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In Not so abnormal psychology: A pragmatic view of mental illness, Ronald B. Miller offers a critical review of the field of abnormal psychology (a domain of knowledge that is also commonly referred to as psychopathology, psychiatric or mental disorders, mental illness, and problems in living). The author praises eclecticism in clinical practice. He argues that the field has been unfairly dominated by clinical scientists who have emphasized application of the scientific method to clinical endeavors. As a result, the field has underscored cognitive and cognitive-behavioral approaches, which lend themselves to scientific scrutiny and have produced reliable evidence of effectiveness in clinical trials, at the expense of other theoretical and practical models. Sources of the latter encompass a vast and fractured body of literature, including humanistic psychology, psychodynamic approaches, phenomenological psychology, etc.
The author's narrative assumes a very personal tone from the very beginning. Miller confesses, for instance, that his criticism of the scientific method as a tool to determine the effectiveness of clinical interventions emerged in graduate school and was reinforced by a series of personal and professional experiences encompassing a productive career as a scholar and practitioner. His central argument is that most theories share a common creed despite the fact that they often find themselves in irreconcilable disagreement regarding the sources and nature of the human mind and related suffering. Namely, the path to recovery (i.e., mental health) stems from one's understanding of his/her inner experience. The author advocates practitioners' focus on "empathetic understanding", which includes the clinician's appreciation that both his/her inner life and experiences and those of clients reflect a common humanity. Of course, diagnostic labels of mental illness can easily depersonalize practitioners' view of the client to the point of transforming him/her into a sketchy caricature defined by an array of symptoms. As such, labels of mental illness undermine the commonalities that exist between the phenomenological experiences of clinicians and clients, objectifying the latter and making their problems "abnormal events" unlikely to be experienced by the "normal" clinicians. Yet, the critical issue here seems to be the content of knowledge of another person and of one's self that can be gathered from what the author calls "openness to self-awareness". Since human beings are susceptible to self-deceptions, can such knowledge be realistic? Must self-knowledge be realistic or does it simply need to be beneficial to the person who holds it? What are the parameters by which such knowledge can be judged as beneficial if all that counts is subjective experience? For example, are successful therapeutic interventions merely those that help clients create an acceptable and coherent narrative of themselves which explains their past and present and defines or re-redefines achievement goals realistically attainable in their future?
The tenets of an eclectic approach to clinical interventions are undoubtedly appealing, but they remain difficult to evaluate if vagueness plagues core contents. For instance, the reader may consider the author's assertion that technical expertise and professionalism are not sufficient to produce an effective (i.e., beneficial) therapeutic intervention without a respectful consideration of the client's mental life, experiences, and sense of control, all of which are assumed to be nurtured by the practitioner's "openness to self-awareness". If taken at face value, the assertion is sensible; but even a cursory critical analysis is likely to note the lack of semantic specificity of its key terms. What role does critical analysis play in one's openness to the contents of introspection? Is the meaning of the attribute "beneficial" subjective, changing depending on the client who is undergoing a specific treatment? To what extent are the "beneficial effects" of a treatment shaped by social norms and customs and related to the client's conformity and compliance habits and necessities? To what extent can the practitioner's introspection and "empathetic understanding" of individual clients be distorted by his/her own cultural, conceptual and emotional biases?
The author openly questions the work of clinical scientists assumed by many to express a cumulative and rational enterprise which is based on the scientific method and is capable of leading to empirical and unbiased knowledge of both normative and deviant human cognition and behavior. He argues that the contribution of scholarly literature outside the mainstream of science-oriented clinicians has been largely ignored. As such, the field of abnormal psychology, including assessment and intervention practices, has objectified clients and their issues and thus prevented a deeper understanding of their mental life and actions. He advocates clinicians' reliance on case studies as a research and clinical tool based on the assumption that human activities, such as thoughts and actions, in everyday life generally have multiple causes that cannot be easily replicated in laboratory settings. In my modest opinion, abnormal psychology and related fields (e.g., clinical and counseling psychology, personality psychology, neuropsychology, and psychopharmacology) have made great progress towards the establishment of psychology as a science. Clinical scientists and science-oriented practitioners alike have questioned their field's reliance on often questionable diagnostic categories, vague theories and difficult-to-test interventions. The use of standardized procedures to collect evidence of the effectiveness or ineffectiveness of therapeutic interventions does not render clients "faceless numbers" and deprives them of their humanity (as the author dreads). On the contrary, standardization has given clients the opportunity to be exposed to treatments that have a verifiable likelihood of being beneficial and avoid those that have been discredited (e.g., rebirthing, recovered memory, and energy therapies).
Of course, benefits remain in the eyes of stakeholders as debate exists on how to define and measure benefits. In fact, because clients are likely to have entered therapy during a crisis, perceptions and reports of "improvement" may be merely the result of the passage of time. Perceptions of "improvement" may also be distorted by the need to justify the investment of time, money, and effort made. Practitioners' perceptions of the effectiveness of their interventions may be clouded by similar needs and sampling biases (e.g., clients justify leaving therapy by stating their well-being and stay in touch if they are satisfied, making practitioners more likely to be aware of the failure of other types of interventions than their own). Thus, although sorting facts from fiction is the goal of outcome research and evidence-based practice, how to conceptualize the effectiveness of clinical interventions is still a matter of debate. For instance, irrespective of practitioners' training and experience, effective treatments are said to offer hope of improvement, a sensible explanation of undesirable symptoms, a new perspective of life, and an emphatic, trusting, and caring relationship (Strupp, 1986; Wampold, 2007; 2013). The actual content of each of these benefits, however, may vary from intervention to intervention and from person to person, thereby making it difficult to capture their essence and relative importance in context. Notwithstanding the challenges of defining the outcomes of therapeutic interventions, clinical decision-making is no longer seen as merely a form of practical wisdom which is too complex and intuitive to be subjected to the law of scientific inquiry. On the contrary, clinical scientists and science-oriented practitioners alike routinely question the validity and reliability of diagnostic categories, give serious consideration to the biases that arise from the use of diagnostic labels, and make clinical decisions based on research evidence and knowledge of the client. As such, evidence-based clinical assessment, decision-making, and interventions not only make practitioners accountable for their actions, but also protect the public from discredited therapies and snake-oil salesmen (see Lilienfeld, Lynn, & Lohr, 2015).
Undoubtedly, a great deal of work is yet to be done to overcome the complexities of the tasks involved in defining the array of psychological phenomena that produce human suffering, identifying their sources, and developing valid and reliable assessment procedures. Similarly, a great deal of work is yet to be accomplished not only to estimate the extent to which different treatment interventions may be beneficial to different individuals, but also to define desirable outcomes unambiguously and objectively (if possible). Application of the scientific method to such endeavors is unlikely to deprive consumers of their humanity in the therapeutic relationship. For instance, one of the author's fears is that research protocols for assessment and treatment in clinical trials are so scripted (i.e., standardized) that they restrict interactions between client and practitioner and thus prevent the latter from "getting to know" the former. Although standardization may introduce simplifications and distortions in assessment and treatment interventions, additional research may determine whether such simplifications and distortions across different client populations are indeed relevant and substantial, and, if so, suggest possible remedies. Similarly, research may further explore the effects of combining aspects of diverse theoretical approaches in treatment interventions devoted to different client populations, thereby assessing the merits of eclecticism in the context of human diversity, as well as respond to the demand for well-defined and measurable outcomes in clinical practice.
In conclusion, application of the scientific method to clinical settings may feel like a straitjacket to some practitioners, and the knowledge gathered from it may appear partial or even distorted. However, any accumulation of knowledge through systematic replication that the scientific method affords may resemble a pair of wings to the same practitioners as the field becomes more established. Thus, my modest advice to individuals interested in the field of abnormal psychology, including seasoned clinicians, students, and laypersons who are consumers of therapies, is to read with an open mind the well-written and engaging narrative of Not so abnormal psychology: A pragmatic view of mental illness. They will discover a book that challenges them to think of the field of abnormal psychology critically, thereby identifying its current strengths and weaknesses. Irrespective of whether readers possess at the outset a viewpoint that is similar or different from the one proposed by the author, or do not have a firm preference, they will certainly find themselves holding a more informed and well-conceived opinion at the end. The book written by Ronald B. Miller is so difficult to ignore and its content so valuable for this very reason.
Lilienfeld, S. O., Lynn, S. J. E., & Lohr, J. M. (Eds.). (2015). Science and pseudoscience in clinical psychology. New York, NY: The Guilford Press.
Strupp, H. H. (1986). Psychotherapy: Research, practice, and public policy: How to avoid dead ends. American Psychologist, 41(2), 120-130.
Wampold, B. E. (2007). Psychotherapy: The humanistic (and effective) treatment. American Psychologist, 62, 857–873.
Wampold, B. E. (2013). The great psychotherapy debate: Models, methods, and findings. New York, NY: Routledge.
© 2016 Maura Pilotti
Maura Pilotti, Ph.D., Ashford University