/ watch?v=bULL3sSc_-I&list=PL_L7KEOxOeQ_gwUQX8ExtaIt3jSm8XYbK&index=12

Rodríguez, Leonardo S. A response based on evidence , 2014, Analysis, Analysis (Australian Centre for Psychoanalysis) (Vol. 19)

Wardle, T (2018) Three Identical Strangers [Film] IMDbPro

Watson, J.B.; Rayner, R. (1920). "Conditioned emotional reactions". Journal of Experimental Psychology. 3 (1)

Westbrook, S. R., Hankosky, E. R., Dwyer, M. R., & Gulley, J. M. (2018). Age and sex differences in behavioral flexibility, sensitivity to reward value, and risky decision- making. Behavioral Neuroscience, 132(2), 75–87. http://dx.doi.org/10.1037/bne0000235

Synthesis behaviour therapies: an evidence base without a premise

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