History: where do nudges or ‘small safe experiments’ sit?

To be is to do: Jean-Paul Sartre (French philosopher)

To do is to be: Paulo Friere (S American radical Priest)

Do-be-do-be-do: Frank Sinatra (um …. crooner)

As you can see, I am being frivolous at the beginning of a new decade. I wanted to look back over the history of my profession. As this is a potted history – just my helicopter ride around the topic – I thought a light-hearted beginning would be best. Even so, I’d ask any readers to correct any errors of fact (not opinion).

My joke does describe a context in which ‘small safe experiments’ can be devised and implemented. Effective experiments do things differently and we notice how the results alter our sense of who we are and what we are being.  Before I run the risk of presenting the small, safe experiment as some new approach to therapy, let me mention Roger Bacon, a writer and thinker who lived between 1214 – 1292.  He pointed out, even then, that “there are two ways of acquiring knowledge; one through reason, the other by experiment”.  This attitude demonstrates that change, through experiment, has been around for centuries. In similar fashion, therapy has been evolving.

It is possible to see the  Freud or, in the US, William James, as early ‘influencers’ in the world of therapy. However, there are even more ancient roots to rummage around. ‘Socratic questioning‘, from the Greek philosopher, is a technique central to the skills used by the modern therapist.

So, the approach to caring for others has changed over the decades and centuries. It could be argued that each prevailing model of care mirrored the ways in which communities were organised at the time. Different models of caring defined the ‘old normals’.  There is a useful history of these different models described by:

Barber_JP_Muran_JC_McCarthy_KS_Keefe_RJ_(2013)_Research_on_Psychodynamic_Therapies

In_MJ_Lambert_Ed_Bergin_and_Garfields_Handbook_of_Psychotherapy_and_Behavior_Change_pp_443_494_New_York_NY_John_Wiley_and_Sons_Inc

When there were no ‘therapists’, communities still had listeners – sages and religious leaders. True, it was often not so much that we were being listened to – as being told! Here, in an England long past, with low rates of literacy, there were people who helped to interpret the laws of the community, say, by referring to the Bible. Attendances in church were high and individuals found themselves ostricised for not attending church regularly. People were easily reached and they did not travel far. The sermon was a grand device for group therapy – if rather prescriptive.

Today, we have different prescriptions, e.g. from doctors using their perception of their patients’ ‘ills’. The predominant concern in this model is to find out what is ‘wrong’ and find ways to put it ‘right’. Technology, science and medicine became rather complicated over time. The local sage – even barbers – gave way to a body of trained and well-informed men. It took sometime before women found their place in the world of medicine despite having played a rather larger role in the pre-Christian and Medieval traditions.

Doctors became so thoroughly trained that patients became subjects to be studied, rather than people to be engaged in a process of change. It’s not easy to explain why a medication worked –  so simply “try it”  seemed a prevailing outlook. An experiment, maybe, but not one requiring you to have an opinion.

One group of doctors, now called psychiatrists, emerged to pay attention to the Mind. It was not difficult, at that time, to see the doctor-therapist as a wise person to be trusted with our healing. There was no particular need for you to participate actively in the healing process!! Indeed, today in the UK, your local GP still has formal responsibility for both your physical and mental health.

So powerful was this group that early psychologists, or carers, felt obliged to get a ticket as a doctor. Freud was qualified as a medical doctor and even less well known names like Cecily Saunders – a founder of the palliative care movement – realised she had to train as a doctor if she was to have any clout. In her case, I suspect being a woman had something to do with it as well.

In America, by contrast, psychologists established their position with more confidence when William James made moves to organise the study of the mind and human behaviour as the twentieth century opened. Other leaders in the US field included John Watson, B.F Skinner and Clark Hull. Their focus on behaviour – what animals and humans could be seen to do – seemed much influenced by the behavioural findings of the Russian scientist, Ivan Pavlov.

This US position seemed to depart from a European tradition still interested in the ‘black box’ of our inner experience. This ‘black box’ was less easy to study, and this led to much speculation and a reliance on metaphor (hence the Freudian fascination with Greek mythology). Time showed that the ‘black box’ could not be wished away. Humans became ‘intervening variables’ and that was an inconvenience!

In the middle of the twentieth century, a larger group of therapists began to emerge in Europe. Psychologists such as John Bowlby and Donald Winnicott, here in the UK, began to examine Human Growth and Development in a systematic way.

These Doctors – of research as well as medicine – built bridges with the then expanding world of therapy. Initially dominated by the psycho-analytic thinking of Freud, Jung and Adler – later by their ‘disciples’ such as Anna Freud, Melanie Klein – the world of therapy began to split.

Initially the number of schools of therapy could be counted on one hand and, by the 21st century, there was a very many hundreds of them. The different schools seemed driven by different priorities:

The Analytic Schools: wanting to understand the inner workings of our minds and split into Freudian, Jungian, Adlerian and Kleinian Schools, to name just a few. In later years, a Relational school emerged sought to build bridges within the analytic schools, and other therapies.

The Humanistic Schools: wanting to experience the person that is a client. These schools later split into a number of different perspectives, often based on a difference of ’emphasis’ about how best to relate to the client. Such schools included Existential, Person-centred, Gestalt and Psychodrama to name just another few.

Behavioural Schools: focused on behaviour – what we are seen to do, rather than what goes on inside our head. This later split into a number of schools as some were more willing to investigate the ‘black box’. Others remained determined to assess only that which can be seen to happen. Transactional Analysis (TA) wsa developed in the mid-20th century to build a bridge between the raqdical behaviourists and the traditional analytic schools.

In later years, the strict Behaviourist perspective morphed into a number of Cognitive schools including Cognitive Behavioural (CBT), Rational Emotive Behavioural Therapy (REBT) and Schema therapy. A special case to consider here was Eye Movement De-sensitisation and Reprocessing (EMDR). This emerged at the end of the twentieth century.

Even more recently, the ‘black box’ of our inner experience has been laid more bare by advances in neuro-science. This spawned a set of sophisticated therapies integrating body, mind, relationships and meaning-making. You will see my references to this in other pages concerned with the work of Allan Schore, Dan Siegel, Bessel van der Kolk, and Stephen Porges, among others. This work has emerged after the Second World War. Because of the psychological problems created by persistent exposure to warfare, medical doctors made something of a come-back. The First World War notion of ‘shellshock’ was moved, slowly and surely, towards the concept of trauma and Post Traumatic Stress Disorder (PTSD). This only added to the growing profusion of treatments. In time we could train and practise in:

Trauma Incident Reduction (TIR)

Eye Movement and De-sensitisation and Re-processing (EMDR), and a number of sub-sets.

Trauma-informed Cognitive Behavioural Therapy

Prolonged and/or Graded Exposure

…. to name a just a few off the top of my head.

All the while, alongside all this, there was a fringe interest in hypnosis. Fringe, because hypnosis was not a well understood phenomenon, and it was rather too easily hi-jacked by charlatans. This was a shame, in many ways, as Freud himself had seen merit in hypnosis having worked with the reformer French Doctor, Jean Charcot who worked with hypnosis at the end of the 19th century.

Fortunately, hypnosis hung on in there and turned into the more respected school of Eriksonian Psychotherapy attributed to the American doctor, Milton Erikson. Here was a practitioner who focused on the style and quality of the communication he was having with a client. I have to declare a bias here as Erikson’s work influenced me a great deal. For example, he once said:

“Each person is a unique individual. Hence, psychotherapy should be formulated to meet the uniqueness of the individual’s needs, rather than tailoring the person to fit the Procrustean bed of a hypothetical theory of human behavior.” – Milton H. Erickson

And I trust that this is a theme that emerges time and again here on my web site. This is a ‘person-centredness’ I can subscribe to as it offers a genuine attempt to meet the uniqueness of every living person. Even so, my recommendations do return to good old-fashioned behaviourism – with a twist – as you will see.

However, even Erikson’s work became a subject of a ‘competition’ between later twentieth century writers such as:

Gregory Bateson: primarily an anthropologist, but later much concerned to understand schizophrenia. Bateson had a big influence on Systemic therapies.

Paul Watzlawick: was primarily a philosopher and analytic therapist who turned his attention to communication patterns. Much influenced by Gregory Bateson, Watzlawick was a seminal influence on the growing field of family therapy. This was important as communication within the family provides the environment within which our understanding of our world is constructed. The Scottish therapist R.D Laing propounded a radical view of these ‘social constructions’ in his several publications.

John Grinder and Richard Bandler: both are generally regarded as the founders of Neuro-linguistic programming (NLP). This model offered a psychological approach to analyzing the strategies of successful communicators (including Milton Erikson and Virginia Satir). The model relates the thoughts, language, and patterns of behaviour used by respected therapists to show how their work obtained specific outcomes with their clients. 

NLP regarded all human action as positive and that is why it has some appeal for me. In effect it is saying our experiences are neither good nor bad. The model is more respectful when the outcome of change is a ‘small victory’ or a ‘small defeat’.

In effect, then, NLP became part of the positive school of psychology with which I associate myself. For more information research into Martin Seligman and others.

Others who took to building bridges between the Eriksonian and Systems Schools include Jay Haley and Bill O’Hanlon, leading -in time – to the development of Strategic Schools of therapy.

Ironically, the growing incoherence emerging from the proliferation of ‘Schools’ was made worse by researchers as they became more aware of the splitting process I have described here. The wish to resolve this process led to building even more bridges! For example, consider:

The Integrative Movement: a movement that wanted the therapist to demonstrate the intricacies of several models in their practice.  The aim was to tailor therapy to the individual client and find out ‘what works for whom’. It is a unifying approach seeking to respond to the unique client on every level – the affective, behavioral, cognitive, and physiological levels of functioning, as well as in the spiritual dimension of life. Sounds good but what does that say about therapists not trained within this movement and/or the clients with a different agenda!

Transactional Analysis (TA): A rather neglected school today, in my view, but one that had a large impact on me. As said, TA sought to build a bridge between the Analytic and Behavioural Schools. Eric Berne’s Transactional Analysis (TA) realised that the intricacies of Analytic Psychology could be made more readily understood to a modern audience less immersed in classical mythology. TA offered simple and concrete descriptions of the behavioural elements as we presented our inner experiences to the outer world. From this, the rather famous PARENT, ADULT AND CHILD ego states emerged. The ego state idea was to catch on and become the basis for numerous other ‘schools’ such as Parts Therapy, Schema Therapy, Family Systems therapy, Internal Family Systems etc.

Systems Thinking and Therapy: systems thinking did not really start in the world of therapy. It emerged from the work of Watzlavick and Bateson mentioned above, supplemented by the practice wisdom gleaned from Virgina Satir and Salvador Minuchin – amongst others. This way of thinking soon caught on as essential in counselling – not just with individuals – but with groups such as families and management teams. It informed the important work in the change process put forward by Prochaska and Di Clemente. In these writings can be found an interest in the ‘trans-theoretical’ models of therapeutic interventions; that is, practises and techniques that focus less on ideas and more on the ever-changing processes involved in therapy.

Existential Therapy: Here is a model that paid careful attention to philosophy behind emotional and psychological treatment. Possibly set more in a European tradition, the UK is well represented here by the on-going work of Ernesto Spinelli. Like the trans-theoretical models mentioned above, the existential approach is not seeking to be a particular method of therapy. It pays attention to meaning and attends to the way a therapist and client discover and shape meaning together – in the pursuit of some change.

I want to put some emphasis on this approach as I assert that small safe experiments are only as good as the meaning that emerges from them. If no meaning is obtained from a known outcome, then the experiments might just as well not exist. How can I build on something I have not noticed? How I can I do something different if I do not respect the small defeat I have just experienced?

Only some of these splits in the world of therapy have been touched on here. I do not want to write a book on the subject!  However, I cannot finish without reference to a ‘darker’ side in the process of splitting. This is seen in the growth of training systems dominated by charismatic individuals who wanted to attach their name to a brand, and gain a profit from it. Ownership became important and diverted us from the fundamental intentions of therapy: to enable people to recover their well-being and to develop a robust self.

This egotism has been recognised more in recent years and became evident after the scandal of the Kids Company collapse in the UK during the summer of 2015. The term Founder Syndrome became better known, but I see no evidence of countering it very robustly. It’s a polotical problem, as much as anything and, until it is confronted, specific ‘schools’ of therapy will continue to proliferate.

Some schools have gained favour in more recent times. Cognitive Behavioural Therapy (CBT) is the obvious current one. To end on a contraversial note, I would invite you to consider how this ‘favour’ is attained today. There is a present concern with ‘evidence-based research‘ into the impact of therapy. You might think this is non-contentious; we should provide evidence to separate out effective therapists from charlatans. However, CBT is in an ascendency mainly because research ‘evidence’ shows it produces ‘results’. However,  do consider what we mean by ‘results’?

As I see it, CBT practitioners have been politically astute. They gain an advantage by maximising the match between treatment model and favoured research models. Those research protocols found their roots in Western medical traditions.  These lead to practice manuals,  and manuals tell the therapist what to do to get people better. Sadly, the manuals do not tell us what each person needs to do to get ‘better’.  Manuals are hard pressed to tell us how to work together in order to create effective change.  More problematically, over time, the political convenience of the NHS buying into a particular model such as CBT has come to mean that the perspective is becoming too big to fail. Echoes of the banking crisis!!

However, when the reasons for favouring a particular way of researching is questioned then the picture becomes cloudy. For example, blind random controlled tests (BRCT) are advertised as the ‘gold standard’ in scientific research. That makes sense when testing drugs that have the potential to maim and kill human beings, e.g. as with the Thalidomide in the sixties. However, it is a ‘category error’ –  ‘strict’ protocols make less sense when a human being is learning to design of ‘research’ and make a plan. to initiate a change in their life.  If researchers gain acclaim from a convincing Curriculum Vitae (CV), and through publishing a lot of findings, then ‘clients’ do it one small step at a time and they publish little. They have less incentive to publicise their own way of succeeding. As with pain, so with change: once we’ve gone through it, we forget it!!

In effect, ‘good’ practice is too easily defined by those that presume to tell us what we should notice about the change process, rather than encouraging us to listen to a range of things that may, or may not, be important. What is important to one person, may not be so to another.

Astoundingly, this abuse of power has continued for decades despite a growing body of other research that tells us ‘schools’ make little noticeable impact on the ‘results’ of therapy. The therapeutic journey is a process negotiated between two intervening variables – therapist and client – about which little is known. The therapeutic task is to know just a little bit more and then another little bit more.

I found a useful personal essay by Keith Myers that reflects on how theories can inform our practice as long as the relationship between the client and the therapist is not lost in other ideas.

If you want more on the scientific concerns inherent in much ‘evidence-based’ research and practice, then take a look at:

this 2018 Editorial in the British Medical Journal

There are other good reasons for questioning whether the evidence-based rules of the medical sciences are so relevant in the world of therapy. In my view, a category error is made when we assume we can study changes made by clients using the same protocols employed by scientists.

So – coming up to date:  what seems to work when we are more focused on a process of change initiated by two people?  My view is that relevant ‘evidence’ is found in the outcomes obtained from a series of small, safe experiments. These experiments, and the often seemingly ‘minor’ results, can come up with unexpected outcomes.  That’s why it is best to take small steps – just in case we need to stop and re-shape our plan, or even turn back. This rather tentative approach to change does not work in the life-and-death world of medicine.

So, in my opinion, what approaches to therapy help most people (not all) to devise and implement effective safe experiments?

  1. the neurologically-informed cognitive therapies of Stephen Porges, Bessel van der Kolk and Dan Siegel, to name just a few. Specialist training information on these individuals are available from internet resources such as NICABM and the PESI Institutes.
  2. Attachment-informed psycho-social therapies. Allan Schore is a current name worth following up here, as is Dan Siegel. Understanding this core area requires an appreciation of the long ‘history‘. Too often there is a tendency to ignore the giants upon whose shoulders we are standing.
  3. Acceptance and Commitment Therapy (ACT): I say more about this approach as it is an approach to therapy, more than a theory to be learned. It shares with TA an ability to produce some interesting diagrams! This information does not appeal to all.
  4. Compassion Therapy: again, I say more about this approach as it is another approach to therapy rather than a theory to be learned.
  5. Mindfulness: I mention this rather reluctantly as it is in danger of falling into the same trap as Neuro-linguistic Programming (NLP) – becoming a ‘flavour of the decade’ -exploited by a number of people lacking the necessary knowledge and insight or training (see, I don’t dismiss training after all!). There is a ‘school’ of training called Mindfulness-based Cognitive Therapy (MBCT) but I would recommend the less demanding Mindfulness-based Stress Reduction (MBSR) programme. It is practical and requires a ‘sensible’ commitment from you (an eight week programme, as I understand).
  6. I want to add a final, rather ‘old fashioned’ element to my ‘mix’: behaviour modification, and the Problem-Solving Therapy (PST) that emerged from it in the mid-20th century. Problem-Solving Therapy (PST) is a cognitive-behavioural intervention training me in problem-solving. This may include helping me to learn new skills, or to change my attitudes. ‘Training’ focuses on fostering a positive attitude to problem-solving, as well as the development of the necessary skills. The dilemma this approach presents is its ‘nod’ to ‘helping’ clients, whilst still having firm ideas about what constitutes effective problem-solving skills. In so doing, this ‘school’ made the same error  some person-centred therapies;  both default to a set of ‘rules’ and values paying lip service to clients and still quietly ‘telling’ them what to do!! There is a problem of ‘attitude’ here.
  7. Solution-focused therapy: this has been a central influence on me over the years.  There is a very useful introduction to the ‘five questions’ commonly employed in this model; questions that may  well help you design your own small, safe experiment. I will be saying more about this elsewhere. 

In short, effective therapy, in my view, needs to be less concerned with what is ‘good’ for clients, ‘good’ for research or even ‘right’ and ‘wrong’ according to some external rule; what helps change is an ‘attitude’ negotiated between two people – not one helping the other –  but each respecting the unique relationship they are able to create from ‘scratch’..

For that reason, despite my earlier reservations, mindfulness is important in therapy. It offers an attitude to living that can support some people and it is not ‘common-sense’. Do read some of the original material produced by Jon Kabat-Zinn and others, if you want to know more.

Put together, the threads 1 – 7,  listed above, seem able to make a difference. No longer is it about a ‘school’ of training, but rather more about the space created by two (or more) people. To be fair, earlier models do place value on relationship:  even psycho-analysis attended to the ‘analyst and and the analysand’. Person-centred and existential therapies made much of creating a healthy environment in which a good relationship could improve things. There was even a departure from the concept of the ‘cure’ towards the notion of a negotiated way in which to re-write the narrative governing our lives.

Sadly, few approaches to therapy explicitly addressed the power relationship between client and therapist. Sometimes, proponents will say the right thing, yet not be seen to do it.  It is not easy to address a problem if it is hidden and we do not look it in the face. If anyone is in doubt about the insidious impact of power abuse in the caring professions, please read the rather old,  but still highly relevant:

Adolf Guggenbuhl-Craig Power in the Helping Professions

…. where you will read how therapists are at their most dangerous when we become certain in our views.  Let me know when my website starts to do just that – it might well do so!!

 

Return to:

Welcome

How to give yourself a nudge

Doing safe experiments