The Third Story

In one of my favorite musical satires, Tom Lehrer sings that during “National Brotherhood Week” (yes, there really was such a thing from the forties to the eighties) “to hate all but the right folks is an old established rule.”

The field of psychology has had more than its share of attitude polarization. As a graduate student, the humanistic psychologists were steadfastly at war with the behaviorists, the behaviorists poked fun at the Freudians, the systemic family therapists despised the psychoanalysts, and even the analysts fought deeply among themselves. Yet there were always those who struggled to build bridges, to find common ground. These were often the psychotherapy process researchers, looking for the ingredients common to successful outcomes among the various approaches.

In the field of autism, we have our own polarities: those who believe autism is caused by immunizations versus those who believe the cause is genetic; those who believe we are in the midst of an epidemic versus those who believe we are simply identifying and labeling more children; and those who believe the best treatment is behavioral versus those who believe the solution is psychodynamic or relationship based.

Although I proudly identify myself as a behaviorist, I suspect, like those who have identified the common ingredients of successful psychotherapy outcome, there is common ground to be had among all these apparent differences. In relationship to the question of whether or not the best treatment is either psychodynamic or behavioral, the data are apparently in, at least that’s what the surgeon general says, and that’s what the committees who agree on “best practices” would say. But here’s my personal story:


At my first "real job" out of graduate school, I was assigned two Special Ed classrooms to supervise, and a caseload of about ten children to see in individual, group and family therapy. Two of those children had been diagnosed with autism, and each of them had an interesting treatment pedigree. One of them had been a member of Lovaas' original research study, and had been designated as "cured" by his strictly behavioral methodology. The other child had a book written about the novel treatment approach taken, which turned out to be a very intensive form of psychodynamic play therapy in which the therapist essentially mirrored the child around the clock. The therapist, a woman named Rachel Pinney, also claimed this child was cured.

Both children were remarkably similar. They were highly intelligent, and each had savant qualities. The child treated by Pinney had memorized the entire LA bus system, along with time schedules, and could tell you how to get from anywhere to anywhere, including the best way to transfer. The child treated by Lovaas could build anything out of Legos, intricate jaw dropping structures. According to their parents, both children clearly made remarkable progress, despite the great differences in their treatment methods. Yet, both had many severe behavioral problems which necessitated them being in a special education setting.

Neither child had any friends, both were remarkably self centered, incapable or unwilling to consider another person's feelings, compulsive and prone to severe tantrums if they didn't get what they wanted.

At the time, I had been trained in both behavioral and psychodynamic methods. I primarily used behavioral methods in the classroom and psychodynamic methods in the therapy office. Eventually, I abandoned psychodynamic methods. After years of working "on the floor" with children, I frankly could see very little progress. The lack of progress was frustrating for parents, the children themselves, and for me.

Behavioral methods simply seemed to work better, although at the time they were receiving horrible press. The bad press was in a few cases warranted. There were places that used aversive methods, such as squirting water in children's faces, and even Lovaas himself was known to give an occasional slap or pinch under the table. But mostly, the bad press was unwarranted, and it was clear to me from my first two children with autism that the claim that behavioral intervention turned kids into robots was ridiculous. It was ridiculous because the robotic affect that does sometimes accompany autism was clearly a hallmark of the disease, and not a result of treatment. The child who was lovingly mirrored into psychodynamic health was just if not more robotic in his affect as the child who had been treated by Lovaas.

It has long been said that if you get three experienced clinicians together who approach their work from vastly different theoretical perspectives, and have them all observe the same therapy session, they will all agree on which therapists are most competent, and the extent to which the sessions represent "good therapy". They will, however, each describe the reasons for their determination with their own language, giving vastly different explanations.

The kind of therapy my first two children with autism received couldn't be more dissimilar. Yet both methods did share some common ingredients. Both were extremely intensive, which is to say that each child received over 40 hours a week of therapy. Their therapy was their lives. Both methods were quintessentially individualized. Behavioral protocols were designed specifically to meet the child's needs, and those protocols were changed frequently as the child mastered new skills, responded to some interventions and less to others. Psychodynamically, the child received the therapists' undivided attention, and the therapist did all she could to fulfill the rapidly changing wishes and needs of her client. Both children received attention that was no doubt caring in nature. And there can be no doubt that despite efforts to mirror and lead, it is unlikely that there weren’t subtle prompts occurring that pointed the way to progress.

These ingredients may contribute to the potency of all therapeutic interventions: the intensity of the treatment, the loving and caring attitude with which the interventions are delivered, and an individualized (as opposed to cookie-cutter) approach. One should never underestimate the power of these ingredients.

Perhaps it is natural to polarize. The Talmud states that there are three sides to every story. Those of us who work in any field are typically well-versed in our own story, and hopefully we are fairly well-versed in the stories our competitors tell. It behooves all of us, however, to become versed not just in the two competing stories, but also in the third story. It is through our knowledge of the third path that we are most likely to reach the greatest depth of understanding.

[By the way, you can watch a video of Tom Lehrer singing “National Brotherhood Week” on YouTube at http://youtu.be/CgASBVMyVFI, and Rachel Pinney’s book, titled “Bobby,” is available for under a dollar at Amazon.com.]

Flying

I have spent most of my adulthood as a child psychologist. (That is probably because I spent most of my childhood as an adult psychologist, but that is another story.) In the last decade I have had the good fortune of indulging in a hobby that I had dreamed about most of my life—flying. The parallels between my vocation and avocation are at times striking.

As a pilot, the most important decision one often makes is whether or not to fly on a particular day: the decision to launch is often called the “go/no-go” decision, and one of the most important predictors of safety. It consists not just of checking the airplane, but also of checking all the circumstances surrounding the airplane, not the least of which is the weather. Airplanes have a way of doing exactly what you tell them to do: the weather doesn’t. What goes on around the airplane is equally as important as what goes on inside.

As a child psychologist and behavior analyst, what goes on around a child can be equally important to the successful outcome as what goes on inside. For those working with children, understanding the family environment is like understanding the weather for the pilot. It can predict the success or failure of your mission.

As a pilot, one must always be “ahead of the airplane,” a term that roughly translates to making sure that you have done the planning, practiced scenarios, and know how to operate the machinery so well that the airplane doesn’t lead you where it wants to go, but instead that you are in command of the direction and manner in which the airplane performs. As a behavior analyst, you always want to know where you are going, and it behooves a good behavior analyst to know what the goals are and be facile enough with one’s tools that one can react quickly to any deviation that may arise. While one should always have a plan, as both a pilot and a psychologist, one must be prepared at a moment’s notice to give it up and let it go should the unpredictable complexities of life demand an alternate course of action. But when an alternate course is necessary, both the pilot and the psychologist ought to have the tools and preparation to react swiftly and effectively.

Good pilots need to relax under pressure. It is well known that many accidents occur as a result of a pilot panicking under adversity and making nonsensical decisions. As a psychologist, children will sometimes surprise you by pressing buttons you didn’t even know you had, or raising the stakes with sometimes egregiously self- or other-destructive behavior. Thinking clearly and calmly under those circumstances (and remembering your training) can go a long way to positive outcomes.

And, as is true in nearly endeavor, practicing your skills and keeping current is essential. It is said in flying that experience is the thing you get as a result of not having any. And, of course for psychologists, it is no wonder that what we do is called “practicing”. We only get better by doing what we do over and over again, and constantly learning better and more effective ways of using our tools.