The Restoration of Hope

2005-12-18T16:21:00.000-08:00

Preface

2005-12-13T20:14:00.000-08:00

THE JOURNEY IS THE GOAL

It is ironic that in this time of concern about managed care and reduced lengths of treatment for troubled children and adolescents in the United States, we are confronted in residential treatment with an ever larger number of children with chronic disturbances, most often children born in circumstances of urban social disorganization and personal despair, who are unable to profit from customary modes of intervention. Often psychologically damaged during early childhood, these children have been described as throw-away children, the children that no one wants. Too many professionals in the field of child welfare have concluded that these children suffer from primary attachment disorders and are unable to respond to remediation. Often unable to respond to short-term treatment approaches, they sometimes become incorrigible adults with often horrible criminal outcomes.

The effects of American public policy aligned with managed care directives have had effects in the field of residential treatment which parallel the impacts upon mental health care in general. Traditional models of group care have come under attack as the scientistic perspective of treatment has filtered down through the managed care climate and converged with a public policy about troubled children which ideologically promotes “permanency planning,” the “least restrictive environment,” community placement and “family reunification” over the needs of some children for longer-term and more protective individual and milieu treatment. Within residential care, this is observed in combination with a managerial preoccupation with empirical outcome research, some would warn at the expense of a devoted attention to the theory and details of the clinical practice actually being provided.

In place of the clinically rich reports and case studies of extended treatment so prevalent during the earlier years of residential care, we have witnessed a rush to accommodate to the demands for shorter-term treatment models. Accordingly, painstaking psychodynamic treatment has often given way to objectivist models of treatment relying primarily upon “consequences” and “reinforcers” for behavior, forms of care which give little real credence to children’s feelings, wishes, or motivations in their formal treatment protocols, since these phenomena cannot be easily counted or measured. We have also witnessed the proliferation of individual and group forms of treatment tailored specifically to particular symptomatic issues or interpersonal deficits (for example, “anger management” or “social skills enhancement”), as well as the popularization of short-cut treatment approaches, such as those which claim that in treatment of the effects of early physical or sexual trauma, the cathartic experience alone is largely sufficient for psychological recovery.

These shorter-term approaches too often avoid the kind of existential issues which so often fuel the intense behavioral disorders displayed by young people. This kind of issue was illustrated by one long-abandoned teenage boy’s intense craving for mirroring attention, a gnawing fear that “no one in the world thinks I’m the most special one to them.” It was this very existential issue which time and again drove the boy to explosive rages, outbursts which were impervious to behavioral methods, but which eventually responded to a psychodynamic, relational approach attuned to the boy’s underlying needs (Zimmerman, 1999). Another example involved an adopted teenaged girl with a severe learning disability from a highly professional family, where the other siblings were considered to be geniuses, taking the fast-track to Ivy League colleges. In her case, the symptoms included wild histrionic behaviors, sexual promiscuity, and finally a suicide gesture. The underlying issue was eventually revealed to be the girl’s feeling that, in comparison to others in her family, she was “damaged goods” (Zimmerman, in press). As in the previous case, behavioral consequences and rewards offered no therapeutic match for the accumulation of interactional moments in a long-term relational treatment approach, which enabled her to replace a degraded self-image with some conviction that she was a valuable person in her own right.

But the crucial point here is not simply that the shorter-term methods trivialize the critical existential issues in clinical practice. The objectivist theories underlying those methods also minimize the very worth of asking the kinds of questions which motivated the early founders of residential care for children, because those questions were about inevitably indeterminate human qualities. Such inquiries included the question of how we might provide the best care for children, which necessarily led to the question of what do we need to attend to as children grow up, in turn leading to various theories about child development. There were the important questions explored by Aichhorn and Anna Freud about the impact of early attachments, and the possible long-term psychological effects of specific problems in those primary relationships. There were other important questions, such as Anna Freud’s attempts to provide a framework for how we think about children’s adaptive capacities, Fritz Redl’s curiosities about how we might find better ways do deal with violently aggressive children or “the children who hate,” and Bettelheim’s attempts to understand the existential issues which seemed to be associated with childhood psychosis.

The issue of whether the conclusions reached by pioneers such as these were correct or not is of less importance in this discussion than the fact that they lived in a climate where such questions were taken seriously. And the danger of today’s scientistic climate is the tendency to conclude that because the scientific method doesn’t work so clearly for such questions, they are either unimportant or wrong. This rigid “pragmatism” of our time betrays a stunning lack of curiosity about the problems it cannot solve. It is a dangerous atmosphere which encourages facile, morally bankrupt responses to the sometimes unfathomable richness of the textures of human existence and culture. The scientistic dehumanization of human experience and culture has been perhaps nowhere more clearly indicated than in B. F. Skinner’s (1953) proclamation that culture is no more than the accumulation of social reinforcement contingencies by a group, a pronouncement which has in recent times become the anthem for much of modern-day objectivism. From this perspective, the values and intellectual achievements of a particular culture are reduced to the status of reflexive responses to environmental pressures. In this view of humans as no more than passive objects of environmental influences and manipulation, social contingencies, or the behaviors they generate, become the “ideas” of a culture, while the reinforcers that appear in the contingencies are said to be its “values.” Extreme forms of objectivist “pragmatism” thus purport to offer yet another “final solution” to the problem of understanding humanity and culture, but instead, some might claim, it vacuously creates a barren caricature of culture, ignoring the complexity, depth, and darkness of human life.

On the other hand, staunch opponents of the more rigid forms of the objectivist perspective warn that individual freedom, will, choice, creativity and imagination are all ultimately in danger of succumbing to the exclusionary claims of this type of scientistic thinking. It is probably more reasonable, however, to resist absolutist views of the effects of social influence and post-modern convictions about social-embeddedness, as well as the belief that humans can function as totally autonomous agents. In other words, the experiential gap between social influence versus freedom seems rather to point to a conception of “relative freedom,” where there is a recognition that even as “free agents,” there is no ultimate resolution of the indeterminacies of life, either by an ever-more careful attention to our “authentic selves” or by a dedication to discovering our “true aims” (Hoffman, 1998).

Rather than siding exclusively with either the claims of social influence or of total human freedom, a conception of “relative freedom” requires that we develop the capacities to create the most skillfully-crafted, well-informed syntheses that we can realize with regard to the decisions and choices we must make in the face of the ambiguities of life. To make a closely paraphrased extrapolation from Hoffman’s observations about the dialectical-constructivist clinical perspective, it is a conception of agency which acknowledges that there are indeed both given known and unknown limitations to our sense of freedom. In this sense, it is acknowledged that human experience is essentially heterogeneous, and that we can never know, particularly in light of the many contingencies that are beyond our control, what it would have been like to follow certain life courses not taken. The result of these factors, and others, is a sense of more or less acknowledged existential uncertainty, a sense of indeterminacy that accompanies whatever path is chosen, whatever decision is made, despite whatever degree of conviction we might bring to it. The responsibility to make choices in the context of irreducible uncertainty is highly disturbing. However, grasping at external guideposts for direction, whether beliefs in the ultimate effects of “social influence” or absolutist tenets about human insight or “freedom”, probably serves mainly as a defense against the responsibilities we all face in making important choices for our own life actions (Hoffman, 1998, 25-26).

Introduction.

2005-12-13T20:11:00.000-08:00

In the Beginning

The practice of contemporary psychonalysis is completely different today, and quite unlike the public perception and presentation of psychoanalysis. Thinking about psychoanalysis, one might begin with a discussion of the attacks upon Freud, which really are assaults upon the concept of being human. The attacks upon Freud, however, are made by those who are afraid of him. Those who are not afraid of him are free to think about what parts of his theories still apply today, and which do not. Further, when not influenced by the power of the fear of Freud, it becomes possible to think about how the transformation of some of his ideas (i.e., within the context of todays world) might make them quite useful in psychoanalysis, as well as in everyday life.

The following discussion about the attacks upon Freud is drawn from an article that I published,entitled "The Human Toll of Scientism":

Scientistic thinking would have us believe that we can achieve truth about our conscious selves and experiences, where in reality there are some human things which are indeed factual, but many other important human things which are more ambiguous and indeterminate.

The emergence of today's profusion of rapid-repair home remedies geared to temporary narcissistic rejuvenation may be seen as a response to the refusal to recognize the mysterious and sometimes tragic dimensions of life, which are in turn anchored in the ambiguities of both unconscious and conscious dimensions of human experience.

It is this broader rejection of ambiguity and uncertainly in our everyday lives which fosters the illusory hopes offered by the present-day explosion of self-help books about diet programs, exercise plans, techniques for finding the right romantic partner, practical schemes promising the quick accumulation of financial wealth, and various homespun remedies for the alleviation of specific neurotic symptoms.

Each of these practical strategic programs promises shortcuts to a particular version of human happiness, claiming to have exclusive knowledge about what the elusive nature of that happiness really is. The tunnel-visioned conviction that there are such shortcuts to human perfection signals a culture which is all too eager to ignore the deep, complex, and often darker dimensions of human existence.

But the driven cultural repudiation of Freud, and by implication of psychoanalysis and most forms of verbal psychotherapy, is not just a repudiation of the deep and unconscious dimensions of human experience, but it really involves the more broad-ranging attempt to avoid the more troubling questions about both unconscious and conscious human motivation and what makes life meaningful for an individual.

There are, of course, specific political implications of the scientistically-based cultural view that ignores the ambiguity of much of human motivation. The short-sighted approach to meaning as valid only to the extent that it is revealed by the straightforward application of reason results in a particular opinion about what citizens are like in our democratic society.

This view depicts humans largely as preference-expressing political atoms measured by political polls, or as consumer units reflected by the fluctuations of daily stock-exchange reports. In both cases, society becomes an aggregate of these atoms, and the only irrationality recognized in their existence is the failure of these preference-expressing units to conform to the rules of behavioral, learning, or rational-choice theories.

In contradistinction, the claim of psychoanalysis is that the world is not entirely rational, and the techniques of psychoanalysis are partly an attempt to take the ambiguities of both unconscious and conscious motivations into account in ways that makes them less likely to disrupt human life in confusing and sometimes destructive ways.

The attack upon Freud then becomes less an assault upon the father of psychoanalysis as upon the idea of indeterminacy in life, an attack upon the belief that that we are free agents in determining the courses of our lives, but also that as free agents there is no final resolution of indeterminacy through ever-more careful attention to ourselves in the efforts to determine our "true" aims and to decide which compromises in life are ultimately "best."

With the acceptance of this kind of indeterminacy, there is an awareness that ambiguity is not temporary, but rather that ultimately ambiguity is irreducible. Human choice always involves choosing one course of action, while abandoning others, some of which may be in some respects equally preferable.

The attempt to restrict the foundation of human choices to empirical rules obscures the ambiguity inherent in many of our important decisions by creating the myth that there are some good ways and some bad ways, and that ultimately we can always come to "know" the differences between those paths.

But in many important decisions to do something, there is no linear, temporal relationship between thought and action. In those cases, our choices emerge largely as an expression of an indefinite number of both formulated and unformulated influences within the individual's experiences.

The scientistic assault represents an evasion of the belief that humans are in the painful condition of having the potential to make more meanings than we can knowingly grasp, an evasion through the flight into the illusion of scientific certainty and the wish that human choices could ultimately be technologically rational.

But in fact, since there are many things which cannot be found out by the methods of natural science and practical reason, the conviction spreads within our culture that we do not need to find out about these things. And then, since we do not need to find out about certain things, in a sense we come to live in the fantasy that somehow we already know about all of the things that really matter. This illusory equation of science with certainty as leading to a culture of "knowingness."

With the glorification of the rational mind, pure reason becomes associated with the belief that only it can solve any problem, an association which is made possible by the fact that it cannot or refuses to acknowledge the kinds of existential problems it cannot methodically solve. The claim to "already know" distorts any real attempts to discover or find out about dimensions of meaning and life which do not conform to the belief that practical reason can solve every problem.

This is the true essence of the attacks upon Freud and psychoanalysis, the advancement of a dangerous belief that if psychoanalytic ways of thinking can be empirically discounted, there will no longer be any need to either recognize or account for the fact that ultimately the world of human motivation and meaning is ambiguous.

In other words, killing Freud ultimately stands for a reaffirmation of the scientistic self-assurance that all real human problems can be both formulated and resolved solely through the readily apparent, methodical application of practical, scientistic reason.

Unfortunately, it also stands to some degree as a renunciation of the uniquely human freedom we each exercise in ultimately being responsible for choosing our own particular courses of action in life.

Chapter I.

2005-12-13T20:08:00.001-08:00

BEHAVIORAL AND COGNITIVE-BEHAVIORAL THERAPY APPROACHES

(First Version)

PROLOGUE

In a time of concern with policies of managed care, more limited financial resources and reduced lengths of residential treatment for troubled children and adolescents in the United States, we seem to be confronted ironically with an ever larger number of children who are growing up in circumstances of social disorganization and personal despair. This dilemma is further complicated by the fact that short-term behavioral and cognitive-behavioral methodologies currently have come to the forefront in many aspects of group and individual treatment for children and adolescents in the United States. The discussion focuses upon a critique of some potential impacts associated with those perspectives upon individual and group treatment, as well as upon our views of the individual and culture in general.

This discussion does not attempt to present an exclusively rejecting, strident criticism of the medical model or behaviorally-oriented therapies. The intent is more simply to point out some of the limitations of relying exclusively upon those perspectives. A continued awareness of those potential consequences is essential to mitigate their potentially anti-therapeutic effects.

ISSUES NOTED IN SELECTED OUTCOME AND FOLLOW-UP STUDIES

Despite the great popularity of behavioral and cognitive-behavioral models of residential treatment at the present time, there are real difficulties embedded in the shift to therapies based upon these theories in group care. As one example of such models of group therapy, a major problem in social skills training groups based upon cognitive-behavioral techniques involves the lack of generalization of skill gains. Schneider [66] used a meta-analyis of 79 social skills training studies published between 1942 and 1987 and found that, overall, short-term effectiveness was only moderate, with only nine studies using follow-up intervals longer than three months. Beelmann, Pfingsten, and Losel [67] applied meta-analysis procedures to the effects of 49 studies published from 1981 to 1990 and found that social skills training was moderately effective in the short term, but that there were no significant follow-up and long-term effects. Grizenk, Zappitelli, Langevin, Hrychko, El-Messidi, Kaminester, Pawliuk, and Stepanian [68] concluded that although many single studies have demonstrated moderate short-term positive effects for social skills training, there is still no strong evidence that supports a conclusion that such programs have had significant long-term effects. Further, they note, even when a combination of several training modalities (modeling, reinforcement techniques, cognitive problem-solving, self-control training) has been utilized, the problem of poor generalization remains.

A THEORETICAL CRITIQUE

With regard to the classical behavioral approaches, Staddon [69] argues that only some things that animals (and by inference humans) do can be selected through operant reinforcement and that real-life social questions cannot always be the subject of meaningful experiments. Further, he argues that knowing the causal chain or predictability of events does not necessarily deny the existence of human free agency or the genuine feeling of freedom and that human behaviors, preferences, and learning are not solely dependent upon past experiences or past histories of reinforcements. In terms of cognition, Staddon readmits the importance of internal private events, as well as the world of both conscious and unconscious realms of cognition.
Staddon is also somewhat equivocal about the advances of more contemporary models of cognitive psychology. For example, cognitive-behavioral psychotherapy depends heavily upon the concept of cognitive “schemas,” which in turn depend upon an assumption that internal mental representations truly exist. On the one hand, Staddon admits that a few ingenious studies provide results that are consistent with the idea that some perception involves a “mental representation” with properties quite similar to the real object. Unfortunately, according to Staddon, modern cognitive psychology assumes that those few studies are perfectly general, that the “copy theory” of perception is universally valid. However, Staddon cites other studies from the field of artificial intelligence, which argue that that there is no special internal cognitive representation of the external world. Those studies propose that such representations are unreliable by-products of the unintelligent action of more or less independent, simple cognitive processes.
In other words, the world of schemas and cognitive distortions common to cognitive-behavioral therapy may not be as scientifically demonstrable as we have been persuaded in part by the excitement of developments in that field. Therefore, Staddon advises that we should continue to value the subjective, phenomenological domain of our lives, even if positivistic science has nothing to say about it. “…[Surely}, phenomenal experience is worth something…After all, percepts seem to be so rich, so detailed, so real. About the vividness, we can say (scientifically) nothing. But about the richness of detail, we can say at least this: If the brain is a classifier, it is a very capacious one” [70].

CONCLUDING THEORETICAL NOTES

Considering the rather major shift to models of shorter-term behavioral and cognitive-behavioral treatment in residential care, at a more general theoretical level it is important to emphasize that the early forms of radical behaviorism did much to eliminate intra-psychic issues and matters related to “the mind” from psychology. In other words, the subjective world of man came to be seen as “off limits” for empirical psychology, since it was not directly observable. In more recent years, that trend has been somewhat reversed, and the mind has been readmitted as a subject of legitimate inquiry for psychology with the advent and popularity of cognitive-behavioral theories and techniques. However, the version of “the mind” that was initially re-admitted to psychology by the cognitive-behaviorists was an objectivist model, the mind as something akin to the computer with specific rules, formal systems, and cognitive representational schemas.
This relatively “scientific” model of the mind was a basically a pragmatic one, marginalizing the realm of human unconscious meaning. Proposing that any real human problem could be posed and solved solely through the application of practical reason, this new version of the human mind in psychology lacked a sense of real depth, an interest in the myriad layers of meaning that might be obscure to our to our own immediate understanding, in favor of a view of ourselves that was more or less completely transparent and immediately knowable to ourselves [71].

As noted earlier, the shifts from psychodynamic to behavioral and then cognitive-behavioral therapy techniques in residential care were later associated with the proliferation of social and life skills therapy groups as didactic enterprises. However, it may well be that either behavioral or classical cognitive-behavioral therapy approaches presented in didactic, manualized treatment programs may not suffice for the real development of firm intrapsychic, social and life skill growth. Such manualized treatments are based upon a number of fictions, including: (1) that there are such things as an average patient with an average case of a particular disorder; (2) that teaching or treatment will inevitably progress from step or stage A, to B, to C in an invariant progression; (3) and that patients will eagerly give up their symptoms.

It is probably more true to the matter that people are quite attached to their symptoms and difficulties, and that no amount of teaching of behavioral or cognitive skills can predict if and when they will give up their difficulties or learn the proposed skills. That depends on when or whether they decide to let go of their problem behaviors. Emotional difficulties and problem behaviors are not like viral or bacterial infections that have a natural course when treated with an antibiotic. In the case of intrapsychic and interpersonal competencies, the cognitive-behavioral approach is still a matter of talking with real people about real choices about which they might or might not be able to make personal decisions and life changes over time. Said otherwise, young people are relatively free agents in terms of whether or not they want to develop new social and behavioral competencies, and later in terms of whether or not they want to enact them.

Another crucial point is not simply that the shorter-term methods may be seen as trivializing the critical existential issues in clinical practice. The objectivist theories underlying those methods also minimize the very worth of asking the kinds of questions that motivated the early founders of residential care for children, because those questions were about inevitably indeterminate human qualities. There were the important questions explored by Aichhorn and Anna Freud about the impact of early attachments, and the possible long-term psychological effects of specific problems in those primary relationships. There were other important questions, such as Anna Freud’s attempts to provide a framework for how we think about children’s adaptive capacities, Fritz Redl’s curiosities about how we might find better ways do deal with violently aggressive children or “the children who hate,” and Bettelheim’s attempts to understand the existential issues which seemed to be associated with childhood psychosis.

The issue of whether the conclusions reached by the early pioneers was correct or not is of less importance in this discussion than the fact that they lived in a climate where such therapeutic questions were taken seriously. And the danger of today’s scientistic climate is the tendency to conclude that because the scientific method doesn’t work so clearly for such questions, they are either unimportant or wrong. This rigid pragmatism of our time betrays a stunning lack of curiosity about the problems it cannot solve. It is an atmosphere that encourages facile responses to the sometimes unfathomable richness of the textures of human existence and culture. From the objectivist perspective that the individual’s personality and behaviors are no more than the accumulation of social reinforcement contingencies, the values and intellectual achievements of a particular individual are reduced to the status of reflexive responses to environmental pressures. In this view of humans as no more than passive objects of environmental influences and manipulation, social contingencies or the behaviors they generate, become the “ideas” of a culture, while the reinforcers that appear in the contingencies are said to be its “values.” Extreme forms of objectivist pragmatism thus purport to offer a final answer to the problem of understanding humanity and culture, but instead, some might claim, it creates a barren caricature of culture, ignoring the complexity, depth, and darkness of human life.

On the other hand, some opponents of the more rigid forms of the objectivist perspective argue that individual freedom, will, choice, creativity and imagination are all ultimately in danger of succumbing to the exclusionary claims of this type of scientistic thinking in psychotherapy. It is probably more reasonable, however, to resist absolutist views of the effects of social influence and post-modern convictions about social-embeddedness, as well as the belief that humans can function as totally autonomous agents. In other words, the experiential gap between social influence versus freedom seems rather to point to a conception of “relative freedom,” where there is a recognition that even as “free agents,” there is no ultimate resolution of the indeterminacies of life, either by an ever-more careful attention to our “authentic selves” or by a dedication to discovering our “true aims” [72].
Rather than siding exclusively with either the claims of social influence or of total human freedom, a conception of “relative freedom” encourages the development of a capacity to create the most skillfully-crafted, well-informed syntheses that we can realize with regard to the decisions and choices we must make in the face of the ambiguities of life. To make a closely paraphrased extrapolation from Hoffman’s observations about the dialectical-constructivist therapeutic perspective [73], it is a conception of human agency capable of acknowledging that there are indeed both given known and unknown limitations to our sense of freedom. In this sense, it is acknowledged that human experience is essentially heterogeneous, and that we can never know, particularly in light of the many contingencies that are beyond our control, what it would have been like to follow certain life courses not taken.
The result of these factors, and others, is a sense of more or less acknowledged existential uncertainty, a sense of indeterminacy that accompanies whatever path is chosen, whatever decision is made, despite whatever degree of conviction we might bring to it. The responsibility to make choices in the context of irreducible uncertainty is highly disturbing. However, grasping at external guideposts for direction, whether beliefs in the ultimate effects of “social influence” or absolutist tenets about human insight or “freedom,” probably serves mainly as a defense against the responsibilities we all face in making important choices for our own life actions [74].

Chapter II.

2005-12-13T20:08:00.000-08:00

In process.

Chapter III.

2005-12-13T20:05:00.000-08:00

In process.

Chapter IV.

2005-12-13T20:02:00.000-08:00

In process.

Chapter V.

2005-12-13T20:01:00.000-08:00

In process.

Chapter VI.

2005-12-13T19:58:00.000-08:00

In Process.

The Restoration of Hope

Table of Contents

Preface

Introduction.

Chapter I.

Chapter II.

Chapter III.

Chapter IV.

Chapter V.

Chapter VI.