Over the past few decades the focus of psychotherapy increasingly returned to its emphasis on the internal state of the individual. While psychoanalysis focused on unconscious processes newer models emphasize a focus on thoughts, (such as Acceptance and Commitment therapy), management of emotions/self-regulation (such as DBT and Mindfulness), and even on neurobiological differences. While much has been gained from these new models they have the unintended consequence of narrowing our focus to the individual, and neglecting the context or structure that influences the individual.
I was reminded of this unfortunate narrowing by two very different sources. First, I just finished reading Michael Lewis’ excellent new book, The Undoing Project, on the work of Amos Tversky and Daniel Kahneman, two psychologists whose work have challenged many of the basic assumptions held by psychologists, economists and others (though there work has never explicitly address issues of therapy). Second, I recently held a series of sessions with a young boy and his parents regarding the boy’s food refusal (specifically, he refused to eat any but an extremely narrow range of foods, but if served these would readily eat them).
A summary of Tversky’s thoughts on the importance of context in understanding behavior:
Lewis relates how Tversky was asked to consult with Delta airlines regarding a pattern of pilot error that worried the airlines in the 1980s. Airlines efforts reported all efforts to work with pilots on their decision making had not lessened the problem. Tversky’s input was that the structure or organization of the flight crew was the issue. He noticed how the culture of the cockpit was such that pilots were never questioned and their decisions were always deferred to (i.e., crew members failed/were afraid to speak up) when the new the pilot was making a poor decision. The airline reportedly implemented changes that changed the culture of the cockpit, i.e., encouraged others to speak up and question the pilot’s decisions when they had concerns. This change greatly reduced error.
The clinical example is as follows:
The well-meaning parents detailed how they repeatedly had tried to induce their son to try other foods and be more flexible. Their efforts ranged from well-defined reward systems for trying new foods, to punishments for not trying new food, and lengthy lectures (from them and medical personnel) on the importance of nutrition. They reported considering a recommendation to go to an occupational therapist who did “food therapy” that involved having children purportedly become comfortable with different foods by playing with the foods. This psychologist was able to prevail upon the parents to let the boy eat what he wanted, to simply serve him the food he preferred and make this issue a non-issue. The parents proceeded, after some struggle, to implement this approach, and over time the child voluntarily tried new foods (in a developmentally appropriate fashion). Rather than changing the child, the parents changed the structure or context. For the record, strategic therapists have been recommending these approaches for years (see the work of Cloe Madanes, and Paul Watzlawick and his colleagues). Moreover, wise parents and adults have used “reverse psychology” for years. Perhaps the best illustration of this in the classic children’s book, “Bread and Jam for Frances” about a picky badger who only eats bread and jam until her parents allow her to only eat bread and jam at every meal.
The point: we need to remember to look beyond the individual to understand the behavior of the individual. This adage is obvious, when we stop to reflect on it, but all too often we lose sight of this wisdom and focus on the inner workings of the individual when the context is the key.