Academy Introduction 

by Theresa I. Egan, Ph.D.

Good morning. I am Dr. Terri Egan. I am a member of the Academy for the Study of the Psychoanalytic Arts, and I currently serve as the Chair of its Program Committee. I’d like to thank my fellow committee members, Dr. Linda Young and Dr. Etta Saxe, for your assistance in the planning of today’s program. On behalf of the Academy, I welcome each of you to what we hope will be a lively and inspiring day of discussion and debate.  

It is my distinct pleasure to welcome our speakers, Dr. Arthur Bohart and Dr. David Downing, and to thank each of you for coming here to share with us your experience and your perspective about how the changing discourse of psychology and psychoanalysis both reflects, and in turn contributes to a mind set, or ethos that brings with it important legal, ethical, and professional implications for the future of psychological theory, education and practice.

We have entitled our program “The ETHICS and ETHOS of the Evidence-Based Therapy (EBT) Debate: OR What happens when the null hypothesis is used to insure that YOUR psychotherapy is NULL and void?”

Members of the Academy view the mounting pressure to follow specific, evidence-based protocols for the practice of psychotherapy as evidence, in-and-of-itself of a much larger movement, which has the potential to restrict the freedom to choose, from among psychology’s diverse perspectives, a way of practicing that is consistent with one’s own way of thinking. There is increasing pressure in this country, coming from a variety of sources, to operationally define, linearize, concretize, and monitor professional services so as to identify “proof of what works” and to extract the assurance of “accountability”.  The Evidence Based Therapy movement is, among other things, a powerful and welcome response to that pressure in some circles, with its promise to scientifically define, legitimize, and deliver such assumed certainties to those entities that seek it.  Under the guise of “protecting the public”, the danger lies in the growing efforts within the American Psychological Association (APA) to impose adherence to evidence-based therapies upon all practitioners regardless of theoretical orientation, in order to serve these aims. Originally coined “empirically supported treatment”, the concept of evidence-based therapy is based upon a particular model for science and research. This model identifies good research as that which can produce the type of results that can be manualized and proceduralised. In so doing, it necessarily limits the definition of “evidence” to that which can be derived from those therapies (e.g. Cognitive Behavioral Therapy) whose basic assumptions more easily lend themselves to linear observation, quantifiable measures, operational definitions, universal meanings, and generalizable results  that can be organized into trainable protocols and procedures.

Stevenson & Haberman (1998) point out that “different conceptions of human nature lead to different views about what we ought to do and how we can do it”.  The emergence of evidence-based therapy (or indeed ANY one approach to therapy) as psychology’s “gold standard” for how one “ought” to proceed in the consulting room cannot be talked about in a vacuum that excludes a conversation about different conceptions of human nature, the ethos from which they emerge, and the ethical considerations that they produce with regard to how we think about and respond to human problems in living.

The matter of ethics is never a-theoretical, unless its philosophical foundations are lost, and its meaning is streamlined into compliance with organizationally and professionally determined practice norms and values. The question of how a person, profession, or culture “ought” to conduct itself (ethics) is contextualized by those fundamental values which that person, profession or culture holds (ethos). Thus, ethicist Stephen Pattison (2003) writes that “Conformity to a code is not necessarily the same thing as acting ethically in the broad philosophical sense… Indeed, if conformity is uncritical, it may actually be unethical.” 

In the field of psychology, there exist different systems of thought that are built upon sometimes paradigmatically different values and assumptions regarding human nature, the meaning of differences, the nature of personal problems, and the role of therapy in addressing these issues. Each system of thought contextualizes and formulates an ethics consistent with the values and assumptions that it holds. If that be the case, then the notion of “evidence” for whether psychotherapy or psychoanalysis “works”, or is useful to someone – what that means, and how it might be investigated - is not separable from the particular theory from which the therapy proceeds. And the theory from which one proceeds is not separable from whether or not “evidence” is interpreted as synonymous with “proof”.  

While this would apply to theories as diverse as Humanistic, Psychoanalytic, and Cognitive-Behavioral, it would ALSO extend to a non medical framework which might view “theory” itself as that which is held by the patient or analysand – in which case, to say that “evidence is defined by the theory”, is to assume something very different by terms like “theory”, “research”, “evidence” etc.  One of the questions we pose today is “Is it ethical for any one system of thought to shape the standards of practice for all practitioners?” Arguing there are different “grounds” for ethical practice, Dr. Bohart (2003) has stated  that “ethical scientific practice does not try to force one model of science on everyone …”. 

The Academy is committed to the rethinking of psychoanalysis within a psychological framework that is other than health care in the medical sense, and as a creative intellectual discipline dedicated to the understanding of the psyche. It involves the re-thinking of psychoanalytic practice as consisting of a collaborative inquiry dedicated to the furthering of self-understanding, rather than to the "treatment" of disease, disorder or deficiency. Of particular interest to us today is the question of articulating and advancing an ethic and ethical principles consistent with this ethos.

Because existing institutions and standards have been established around the view that psychotherapy and psychoanalysis are forms of health-care, and because health-care in this country is situated within the assumptions of a medical ethos that reflects fundamental values specific to this culture, our consideration of the ETHICS and ETHOS of the Evidence-Based Therapy Debate raises some fundamental, practical questions:   

? If practitioners explicitly reject the assumptions that underlie the medical model that supports evidence-based therapies, where does that leave them with regard to existing standards in law, ethics, education, and professional practice?

?And, to the extent that these standards only make sense within a medical context, how do we articulate and legitimize the philosophical and ethical bases for an alternative way of thinking?

?Can the ethos that prescribes “evidence-based” therapy ethically include space for those who subscribe to a non medicalized, more holistic approach to psychotherapy that responds to the whole person whose difficulties are seen as part of a rich matrix of communication, and not reduced to “symptoms”?

?Is it possible to argue on ethical and philosophical grounds that any individual has the right to the private exploration of his or her personal experiences for the express purpose of better understanding them and discovering ways in which they might relate to current life situations of concern?

?Does positioning oneself outside the medical model create new questions that are not even askable within a medically dominated ethos of knowable certainty that derives “truth” and “evidence” solely from linearized thinking, and objectivity reality?  

Do such questions as these involve a re-thinking of what it means to practice ethically? From within a psychological framework that is other than health care in the medical sense, what if we were to begin with the assumption that it is an individual person’s uniquely subjective reality that contextualizes everything? And what if it is this reality that creates that individual’s own internal, personal ethos from which an unrecognized and unspoken personal ethic has arisen about how one “should” proceed in life in order to serve some not yet articulated purpose? What if it is assumed on the part of both people in the consulting room that the pursuit of understanding the experiential evidence for this reality is worthwhile in and of itself? Very different meanings of, and plans for “treatment” emerge from assumptions grounded in evidence that is understood to originate inside (rather than outside) the consulting room,  and which derives its data from the meaning-saturated emotions and experiences that are collected over time as thoughts freely come to mind. Do concepts like treatment plans, diagnoses, disorders, cures, psychopharmacological interventions, correspondence with insurance companies, discussions with managed care personnel and family members, HIPAA forms, behavioral treatment goals etc. have any meaning from this non medical perspective? How do we think about what is “ethical” in this more nonlinear, context-based configuration where “what determines what” is ever so fluid and constantly in flux? 

With regard to research, is it valid to  prioritize the research that is carried out in the consulting room, as two people collaboratively search for, sort out, and re-search the infinite ways in which the personal meanings of an individual’s life experiences come to contextualize and influence all aspects of his or her feelings, behaviors and choices? Does reliance upon this type of “data” collection as the primary source of  “evidence” for how we “ought” to proceed, create a different ethical imperative centered around exploring the IS of what has come to BE for a particular individual?

If “problems in living” are not necessarily interpreted as medically caused, mental irregularities to be eliminated through psychological treatment and cure, but rather as a complex matrix of communication about life, how it is experienced, and what that has come to mean, then an altogether different ethos arises, along with an interestingly different way to think about principles of right conduct. It even raises the ethical question of what it means for a culture either to eliminate (or to preserve) a professional space wherein an individual may freely and safely come to understand and explore the way in which his or her own uniquely formed worldview has constructed internal rules and standards that have knowingly or unknowingly come to govern her or his thoughts, feelings, choices, actions, and meanings.  What risks might be involved in imposing externally devised, theory-driven, science-based practice procedures upon private, meaning saturated, experience-based realities? What void might this fill? What anxieties and terrors might this nullify? on the part of the individual? the therapist? the profession? the culture?

Today’s program is sponsored in an effort to increase our awareness of a changing cultural and professional landscape, and to create an opportunity to do some brainstorming with our two speakers who are active thinkers, writers, teachers, and leaders involved in organizational efforts to address issues related to professional practice in the humanistic and psychoanalytic communities.

Dr. Bohart will be talking with us about what the Evidence-Based Therapy movement is, and how it originated. He will describe the rationale behind a Task Force that he chaired, through which the Division of Humanistic Psychology developed its own alternative to empirically supported treatment. He will bring us up to date on an escalating debate within the American Psychological Association, where the focus of the dispute is on the specifics of what is meant by “evidence”, within the context of divisional efforts to keep this definition as open as possible by insisting upon multiple ways to define and investigate it. While these efforts may be quite politically important for our profession, they do not address some of the deeper philosophical and ethical issues that we hope to raise and talk about today.

Psychology contains a rich diversity of different systems of thought (both within and outside of a medical way of thinking).  The Academy is interested in expanding the APA debate beyond the specifics of how many ways there are to scientifically define and investigate “evidence”, and to include the significance of  theoretical differences that are accompanied by very different underlying philosophical assumptions, ethical responsibilities, ways of doing research, ways of determining what is valid and reliable, and even… very different meanings about that which constitutes “science”, “research”, “evidence”, “ethics”, and “data”.

Dr. Downing will be speaking with us about the ways in which he sees certain aspects of American culture, and we as its participants, as playing a powerful role in creating the current state of affairs regarding the nature and provision of mental health services. He will talk about a cultural mind set, or ethos, in which American trends toward industrialisation, the commodification of “human services’, and the de-professionalisation of psychological care may serve as efforts to nullify individual subjectivity and unconscious  process, void the certainty of uncertainty, and erode the space for those therapies that hold subjectivity and/or unconscious process as fundamental underlying assumptions. We will have the opportunity this afternoon to talk with him about how the concept of “evidence-based” practice emerges from, and is consistent with, these trends.

We are indeed fortunate today to have two presenters with us, Arthur Bohart, Ph.D. and David L. Downing, Ph.D., who have important contributions to offer toward the Academy’s commitment to maintaining freedom of choice and an ethos of diversity and multiplicity in working with individuals in psychotherapy and psychoanalysis.