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Skin Deep: Our Self-Defeating Resistance To Empathizing With “Superficial” Evidence-Based Therapy Models

– M. Chet Mirman, Ph.D.


In recent decades, the clamor for evidence-based techniques has been pushing aside the values of self-awareness and relational wisdom among psychotherapists. Larger cultural forces have contributed to this trend, but this paper will explore the role played by our lack of empathy for, and our own collective narcissistic dismissal of, the “superficial” other.

The Problem

Depth therapists of various stripes have watched with dismay as much of the therapy world has “evolved” toward a scientific philosophy in which subjectivity, self-awareness, empathy, attachment, and relational wisdom have lost their value. This is due, in part (although not entirely), to the belief that the assumptions and methods of the sciences are equally applicable to all other disciplines – including all areas of psychology and of mental health. Many therapists insist that psychology is a science, and that what we do should be based on that science.  Essentially, they are claiming that therapy is a kind of technology.  The unacknowledged Holy Grail has been the development of a diagnostic system through which every psychotherapy patient can be placed in a single diagnostic category, with each diagnosis having a specific evidence-based, manualized treatment for it.  For Diagnosis A you would have Treatment X, for Diagnosis B you would have Treatment Y, and for Diagnosis C you would have Treatment Z.  Now, it is true that manualized treatments can sometimes be helpful for alleviating the symptoms of some narrowly defined problems (e.g., systematic desensitization for some kinds of phobias). However, in 33 years as a practicing psychologist, I have never had a symptom walk into my office – only complicated human beings who are struggling in their lives. Many do indeed have an identifiable symptom or set of symptoms.  And while many present with a specific problem that they want addressed, as the therapy unfolds, the narrative they have created to understand their suffering inevitably evolves as well.

Jacob Bronowski (2002), a cell biologist at the Salk Institute of Biology, talked about human beings as being both a self and a machine.  He argued that these are two qualitatively different kinds of knowledge:  Knowledge of the machine is physical science, while knowledge of the self can be found in literature. Many of our colleagues have made the mistake of trying to make psychology, and all of mental health for that matter, about the machine.

We are machines, and more of more of what has seemed impenetrable to science has been steadily falling under science’s purview anyway. But therapy is supposed to be about re-humanizing people who have in some way, in some area or areas of their lives, been de-humanized.  That, in my eyes, should always govern the therapy process even if it’s true that we are also machines. Yes, let’s do basic research in psychology. Yes, let’s study clinical syndromes.  And yes, let’s do outcome studies.  But these should inform — not control — what we do as clinicians.

As a result of the pursuit of the Holy Grail of fixing the machine, psychoanalytic thinking has become marginalized, despite Freud’s attempt to develop a psychology that he thought would one day, when the science of the brain caught up, be reducible to Newtonian concepts. His model of the psyche was, after all, essentially that of a complicated hydraulic system that was clearly developed with a nod to Darwinian evolutionary principles.  Nevertheless, unlike the condescending dismissal of humanistic and existential points of view, psychoanalytic ideas have come to be treated with open hostility.

Hostility towards psychoanalytic ideas was illustrated in stark relief by the following example:  I was, for a while, a member of an Evolutionary Psychology listserv.  A wide variety of topics of relevance to evolutionary psychology were regularly presented, discussed and debated – but always in a respectful spirit of openness to ideas that were new or different, even if there was disagreement. This came to a screeching halt when one day a participant made reference to a psychoanalytic concept.  The response to this reference was shocking to me.  It was not one of respectful disagreement – it was a venomous attack.  I might have just dismissed this as the ranting of an outlier participant, however, it was followed by a chorus of similar attacks. I could practically see the spit flying from their mouths as I read their responses.  “This is really weird,” I thought. I had always known that Freud’s statement that disagreement with a psychoanalytic concept could be an expression of defensive denial that effectively validated that concept, but I was – naively, in retrospect — surprised to see this kind of angry defensiveness in a professional discussion.

I’ve agonized as I’ve watched superficial, often dehumanizing ways of thinking about human beings – especially so called evidence-based approaches (generally code for cognitive behavioral therapy) — take over not only mental health care, but also wide swaths of the larger culture. This can be seen in:

1) the corporate world (with its emphasis on productivity and efficiency);

2) medicine (with its interest in stress reduction, brain chemistry, and the dysfunctional thoughts that are thought to underlie depression and anxiety. Whereas I used to receive referrals from physicians to treat a patient with anxiety or depression, those are now referrals specifically for CBT with patients with anxiety or depression); and,

3) insurance companies (an understandable development as CBT’s commitment to brief therapies appeals to bottom line concerns, but I was really taken aback some years ago when I found myself accused of malpractice by an insurance company gatekeeper for not using CBT with a depressed patient I was working with).

I have been alarmed to both hear about and personally witness clinical supervisors who claimed that therapy that doesn’t use manualized CBT protocols is outdated and clinically unsound. Perhaps most disturbingly, I have watched it take over our training programs – including the graduate program in clinical psychology from which I recently retired. This last trend is, I suspect, a result of the changing orientations of faculty bodies brought on by the lack of psychoanalytic education of the new guard, pressures from the American Psychological  Association, and not least of all, lack of interest by the students in more complicated orientations. In the free market of a graduate training program – particularly in the for-profit schools that see students as paying customers and therefore a market that needs to be accommodated — this is a problem for those of us who believe that young, inexperienced students might not always be the best judges of clinical wisdom, of who has it, and of how to attain it.

The Source of the Problem

Writers such as Nancy McWilliams (2005) and others have pointed out the roles played in contributing to this disturbing trend by:

1) the popular hunger for simple, easily understood, quick fixes;

2) by academic pressure from research institutions; and,

3) by economic pressures from insurance companies.

However compelling and disturbing these stories may be, I would like to suggest here that some of the fault can be placed on the doorstep of psychoanalytic therapists and theorists who have been building taller in-house silos but fewer bridges to the rest of the world.

Granted, some of the difficulties we face in trying to reach others are intrinsic to the process of learning to think psychoanalytically.  First of all, psychoanalytic ideas are complex and therefore more difficult to learn and understand than some other theories – particularly when compared to CBT, which happens to be relatively easy to learn and thus something that can be taught quickly, is much more intuitively obvious to a beginning therapist, as well as to the general public.  Secondly, the learning process involves more than simply learning some new ideas – it’s a different way of thinking, and, some might argue, a different way of living.  That makes it a tough sell in a world that seems to have less patience, a shorter and shorter attention span, and increasingly superficial attitudes and values (as exemplified by the obsession with Paris Hilton, the Kardashians, and Beverly Hills Housewives — and remember, therapists are part of this same culture).  This makes it all the more important that we reach out to others to try to help foster in them what McWilliams (2005) described as a kind of “alternative sensibility to the radically individualistic, consumeristic, technocratic mass culture we inhabit” (p. 139).

To be blunt, we have done a terrible job of reaching out to people who are not already in the fold. The International Forum for Psychoanalytic Education (IFPE) is a notable exception to the propensity in psychoanalytic circles to communicating in ways that seem designed to ensure that only members of the club can understand what other members are saying to each other. Good psychoanalytic therapists (actually, good therapists of any orientation) don’t insist that their patients enter their world.  In fact, we understand that we need to be empathic and enter the inner worlds of our patients.  Isn’t it, then, ironic that we would expect students (and other therapists) to enthusiastically enter the world of analytic ideas when there are more accessible paradigms available?

This expectation of others to enter our worldview strikes me as reminiscent of former Vice-President Dick Cheney’s claim that the Iraqis would greet American soldiers as liberators.  He simply assumed that they would, of course, want to be like us – because who wouldn’t?  And, of course, they would be eager to become a liberal Western-style democracy just like us. Instead of this solipsistic process, we instead need to reach out to others by being respectful and empathic, and by taking their ideas and values seriously.  Let’s learn more about the machine, and show respect for those who appear to be focused largely on this.   This will require facing our own resistance to doing so. I’d like to briefly explore that resistance, including the role played by our own collective narcissistic dismissal of the superficial other.

The Nature of the Problem

So why are psychoanalysts, especially the more orthodox among us, so resistant to reaching out to those whom they view as theoretically “superficial”, and whom many psychoanalysts assume have no depth or simply don’t get it?

Let’s face it – psychoanalysts can be, as a group, snobby and elitist. My own snobby bias about this would say that it’s because collectively we’re a more broadly educated group.  Those other practitioners may be scientists, but we psychoanalysts have liberal arts educations and therefore have more wisdom. Our conferences and journals incorporate existential ideas, integrate psychoanalytic thinking with Eastern philosophies, explore personality and developmental issues, and generally seem to be more intellectually ambitious. This is evidenced by the application of psychoanalytic ideas to the arts, literature, larger cultural trends and world affairs – not something that one sees occurring very often from the camp with a CBT perspective.  Many of the psychodynamically-oriented therapists I know thumb their noses at CBT ideas, creating an “us vs. them” mentality that puts us above them, and encourages us to view the supposedly simpler-minded CBT practitioners as the lesser “others.”  We should be careful about this and we should learn from Donald Trump and from our understanding of hate groups about the pitfalls of  “otherizing” different groups.  It seems so obvious when we look at him, but psychoanalysts do it too — maybe not as egregiously and perhaps not with the same harmful consequences to those out-groups, but we really do it too.  Yes, we’ve had to work hard to become members of the club, and yes, we too are just regular human beings who are subject to the same forces as everyone else.  Like everyone else we want the gate low when we’re trying to get in, but then we want to raise it up once we’re inside.  Under the wrong-minded assumption that because I’ve worked so hard to get in; I wouldn’t want to cheapen the value of membership by making it easy for the outsiders to get in after me. It’s really a lot like fraternity hazing.  I’ve heard many a talk that could have been just as insightful with less jargon and more language intended to communicate rather than obscuring the messages with psychoanalytic jargon designed to keep the outsiders outside.

As long as we continue to “other-ize” non-psychodynamically-oriented therapists and dismiss what they know as lacking in depth and therefore of no clinical or theoretical value, we will have no interest in what they might have to offer, no motivation to “go to them” by validating their point of view, or appreciating what they do have to offer, and then helping to put their thinking into a larger paradigm that includes their point of view. Essentially, I see CBT as a tool that can be part of a larger tool bag that a therapist could have and from which we can draw.  What CBT therapists have to offer is the idea that how people think affects how they feel, and therefore, how they behave.  Who can disagree with that so why would we want to denigrate something that’s so obviously true?

An example of how the two worlds might be integrated can be illustrated in the following:  Consider a borderline patient who is struggling with primitive abandonment fears. A CBT therapist might try to simply “convince” the patient that her fears are irrational and misguided (or to use the CBT term, “, than try to help replace that irrational thought with a more functional, or “correct” thought.  Personally, But what if, instead, the patient could be helped to see that much of her pain, her despair, her destructive behavior, her turmoil, her addictions, etc., were essentially ways to try to manage an intolerable state? That state is what an analyst might call a state of objectlessness, but what might be labeled for the patient as a terrifying feeling of disconnection. If the patient can be helped to see the powerful impact on her life of her primitive fear, along with the accompanying primal convictions about her core sense of shame, worthlessness and unlovability, and the many desperate things that she does to protect herself from that fear – particularly when she is in a state of need – she may become more curious about, and more open to, trying to transform the intolerable into a tolerable, albeit painful, state. Much like Freud’s notion about converting neurotic misery into common unhappiness, such apparently minor ambitions can lead to profound life changes.

This sort of conceptualization, simply stated, is not only relatively easy for a reasonably self-aware patient to comprehend, but it is also within reach for a non-psychoanalytic therapist who, upon hearing, could choose to reframe the problem as essentially systematic desensitization (or maybe a not-so-systematic desensitization) that targets abandonment and disconnection as the phobia to master.  Such a conversation with a more behavioral or CBT therapist builds a bridge by affirming the value of their point of view, rather than making them feel inferior for not understanding the analytic approach, a phenomenon that frequently leads to the ego-protecting dismissal of the whole psychoanalytic way of thinking.  I have frequently seen such a process occurring with young, graduate students learning to become therapists.

Another problem is the cumbersome, off-putting language we use (e.g., paranoid schizoid and depressive positions, where the depressive position is actually the healthy alternative; objects vs. others or people, explicit oedipal references – something that truly scares “nonbelievers” away — rather than discussions of sexual wishes as derivatives, and oedipal struggles are being triadic vs. dyadic internal relational matrices, etc.).

Certainly, with patients (especially relatively new patients) I am very cognizant of how my words will be interpreted. I try to use language that will lead my patients toward an understanding of what I mean, but which won’t automatically trigger defensiveness. Unless the patient seems open to such language I am inclined to refer to unconscious processes as tacit ones, and Oedipal vs. pre-Oedipal struggles as triadic vs. dyadic relationships. This is no less true when I am communicating with other therapists or therapists-in-training.  Isn’t the whole point to promote understanding by being understood? Isn’t that more important than demonstrating how deep and insightful we are, or protecting the exclusiveness of our club by making it difficult for non-sophisticates to be a part of the club?

I want to conclude by pointing out the following: CBT therapists are actually in the ascendance while we are moving in the other direction.  In fact, they are already in, and we are already on the outside.  Among psychotherapists they are clearly gaining in power and acceptance in the mental health system. So isn’t it counterproductive (and ironic) to be treating them like the outsiders?

  1. Chet Mirman may be contacted at:


 Bronowski, J. (2002). The Identity of Man. Amherst, NY: Prometheus Books.

McWilliams, N. (2005).  Preserving Our Humanity as Therapists.  Psychotherapy

            Theory Research & Practice, 42(2),139-151.

Source: Other/Wise International Forum for Phsychoanalytic Education