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Thoughts on Psychotherapy and Speculations About Its Star Trekian Future

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Are mild tremors beginning to shake the foundation of psychotherapy? Is a small crack or two beginning to appear? Some believe so. But first, a bit of history.

Years ago, when psychoanalysis made its initial splash in America, it was called the "talking cure." With its emphasis on the unconscious, sexuality and insight, it dominated psychotherapy for five decades. Freud's disciples slowly splintered the original theoretical model and started their own fiefdoms, but the overarching framework of unconscious processes remained in tact. In the history of psychotherapy, this method can be called the Old Testament.

In the 1960s, the behaviorism model emerged. Based on the observable instead of what lurked behind the curtain of consciousness, this New Testament morphed into an amalgam of behavior and conscious thought. Built on university-based empirical research, it eventually became known as Cognitive Behavioral Therapy (CBT). The Freudian dynamic, while not totally discarded, had lost its sizzle. Intellect had supplanted emotion as the focus of therapy.

For decades CBT has dominated the therapeutic landscape. Research has supported its seeming ability to treat a variety of psychological conditions. In addition, it's an "add on" in the treatment of many physical ailments. Most likely, an internist treating insomnia will prescribe medication and recommend CBT as well. Likewise for both pain management and dealing with chronic disease.

Science marches on. Or does it?

Jerome Kagan, an eminent developmental psychologist, argues that CBT "may be on the verge of losing its effectiveness." In his new book of essays, Psychology's Ghosts: The Crisis in the Profession and the Way Back, he speculates that major psychotherapeutic belief systems have a life span of approximately 50 years and, like psychoanalysis before it, CBT's half century is just about up.

He argues that, over time, the excitement of the method declines, thus slowly eroding the practitioner's faith in the ritual. This, in turn, is subtly communicated to the patient, resulting in treatment no better than other methods.

Given CBT's top-of-the-food-chain status, this controversial argument rocks the boat. This is no mere speculation. As noted by Kagan, research is beginning to show chinks in CBT's armor.

While the 50-year hypothesis has merit, there may be a few more variables in the equation.

Let's explore this via analogy. If you take an analogue videotape and make a copy of it, the quality of the image will be slightly degraded. If you make a copy of the copy, the image degrades a bit more. By the time you get to the fourth generation of that tape, the image has degraded dramatically.

The first generation of cognitive behavioral therapists -- or any therapy -- experiences the excitement of a new belief system. They in turn train others and the process continues through the years. That's probably four generations of therapists over that 50-year period of time. In other words, it doesn't matter whether the method was developed by Freud, Fritz Perls, Eric Berne, Carl Rogers, Albert Ellis, Milton Erickson or Aaron Beck, that fourth generation therapist is far removed from the excitement surrounding the birth of the movement.

It should also be noted that, like psychoanalysis, CBT has become fragmented. At last count, there were seven different variations on the CBT theme, each with its own letters. This lends further support to the thesis that the energy behind the initial movement has been significantly diluted. Not everyone is a member of the same church now.

At its most basic level, psychotherapy has only one technique -- the spoken word. Therapists that can establish a quality therapeutic ambiance -- focus, emotional support, flexibility, some structured technique and the expectation for change -- are likely to be effective regardless of which orientation they have.

Kagan's observations beg the question about the extended future of therapy. Perhaps science fiction can provide an answer and offer a glimpse into what lies ahead. Though it is unlikely it will be built for centuries, the holodeck on the Starship Enterprise offers the possibility of a technologically-based psychotherapy.

The holodeck, Star Trek's 24th century Virtual Reality (VR) environment, created props, characters and background to evoke any real or imagined scenario or personality. Its computer-generated representations were indistinguishable from reality.

Given the programming capabilities of this kind of device, the therapeutic possibilities are fascinating. First, all sorts of fears and phobias could me more easily dealt with. Public speaking, flying, becoming more assertive or more social, learning to say no, etc., are ideal candidates for holotherapy.

Likewise, relationship issues could be addressed. Bring in a video of yourself and important others in your life and the device could generate holographic representations and program their behavior. You could watch yourself engage in healthy interactions, then replace the computer-generated representation with yourself and interact. Marriage counseling could benefit tremendously from a "watch first and then practice" therapeutic environment.

Rehab facilities could use holotherapy to have addicts practice sobriety by simulating their trigger environments, thus minimizing problems during their transition back to a daily routine.

Farfetched? Not really. First generation VR technology is already being used in a few phobia clinics with excellent results. Cost is the major factor limiting its use. We may be centuries away from computer programmed holographic realities, but they are an inevitability.

Technology, however, will never replace the need for the human connection. A sophisticated guide will be essential for a high tech psychotherapy to be effective. The therapists of the future will be those guides. The combination will make things more interesting -- and effective.

Beam me up, Scotty.

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