Bulletin of the Psychoanalytic Research Society, Volume V, Number 1, Spring, 1996
Ingratitude, thou marble-hearted fiend!
-- Shakespeare, King Lear
Scientists and practitioners in many fields share at least one characteristic with couples in marital therapy -- each member of the pair claims to be misunderstood and insufficiently appreciated by the other. The popularity of Rodney Dangerfield's comedy act attests to the universality of his message: "I don't get no respect".
The relatively few of us who work empirically with psychodynamic theories believe firmly that we get little respect from the much larger group of psychoanalytic practitioners. While this belief seems to be widely shared, the evidence of this disrespect is difficult to pin down. Two quotations are cited as proof of this bias, a comment by Luborsky that practitioners who cite experimental data risk losing their clinical status, and the observation by Wolitzky (1990) that while a recent book on treatment by 16 analysts cited 200 references, only six of these referred to empirical work, and five of those citations were made by one author. In addition, there is the remarkable comment by Tansey (1992) that "I have until now been singularly uninterested in, if not contemptuous of, anything that the 'number crunchers' have had to say....I have spent my entire career seeing patients in virtually complete isolation from what has been learned through quantitative research". As far as I can ascertain, these informal observations and others like them constitute the entire basis for believing that those who work empirically with psychodynamic theories are insufficiently recognized as psychoanalytic clinicians. Moreover, to sustain this belief, evidence indicating that it is invalid (see Beutler, Williams, Wakefield & Entwistle, 1995) must be disregarded.
Beutler et al.'s (1995) survey of 191 academics and 134 practitioner members of the National Register indicate that practitioners were more highly motivated to keep up with the research literature than academics were to understand the problems facing clinicians. The feelings of disrespect obviously extend in both directions.
The situation is not at all unique to psychoanalysis. Beutler et al. (1995) documented the frequency with which scientists and practitioners in many areas -- dentistry, nursing, gastroenterology, physics, chemistry, computer science -- report being in conflict with each other. Feeling misunderstood seems to be normative in a vastly complex, highly technological world. As Beutler et al. (1995, p. 985) noted, "In virtually every discipline in which the usual access to knowledge is through the scientific method, scientists have lamented that practitioners are inadequately trained, are insensitive to the value of scientific findings, and fail to read the right journals. Conversely, practitioners are dismayed because scientists offer too little, are consumed by irrelevant questions, and fail to appreciate the knowledge that arises from practice".
The complaint that clinicians do not utilize research results is certainly not true for diagnostic testing, where a great many scientifically-based, psychometrically-sound instruments -- including the MMPI and the Exner scoring system for the Rorschach -- are widely used in clinical practice. Nor does that condition hold for some non-psychodynamic forms of therapy in which highly specific, very successful forms of intervention are available for treating child and adolescent obesity, phobias, children's fears, sexual dysfunction, anorexia, obsessive-compulsive behavior, social inhibitions, and panic disorders. All these treatment techniques were developed by academics and are now used by practitioners. In contrast, it is far more difficult to find instances in psychodynamic areas where a scientifically-derived measure is widely used by practitioners. While psychoanalytic theories have given rise to a number of well-constructed tests, including Blatt's Depressive Experiences Questionnaire (Blatt, D'Afflitti & Quinlan, 1976), Holt's (1966) method for scoring primary process thinking, and a system for scoring oral responses on the Rorschach (Masling, Rabie & Blondheim, 1967), these measures are employed almost exclusively by researchers and are not used to answer questions arising from daily clinical practice.
How are we to account for the apparently greater gulf between research and practice in psychoanalysis than in behavioral and cognitive therapies? The easiest answer is to blame our students and clinicians for failing to appreciate the spiritual uplifting that comes from an interest in research. It is analagous to the way American car manufacturers get angry at the Japanese for failing to buy US-made automobiles. Certainly it is comforting to assume that our services are useful and creative, and that those who should -- but don't -- use our research are both ungrateful and undereducated. However, it is equally likely that a more unsettling proposition is true -- that the research we produce is interesting mainly to other researchers and has little relevance to the potential consumer. Instead of complaining that new PhDs and PsyDs move away from research once they leave graduate school, we might well consider why we continue to publish research that will be read mainly by the several hundred members of Section VI of Division 39, but largely ignored by the several thousand other members of the division.
Members of a graduate faculty are privileged to work with one of the brightest and most academically qualified groups of students in the country. These students come to graduate school eager to learn, filled with intellectual curiosity, and pleased to work closely with faculty members on projects of mutual interest. After four or five years of intensive contact with us, the great majority of these same students leave graduate school determined never to conduct another piece of research. Repeatedly we accomplish the reverse of the alchemist's goal: We take gold and turn it into dross.
Most graduate students learn early on that their attempts to be creative, independent and innovative are not encouraged. There is no doubt that the cautious, steady plodder has an easier time of it in graduate school than those who are daring and take risks. Aiding, leading, and modelling this metamorphosis from butterfly to larva is the graduate student's advisor. As a result, most dissertations refect more concern with method than with ideas and more time is spent scrutinizing the experimental methods employed in a study than the problem itself. Students begin by studying a problem, frequently selected by the dissertation advisor, and end by studying their methods. No wonder the dissertation so often becomes an unpleasant, unending series of rather mechanical tasks rather than an exciting intellectual endeavor. Rather than blame the student for finding that research can be tedious and irrelevant, we might -- like good experimental psychologists -- look to the conditions that produce such an unintended outcome.
One obvious solution is to encourage students to develop their own research programs rather than work on their dissertation sponsor's research program, and then spend at least as much time with the content of their ideas as with the methods used to study them. Emphasizing method over content has probably killed the spirit of a great many students. If we truly wish to get attention from practitioners we might begin by investigating topics they find important. That should not be difficult because most of us have some clinical practice as well as an active research program. For a great many of us in Section VI, when I discuss practitioner and scientist I am describing one person.
We could begin the process of detoxifying research by helping graduate students investigate questions they find relevant to their interests. Practitioners and scientists may never develop identical values, but one way to increase feelings of mutual respect would be to become more empathic with the other's situation and issues. Blaming is easy. Empathy will likely be more useful.
More interesting research might well narrow the gap between scientist and practitioner but by itself is unlikely to close this gap entirely. A good deal of research directly relevant to clinical practice is already available. The work of Luborsky (1990), Weiss and Sampson (1986), and Strupp (1986), among others, deals directly with important issues of psychoanalytic treatment and ought to be required reading for all PhD students interested in psychodynamic theories and all analytic candidates. But even here the world of practice seems to pay scant attention to what the best research studies can provide. It is akin to giving a party and having no one attend.
The issues dividing researcher and clinician are not superficial and are not likely to yield to easy solutions. It is important, however, that a start be made on each side to understand the attitudes and vulnerabilities of the other. Attacking the other as ignorant or questioning the other's analytic credentials will only produce defensiveness and counterattack. Perhaps it is time to adopt a more analytic attitude.