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Anger and Forgiveness"Are You There Alone?"10 Good Questions about Life and DeathA Casebook of Ethical Challenges in NeuropsychologyA Companion to BioethicsA Companion to BioethicsA Companion to GenethicsA Companion to GenethicsA Companion to Muslim EthicsA Cooperative SpeciesA Critique of the Moral Defense of VegetarianismA Delicate BalanceA Life for a LifeA Life-Centered Approach to BioethicsA Matter of SecurityA Natural History of Human MoralityA Philosophical DiseaseA Practical Guide to Clinical Ethics ConsultingA Question of TrustA Sentimentalist Theory of the MindA Short Stay in SwitzerlandA Very Bad WizardA World Without ValuesAction and ResponsibilityAction Theory, Rationality and CompulsionActs of ConscienceAddiction and ResponsibilityAddiction NeuroethicsAdvance Directives in Mental HealthAfter HarmAftermathAgainst AutonomyAgainst BioethicsAgainst HealthAgainst Moral ResponsibilityAgency and AnswerabilityAgency and ResponsibilityAgency, Freedom, and Moral ResponsibilityAging, 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MatterWhy I Burned My Book and Other Essays on DisabilityWhy Not Kill Them All?Why Punish? How Much?Why Some Things Should Not Be for SaleWisdom, Intuition and EthicsWithout ConscienceWomen and Borderline Personality DisorderWomen and MadnessWondergenesWould You Kill the Fat Man?Wrestling with Behavioral GeneticsWriting About PatientsYou Must Be DreamingYour Genetic DestinyYour Inner FishYouth Offending and Youth Justice Yuck!
Bringing psychology into the realm of science, out of the realm of
softer, philosophical origins has not been easy. Double blind, intention to treat, random assignment, all the
other trappings of scientific inquiry are difficult entities in
psychology. Many of those in practice
today were trained with a knowledge base that was not subject to scientific
inquiry, and often drew on theories that were little more than elegant
metaphors, rather than models, paradigms, or heaven forbid, actually
epistemologies or ontological in any real, testable way. Nevertheless, they were heuristically useful,
and colored our vision of the patient's complaints.
A major feature of the early training, although un-testable in a
laboratory, was the need to engage in the body contact sport of therapy. The metaphor explained the psychology; the
therapy flowed from that, with transference and counter-transference examined
against the theory of how both collided: therapist and 'patient', theory and
fact, psychology and therapy. Diagnosis, literally 'through knowledge' was work
done by engagement at the metaphysical bedside, the 'klinikos' of Greek origin.
Depending on the theory, mechanisms of pathology derived from some great guru's
mind were looked for, and interventions were creative and Milton Erikson or
Not all were happy: early feminists immediately targeted the lack of
universality of the theoretical claims, and even the seemingly more forgiving
theories such as the family therapy movement provided came under attack.
More recently, and in competition for funding across the world, the need
to justify what one though and did, even in apparently scientific arenas such
as psychometric assessment, became pressing.
In his presidential plenary as newly elected leader of the APA, Joseph
Matarazzo was forced to acknowledge that the gap between Binet and the courtroom
had to be closed by psychologists justifying what they did.
Into this arena came the imperative for evidence based practice. CBT for instance was capable of
demonstrating efficacy and outcome, and so one had to apply it in various
diagnostic sets in order to be funded, or answer in court when
bang-for-the-buck was in question.
Psychology could thus now parade itself as a science, and many
organizations such as the occupational therapists' professional bodies, and
ASSBI in Australia set up websites containing the details of bits of research
that scored highly on criteria such as random assignment and intention to
All has not sat well though for those of us who entered the profession
as a creative enterprise where there must be moments of agonizing closeness,
pathos, tragedy, ecstasy, resolve, where the heavens open and magic happens:
how dry, how droll, to face sadness and despair as depression, to reframe
shellshock as PTSD, grief as adjustment, existential crises as mixed anxiety
depression. Engagement with the full
panoply of human misery became an enterprise of nosological categorizing.
Miller, emerging from Vermont with his PhD and St Andrews in Scotland's
department of Moral Philosophy, has served as associate editor for the APA's
encyclopedia of psychology with responsibility for the coverage of the
historical and philosophical side to the book. Now he enters the arena above
with the sense that the scientific approach to psychology, while welcomed for
many reasons, has drifted from the purpose of psychology, which he argues is
embedded in the balanced, moral engagement with suffering and humanity that
constitutes clinical psychology, rather than academic psychology.
The training in psychology thus provides two somewhat opposing positions. On the one hand, psychology can provide
helpful approaches to furthering people's ability to cope with the fabric of
daily life, in all its complexity, a familiar field for the novice, but on the
other hand there is a most unfamiliar body of scientific evidence and
knowledge, and despite being strange, is promised to provide the most powerful
and useful tools to accomplish the mission stated above in proposition one.
Miller will argue that the two positions are not complementary, but in
direct opposition to one another, and that the second may deny the meaning and
impact of the first. This dawning
realization that all our intuitive, life-based skills are to be set aside for
the promised land of powerful and validated approaches is at first promising,
but later on comes to reveal itself as a kind of "bait and switch"
shell game, introducing the straw men of revised epistemology. In this way, the sturm und drang of life's iniquities are reframed as nosological
entities in a data handbook, a form of mercantile capitalism if I read Miller's
intro correctly, a hijacking of humanity in the name of robust but questionable
heuristic bias. Miller refers to the
reframe of problem redefinition as a subtle flim-flam game that dispatches the
novice psychologist's life philosophies as mere pop-psychology.
The 'truth' offered is that it is necessary to undergo scientific
training in order to be an effective therapist. This truth however is that this necessity is created by academic
psychologists committed to the scientific paradigm, but not really a truth
created by the demands of the logic of clinical knowledge. As we know, lay therapists and poorly
trained social workers or GP's often make very useful therapists, without much
science in their approach, and life-crises and counseling phone lines are
staffed by little more than professional reflectors, with significant gains to
the public apparently.
The relationship between the paradigms of clinicians and academics is
thus a conflicted one, more ambivalent than helpful or motivated. While the chairs of any university are
grateful for the numbers of bushy-tailed students that dominate first year
psychology courses, and of course nearly all are hired on the basis of
publications and their capacity to raise funding for research, they appear to
be not too keen to deliver on the promise of psychology, putting forward well
grounded theories on how problems should or could be approached, but light in
actual delivery of stuff that is heuristically useful. Clinicians and academics thus remain
philosophically dissociated, and the sense of moral engagement has been lost,
subverted by the heuristic bias of the academics towards evidence rather than
Internal validity would always dominate external validity, leaving
students without any valuable ideas on how what they were learning would help
deal with the day to day existential complaints of the sufferer, or how one
could engage in their suffering in a meaningful way or with meaningful
outcomes. Miller writes:
By promoting a scientific approach to problems that are practical,
contextual, highly complex and multidimensional (social, psychological, moral,
political, historical, spiritual, biological, cultural, economic etc)
psychology has done incalculable harm by promoting pseudoscientific solutions
to complex human problems. Students
leave psychology further mystified and further away from understanding
themselves better ... even worse ... leaving prematurely, taking their interest
in practical psychological problems to other departments (page 13).
Academic psychology is thus failing the profession in its core job of
confronting clinical reality. Miller
argues throughout the book that there is a moral dimension to this clinical
reality. Even pragmatist William James
understood the difference between general laws of behavior and practical
application. Miller has clearly also
been influenced by Martha Nussbaum and others in the realm of suffering and the
moral imperatives which become, hopefully, surely (?) clear when we engage with
those who seek our help: there is a historical and philosophical base which is
lost when the endeavour becomes clearly science rather than humanistic based.
He is not alone here, as others such as the Self-Determination Theorists
Theory in the Clinic: Motivating Physical and Mental Health by Kennon M
Sheldon, Geoffrey Williams and Thomas Joiner for details of this) have now sought to combine humanism
and science in the practice of medicine, all arguing for a more human, feeling,
caring and morally engaged approach.
For in philosophy, the
central assertion is of ethics, an approach common to Martin Buber's philosophy
of dialogue and community, although he waits 35 and 108 pages to get to him, so
densely is this book peppered with theorists, many of whom have been
resurrected lately into the mainstream, theorists dear to the creative and
morally engaged clinician.
The last 60 pages of the
discussion are devoted to references and cross references, but at page 243
begins the recommendation section on education and training, evoking and
provoking the community of trainers and clinicians to respond to the demands of
morality and ethics which he argues are central to a humanistic engagement
process. This of course will involve self-engagement, a self-evaluation of
values and systems. He goes into
examinations of family and humanistic theories in the early second hundred
pages, so this is not a long book, with protracted arguments.
He will argue throughout
that it is imperative that we acknowledge that moral and ethical values are not
just another set of attitudes and beliefs that can be paradigmed or modeled
through the scientific method dissected, number-crunched, or teased apart. This
does not tell us what our values should be, what constitutes a moral approach
to engagement with suffering. This is the stuff, the arena, in which we live
and die, and in which patient complaints are best evaluated, from a moral
platform that can collapse into ontology rather than a scientific
epistemological series of events, a far more disengaged process. The nosology of modern diagnosis is a
vocabulary of moral disengagement, and the vocabulary of suffering, compassion,
choice and purpose is critically eliminated in this way, reducing any chance of
moral engagement. Society already does
this; breakdowns of family and community already do this, so treatment should
provide news of difference, of change, in counterpoint to the academic
approach. Clinicians, Miller argues, have the potential to act as a moral
refuge, a bulwark of efficiency against the need for scientific efficacy that
serves more its scientific masters than its therapeutic clients.
It is thus an important book
that as it size indicates does not overstate or belabor its case. It will call for us to examine the beauty of
the case study, the elegance of learning from watching and being watched, of
seeing what other and wiser, not smarter, guru's can accomplish in wielding the
skill and art of the clinician. As
Matarazzo argued, far from being a cold objective science, much of the practice
of psychology involves a subjective component.
Miller puts forward a brave
counterpoint to evidence base, not in challenge to its existence, but to its
dominance in the training, to the detriment of the consumer, of mental health
His arguments, and his book,
are highly recommended, and I would beg their consideration by any and every
university involved in the sculpture of mental health professionals from the
clay of their philosophical and moral feet.
© 2005 Roy Sugarman
Roy Sugarman, PhD, Conjoint Senior
Lecturer in Psychiatry, University of New South Wales, Australia