Modernism

 “In the varied topography of professional practice, there is a high, hard ground where practitioners can make effective use of research-based theory and technique, and there is a swampy lowland where situations are confusing “messes” incapable of technical solution.  The difficulty is that the problems of the high ground, however great their technical interest, are often relatively unimportant to clients or to the larger society, while in the swamp are problems of greatest human concern.”  (Donald Schon, 1930--1997)

Modernism, the prominent philosophic movement of the late 19^th and early 20^th century, embraced the promise of science and technology.  Science was believed to be the path to all meaningful knowledge.  Technology was believed to be the means to a better world for all.

In the day-to-day ethos of Western European culture, Modernism largely displaced religion, leading the German philosopher Nietzsche to pronounce that, “God is dead.”  The existentialist Nietzsche, though an avowed atheist, did not declare God’s death with joy, but with trepidation.  With the collapse of traditional religious values, he anticipated a great void, a void that science and technology could not fill.

Then came the horrors of a modernized 20^th century: two world wars, genocide, nuclear weapons, and environmental devastation on a global scale.  The world felt the void that Nietzsche had feared and prophesized.

For most of my career I worked in an academic, science-oriented milieu. Where I worked was committed to the values of Modernism, devoted to the belief that a better world, including better mental health, would come from science, research, and applied technology.

During my career as a child psychiatrist, I witnessed an exponential increase in scientific knowledge about the brain, about genetics, and about mental illness.  Some of what we learned was of great importance. We learned that autism is not caused by cold and rejecting parents.  We learned that schizophrenia is not caused by double-bind communication and schizophrenogenic parents.

However, along with the increased knowledge came an increased number of possible diagnoses and an increased number of children being diagnosed.  Unfortunately, a diagnosis doesn't necessarily translate to a better life.  It used to be rare to have 1 or 2 children in a school on Ritalin.  Now it is common to have 1 or 2 children in a classroom on stimulants or other psychotropic medications.

ADHD, autism, gender confusion, depression and suicide, drugs and alcohol, trauma and abuse; despite increased scientific knowledge the mental health challenges for children have only gotten worse. But why?

Modernism has fallen short of its promise. Science alone is not enough.  There is a piece missing. There is a game in academia called, "publish or perish." But much that gets published in the professional journals, though sounding quite erudite, is in reality quite trivial. Too much science and research pursues technical minutiae, all the while failing to wade into the "swampy lowland where situations are confusing." However, before we can discover better solutions, we must first learn to ask better questions, questions that address the "problems of greatest human concern."

The Clinician

“I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”  (Abraham Maslow, psychologist, 1908—1970)

In the arena of mental health care, there are three types of providers: the theoretician, the technician, and the clinician.

Sigmund Freud was theoretician.  His theory was psychoanalysis. Psychoanalysis was the tool he used to understand and treat patients.  Freud described his patients according to their ids, their defenses, and their superegos.  He placed patients on his couch and asked them to free associate. He would then make interpretations, trying to make the unconscious conscious. Psychoanalysis was Freud’s hammer.

B.F. Skinner was a theoretician.  His theory was behavior modification (specifically, operant conditioning). Behavior mod was the tool he used to understand his subjects, both human and animal.  Skinner described his subjects according to stimuli, rewards, and responses.  Skinner tried to modify the behavior of his subjects by reinforcing desired behavior and extinguishing undesired behavior.  Behavior mod was Skinner’s hammer.

In the mid-20^th century, psychoanalysis and behavior modification were the prevailing theories informing mental health care.  Each theory had its adherents, some of whom became theoreticians in their own right, expanding and rewriting the works of Freud and Skinner.  Some went on to develop novel theories, viewing mental health through new lenses, creating new and improved hammers.

There are only a few practicing theoreticians. There are far more technicians. A technician works with neither the depth of the theoretician, nor the breadth of the clinician (which I shall get to shortly). The technician works from one model, trying to implement and imitate the work of the theoretician. An informed technician reads journals and attends conferences. A skilled technician may be a warm, genuine, and imminently relatable individual.  Often aided by manuals and algorithms, many technicians are effective therapists.  However, the technician ultimately relies upon the theoretician’s hammer.

 In contrast to the theoretician and the technician, the clinician uses a broad array of lenses in order to explain, understand, and ultimately treat the client.  A clinician first listens, unbiased by any one theory, and then customizes a therapy suited to the unique needs, strengths, and challenges of the presenting client.  The clinician is a pluralist.  The clinician knows that no single theory is sufficient to understand human complexity.  The more theories that are understood, integrated, and utilized, the clearer the understanding of the client.  The clearer the understanding of the client, the better the chances for a successful outcome.  For any one theory, the clinician may not have the theoretician’s depth of understanding.  However, the clinician has a breadth of understanding and a range of tools that the theoretician often lacks.

Whenever I taught psychotherapy, I wanted to inspire future clinicians.  I taught multiple psychological and behavioral theories, believing that each model taught was another tool added to the student clinician’s toolbox. With multiple tools in the box, the student was less apt to enter into practice seeing only nails and using only hammers. By providing them with multiple tools, I tried to prepare students for the craftsmanship of clinical care.