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An Interview with Robert Fancher, Ph.D., on Cultures of Healing

David Van Nuys, Ph.D. Updated: Apr 1st 2010

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Robert Fancher, Ph.D.The son of a Baptist preacher, Robert Fancher learned to value ethics (that part of philosophy concerned with knowing right from wrong) at a young age. He completed his doctorate in philosophy, having studied the Philosophy of Science, and worked in public policy until later deciding to become a psychotherapist. Dr. Fancher is known for his 1995 book, Cultures of Healing, which is notable for its criticism of the cognitive-behavioral school within clinical psychology, which he understands to be based on a provincial vision of the scientific enterprise; one more concerned with engineering outcomes than with understanding the natural world. Dr. Fancher finds that many psychological scientists and therapists simply swallow, unquestioningly, cultural traditions about the nature of the world and the best ways to study it that they have been taught in school, and go on to simply repeat these understandings, believing them to be Facts, rather than a particular and biased understanding of the true and ultimately unknowable underlying world. Therapists' embeddedness and lack of ability to criticise their own understandings blinds them to the fact that they have a worldview (one among many), and that these worldviews both have ethical ramifications that need to be explored, and also bias their interpretations. Many therapists do not attend to their role as moral agents with values and agendas that necessarily influence their clients. Therapists are taught to be 'value-neutral' towards their clients, but this is both an impossible and absurd stance, and also sometimes a damaging one (e.g., when therapists do not take an ethical position towards their clients' unethical behavior).

David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host. On today's show we'll be talking with my guest, Dr. Robert T. Fancher, about his book Cultures of Healing: Correcting the Image of American Mental Health Care.

Bob Fancher earned his Ph.D. in philosophy from Vanderbilt University with a specialization in action theory, the branch of philosophy that studies how thoughts, feelings, intentions, and choices shape what we do. After teaching for two years, then doing two years of research on education, he went back to school to become a psychotherapist. Bob graduated from the Blanton-Peale Graduate Institute, a psychoanalytic psychotherapy institute in New York. He practiced psychotherapy in New York City for 14 years. Currently he maintains a counseling practice in Portland, Oregon.

Bob's book, Cultures of Healing, is critically acclaimed, and has been used as a college text at Princeton, Rutgers, the University of Texas, Antioch, University of Oregon, and other places. Bob served on the editorial board of the American Counseling Association's Journal of Mental Health Counseling for three years. Bob has also published books and articles on education, sports psychology, and philosophy, and ghost written books, op-eds and speeches on health care, business, ethics, history, psychoanalysis and cooking.

Among his college teaching experiences, Bob has taught philosophy at Vanderbilt, the University of South Carolina, and New York University, psychology at the New School for Social Research and Marylhurst University, and literature in Seoul, Korea. He has been a Henry Luce Scholar and a recipient of a National Endowment for the Humanities' summer fellowship.

Bob is not and does not wish to be thought of as a clinical psychologist or any other sort of "licensed mental health professional." He is a person who has spent and spends his life trying to understand human suffering, its meanings, and its relief. He has not found the notions of "mental disorders" or "mental health" especially healthful in that quest.

Now, here's the interview.

Dr. Bob Fancher, welcome to Wise Counsel.

Robert Fancher: Well, thanks. I appreciate being here.

David: Well, I appreciate the opportunity to speak with you. One of my listeners brought your book, Cultures of Healing, to my attention and suggested that you'd be a great person to interview.

Robert Fancher: Well, it's nice that somebody thinks that. I appreciate your listening to them and giving me this opportunity.

David: Yes, right. Well, they thought that you had made an important contribution, and I didn't realize until you called my attention to it that the book is 15 years old. Somehow 1995 seems so recent that it's hard to believe it's 15 years ago already.

Robert Fancher: It shocks me sometimes to realize it.

David: Yes, I bet. But the Library Journal commented on the cover that it's "a landmark book." And I tend to agree with that assessment, and there are plenty of books on psychotherapy that are older than that, that are still considered authoritative.

Robert Fancher: Well, I appreciate that. I really do. At the time that it came out, I had some hopes for the field of mental health care that have not come to pass. There were several books that came out around the same time as Cultures of Healing that had somewhat similar messages. There was a book called They Say You're Crazy. There was Robyn Dawes' House of Cards. There was a book called Constructing the Self, Constructing America. There were several books that attempted to say, now, wait a minute - what's going on in mental health care is important, but what we're saying about it isn't correct. We're making claims we shouldn't be making. We need to stop and think about what we're really doing and try to be a little more humble and a little more honest.

And I was really glad to be part of that, but unfortunately, all of us put together, I think you've had exactly zero influence. I think that if this was a landmark book, it's a landmark on a continent that few people seem to want to travel.

David: It makes me think of Mt. Everest and…

Robert Fancher: There you go.

David: There might be a few things planted up there, some oxygen bottles and such, that most people don't come across.

Robert Fancher: Well, I appreciate that. That's good. I like that.

David: Well, before we get into all of that, let's get a bit on your background. I see that your Ph.D. is actually in philosophy rather than psychology, and yet you became a therapist. How did all that come about?

Robert Fancher: Well, honestly, David, when I was in college, like a great number of people who were attracted to psychology, I was attracted to it because I was pretty screwed up. You know, a lot of psychology students are trying to figure out how to help themselves, and a lot of people become psychologists in hopes of helping themselves. And honestly I thought that was a profoundly wrong thing to do. I just thought it was very wrong for people to go into a helping profession because they themselves were screwed up, so I didn't think it was right for me to become a psychologist, although I knew that what I wanted to try to study was how minds work, how minds, bodies, families, social milieus work together to promote well-being or not well-being. But I really didn't think I had any business becoming a clinical psychologist.

When I looked around at research psychology and more academic psychology, at that point I believed, as I still believe, that psychologists tend not to be very self aware about their assumptions. They tend not to be sufficiently methodologically self critical, so that there are profound assumptions shaping how they look at their data of which they tend not to be aware. And that was very disturbing.

It seemed to me that I could study what I wanted to study - how minds work - in ways that were more self aware, that involved more looking at our own assumptions and seeing how they shape our conclusions, if I was in a philosophy department. And I thought that was a pretty good thing to do, since psychology has only separated from philosophy within the last century. As you probably know, the earliest psychologists were people like John Dewey and G. Stanley Hall, who also were philosophers.

And, frankly, that worked out pretty well. I was really, really happy with the education I got in philosophy. I found philosophy departments at Southern Illinois and then at Vanderbilt to be very hospitable to my trying to look at a wide variety of data, a variety of social sciences and biology, as well as trying to understand the deeper assumptions as well as the ordinary philosophical stuff you have to learn to get a Ph.D. and to try to do something synthetic with all of that.

David: Was philosophy of science your specialty then?

Robert Fancher: That was more my second specialty. My first specialty we call action theory. Action theory is the current term that's used for what would have been called philosophical psychology 30 or 40 years ago, the sort of thing that John Austin would have done or Stuart Hampshire or some of those folks. So it was very much in a psychological tradition. In fact, if one reads psychology in some of the British universities, you're likely to do it in a philosophy department.

So my specialty was action theory, and then philosophy of science was a secondary concern because, as your question implies, if you're going to try to have a science of being human, you have some pretty serious questions to answer, and you might want to have some idea about what science itself is.

And frankly, one of my big criticisms of psychology is that - especially clinical psychology - is that some of the most self righteous clinical psychologists who are beating the drums about, oh, we must be scientific, know next to nothing about the history and philosophy of science, and they end up saying things that frankly are just stupid. They're very self righteous about it, and they tend to say very nasty things about the rest of us, saying that we're unethical and that sort of thing because we don't do science the way that they think we ought to do science, but they tend to have a very provincial, a very limited, notion of the history and philosophy of science. So, trying to understand the philosophy of science seems to me pretty important if you want to understand people.

David: Yes, and it's definitely something that I think our field needs in a complementary kind of fashion. I minored in philosophy as an undergraduate. I found that I was drawn to it and seemed to do surprisingly well in the philosophy courses. And one tends to go in the direction in which you do well and find some reinforcement.

Robert Fancher: Absolutely.

David: Now, at some point you went into psychotherapy for yourself. What drew you into psychotherapy generally and then, I gather, into psychoanalytic treatment in particular?

Robert Fancher: Well, it's a good question, and the answer to that has a lot to do with how Cultures of Healing came to be and what shape it took. Like a lot of… I grew up in Mississippi. My dad was a Baptist preacher. I came of age in Mississippi during the Civil Rights Movement. During the time when all of my wonderful adolescent maturation processes should have been taking place, I spent in fear of my life because I was very active in the Civil Rights Movement. I was literally shot at, fire-bombed, ambushed for a period of about two years. There was not a week that went by that there wasn't a fairly credible threat on my life.

So, as you may well imagine, with having a Baptist preacher dad and growing up as an extremely smart kid in rural Mississippi and dealing with the Civil Rights Movement, I certainly had a variety of issues that I needed to deal with. Like most people in their early twenties, I think you start off - at least of our generation; maybe this has changed - you start off trying to do it yourself. You study, you think, you try to find whatever resources you can, and at some point, if you're smart, you realize this just isn't working; I need somebody outside of myself. So that's sort of how I got into therapy as a patient.

In the meantime, I had gotten into doing… professionally I was making my living doing research on education and public policy concerning education, and that was a curious experience. I had nice success: I did a book with some other people called Against Mediocrity: the Humanities in America's High School that got a lot of attention and it got me a job at a think tank in New York. And it was really in New York that I decided I had to get serious about sorting out some of my own issues. My anxieties were just way too high and that sort of thing. And, frankly, I didn't really enjoy doing public policy work. I found it very… it's so riven with ideology; it's so partisan; it's so hard to do intellectually honest work in the public policy field that I didn't enjoy it, so I was looking for something else to do.

I still had all of the interests that I had had when I originally became a philosopher, and after I'd had a couple or three years of therapy, I felt like, well, maybe I'm not too screwed up to be a therapist. Maybe I'm at least within spitting distance of being healthy enough to be a therapist, and maybe what I need to do is just go back to school and pursue the interests that I've already had, in a way that's going to let me make a living and actually accomplish some good in a one-on-one way.

Now, why psychoanalytic? Become I was in New York.

David: Yes.

Robert Fancher: That's what you… you want to do the prestige thing. You want to do what's considered… I'm sure if I'd been in California, I would have chosen something else. The one reality is none of us ever knows what we're doing when we choose which field to get educated in. We don't know enough to know whether that field is correct.

David: Yes, that's true.

Robert Fancher: So we all, by the time we are in the position of having any expertise, we have a huge investment in believing we've made the right decision: we have investments of years; we have investments of energy; we have investments of our self image; we have investments in money. And it's very hard, I think, for people then to step back and say, "Wait a minute. Did I just spend three, four, five years becoming an expert at something that's wrong? Did I just spend three, four, five years submitting to the discipline of a discipline that's fundamentally lacking in its self criticism?" And not many of us can do that. That's a pretty hard thing to do. If we've invested three, four, five years in becoming expert in a certain field, we have a very large bias to believe that the things we've been taught are correct and the things we've been doing are sound.

And I think that one of the things… I think that's true across the board. That's just a human characteristic. I think one of the consequences that has for our field is that we don't realize how much of what we believe and how much of what we teach our patients is a product of our own cultures, a product of our own institutions, our own socialization. We learn to think certain ways; we acquire certain values, and we have a very heavy investment in continuing them and we pass those on to patients.

Going back to something you said earlier, we tend to go in the direction in which we do well and get some reinforcement. I think in the mental health disciplines what we tend to do is we tend to find something that makes us feel secure, and then we socialize patients into it.

David: Yes, this begins to get into your book, and the book's title is Cultures of Healing, and it's a phrase that runs throughout your book over and over again, and I think for you it has almost a technical kind of meaning. It's a technical term that you're beginning to get into here, so tell us what do you mean when you say cultures of healing?

Robert Fancher: All right. Think about the difference… cast your mind back, say, to the late part of the 19th century, when if you were English or German or French, you basically considered that your world view was the correct world view. You considered that the way you acted was the way to act. You thought that the proper ethics for good English gentlemen were simply the proper ethics period; i.e. you thought that all of your beliefs and your practices and your values simply reflected human nature.

Now, as you and I both know, in the 19th century as travel grew, as the Academy grew, as intellectualism became more professionalized, we began to see anthropology and then sociology develop as disciplines, and we began to say wait a minute. Most of what we think is simply human nature actually is something different - it's culture. It is a set of habits, beliefs, practices, perspectives, values, norms that have developed in a very local place, and what seems to be natural one place is not what seems natural somewhere else.

David: We take it on unconsciously, right?

Robert Fancher: Absolutely.

David: It's like the fish in water.

Robert Fancher: Absolutely. We take it in at our mother's knee, and it's just that's the way it is. Well, I'm saying that the same kind of thing happens as you become a mental health practitioner or a patient of a particular mental health practitioner. You take on a set of ways of looking at the world, of understanding yourself. You take on a set of values, you take on a set of practices, and they feel natural to you. They feel simply, well, this is obviously the way it is. Of course, across the street, there's a mental health practitioner who is part of a very different culture, different school of thought. He sees very different sorts of things as natural.

So the idea of cultures of healing was for me a way of beginning to understand the drastic diversity that you see within mental health care and how, within each culture, what they do seems right, looks right, feels natural; and particularly - this is one of the most crucial points - the ways that different schools of thought do science differs.

You know we have this image of ourselves as, well, we have deployed these scientific method on human nature, and therefore we know some things about what human nature is, where there are deviations from human nature. We understand how suffering results from failures of human nature, and we have these techniques to sort of restore things back to normal. But the funny thing is different schools of thought doing science come up with very different sorts of results, and that's curious.

Well, I think that's an instance of just what happens with cultures. You have different ways of looking at things; you evaluate evidence differently; you evaluate methods differently. Nor in fact, David, there's no such thing as the scientific method. When somebody talks about the scientific method, one of two things is happening: either they are revealing their ignorance, or they're proselytizing or propagandizing. In fact, there are all sorts of scientific methods, and generally, in most of science, you try to match your method with your subject matter. And so what counts as a scientific method differs in different cultures and different scientific cultures, and the underlying assumptions that shape what you make of your evidence, the underlying assumptions - what would count as being healthy or unhealthy - in different schools of thought they'd look natural.

David: Let me have you give us two or three examples of what you mean by different scientific methods.

Robert Fancher: Sure. Well, I think one of the very good examples that's particular to our field is the difference between what's called process studies and randomized clinical trials. If you look at psychotherapy research up into about the 1980s, there was actually a huge amount of very serious research being done about the psychotherapy process. Now, frankly, I think some of this was overwrought. I think how much exactly came of it is debatable, but you had different scientists trying to figure out how to code what was said and done in a psychotherapy session.

And they would code this: okay, this is an instance of X; this is an instance of Y; this is an instance of Z. And they were treating therapy sessions as natural phenomena, natural processes. They were trying to find underlying principles, underlying laws. They were trying to be able to predict, if when the patient says X, Y, and Z with thus and such emotions, thus and such on his mind, if the therapist does Y, what's the result going to be. And it was very much a predictive sort of effort. That fits the historical notion of science. The historical notion of science is that we should describe and explain nature. Okay, that's process studies.

Beginning in the '80s and particularly in the '90s, process studies fall woefully out of fashion among psychotherapists, principally under the influence of Aaron Beck and the cognitive-behavioral therapists, who decided, well, no, that's not the way to do science at all. We need randomized clinical trials. And, as you know, with randomized clinical trials, you do something very different. You assign people to a couple of different kind of treatment methods; you try to systematize what's being done - we call it manualized treatment; you use certain sorts of supposedly objective measures of base lines and outcomes; and you try to figure out which of these schools of thought and which techniques are most effective.

Now, if you notice, you're doing something different now. You're not trying to describe nature; you're not trying to explain nature; you're not trying to predict what's going to happen next in the process of therapy. You've changed to looking at effectiveness; you've changed to looking at does the patient end up feeling better. Now, that's not even what the guys who were doing process studies were mostly trying to figure out. They were trying to figure out what's the natural history of the disease, what's the natural history of a particular sort of intervention within a disease.

But what then happened, as you see for political reasons, that the people who are big proponents of RCTs, randomized clinical trials, got more power politically within psychology and to a lesser extent psychiatry, and suddenly they decided that process studies were not science at all. So you see now, as a commonplace, you have students who've been educated as psychologists in the last 15 or 20 years who will say, without knowing any better, cognitive-behavioral therapy is the only mode of therapy for which there is good scientific evidence.

That's simply not true. It's the only mode of therapy for which there is good scientific evidence of the sort that cognitive-behavioral therapists think is the sort you ought to have. In fact, there's all sorts of therapy that has all sorts of evidence, very good evidence, very conscientiously done evidence, using methods that were very carefully conscientiously developed to try to be appropriate to the subject matter.

Now, that's just one illustration of how different methods, different concerns, result in different sorts of results - resulting results - but then you have people who are educated within a particular culture who just don't know any better. When your cognitive-behavioral therapist tells you, "We're the only people with good scientific evidence," he believes it because he's been educated to believe that that's the way you do science. When in fact, if he knew a little more history and he knew a little more philosophy of science, he wouldn't think that at all.

And, frankly, David, I want to say one more thing. I think it's quite bizarre that randomized clinical trials are considered the gold standard of science in psychotherapy. I think if you actually look at the history of science and if you look at the history of scientific methods, we shouldn't consider RCTs science at all because they do not describe and explain nature.

In fact, randomized clinical trials are product development; they're a part of engineering; they're a part of quality control. They are a way of developing a product: if we do X, what will be the result? If what we mainly want to do is change people's moods, what do we need to do to change their moods? I don't think that's a bad thing to do; I think that's a great thing to do. I think if you want to develop a product and make sure your product works, RCTs are a wonderful thing to do. That's why the drug companies use them.

But then to turn around and claim that that's science - no, that's engineering. That's just engineering and product control. That tells us absolutely nothing about nature. So if RCTs are the gold standard of science and psychotherapy, that proves my point: the science behind psychotherapy is extremely weak.

David: Okay, now, there's so many things here to respond to. One thing is I want to get in real early here is - that might not be clear to listeners - is that you're not saying that psychotherapy doesn't work. In fact, in your book, you repeatedly emphasize that you think that psychotherapy does work, that it does help people to feel better.

Robert Fancher: Absolutely, it does. That's why these questions matter. One of the things that's been [unclear] me, David, is that I think that one of the reasons that people like me have so relatively little influence is, in a certain way, we're too middle of the road. We look sort of radical when you hear us say these things, but I'm not anti-psychiatry; I'm not anti-mental health care. I think this stuff is important; I think people suffer. People suffer and when they suffer, they need help. They need help that has some kind of expertise.

Expertise consists in knowing the very best that you can possibly know about how life works, how suffering happens. Expertise consists in knowing how to sit with a suffering patient and take their perspective, knowing when and how to intervene. There's just a lot that's involved in expertise, and we vitally need these professions. But we need these professions to be more self aware and more honest about what they're doing, because they exert an influence, because they actually change people's lives.

If you go and see one sort of therapist and you are taught a particular set of beliefs and practices and those things give you relief - which will happen; that will happen; 67 to 80% of the time, that's likely to happen if you go into therapy - but then you're going to go out believing, oh, well, this is the way it is. These beliefs are true; these values are correct; and that has effects on the rest of your life. It has effects on the people around you. It has effects on your marriage; it has effects on your job; it has effects on your children.

David: It sounds good, though. Those are good effects, right?

Robert Fancher: They may or may not be. I'll just give you an example. One of the minor specialties I have in my practice is that I help people deal with the aftermath of adultery, and I can't tell you how many people I have come in whose previous therapists have been 100% supportive of their adultery or their spouse's adultery. There's a very popular book, one of the very best sellers in self help, book on how to deal with the aftermath of adultery - a book called After the Affair by Janis Spring - in which she says, "Well, I don't take a position on whether affairs are right or wrong, because they can be very affirming for one of you even as they destroy the marriage."

That's appalling; that's just appalling. The willingness to lie, to cheat, to steal in order to make yourself feel better is a bright line case of unethical behavior for about 3,000 years. So I think that the therapists who have that sort of view, who are supporting people in getting revitalized and pursuing their growth and blah blah blah while they're lying, cheating, and stealing to their spouses - no, I don't think that's a good influence. I think that when you teach people things that…

Oh, here's another one of my favorite examples. You have a patient who's sitting in the room, saying I feel so guilty about blah blah blah. And then they describe an act of self assertion, an act of aggression, an act of hostility toward authority, a fellow worker, a spouse or something like that, and "I feel so bad I did that." And the therapist says, "Well, it sounds pretty healthy to me." Now, that happens all the time. I remember back from my days in peer supervision, in group supervision, hearing other therapists say that, hearing supervisors tell people to say that, being taught to say that myself.

That's ludicrous. The patient is talking about guilt and we've changed the subject to health. And we say somehow, well, if it's healthy, then you don't have to be worried about whether you have damaged people. This patient is worried about whether he's done damage, and we tell him, "Don't worry about the damage you've done. You're healthy." I think that's a very bad effect.

And I think one of the worst effects of the pseudo-science that happens in particular of the cognitive-behavioral field is we don't study our side effects. In drug studies, we have to look at side effects. We have to look… if you're trying to make bones stronger, you have to look, well, okay, but what are the effects on the heart? What are the effects on the liver? What are the effects on the kidneys? In most psychotherapy research, we don't look at the side effects. We don't look on does this make people more conscientious in their thinking? Does it make them more sensitive to their obligations to other people? Does it make them more obtuse?

Think about how many times we teach patients "Oh, you shouldn't be shoulding all over yourself." Or we teach them "why are you giving other people so much authority over you?" "Why are you letting other people's opinion of you determine your opinion?" Well, there's a very good reason: other people's opinion of you pretty much determines what opportunities you get in life. And if we teach people that they need to think, oh, well, that's your problem, not my problem, probably that has some side effects. Probably that has some ramifications in their life.

So I do think that a lot of - now, I'm just giving negative examples - I think a lot of the effects on our lives are very good. I think that there are a lot of ways that we empower people; we help people get a broader perspective; we help people have a better sense of possibility. But we don't bother to study that because we don't own up to the fact that that's what we're doing. We don't own up to the fact that we are teaching people a way to live, and that way to live has consequences that need to be evaluated, and they don't need to be evaluated principally in how they make the patient feel. They need to be evaluated ethically.

David: Yes, that's what I'm hearing. I think most training, it seems to me, stress… they try to teach us to suggest that we be ethically neutral as psychotherapists, whereas I hear you saying that you're going to be taking an ethical stance even if you're trying to be neutral; that you have, through your culture of healing that you came up through, that you have an ethical stance that you maybe haven't made explicit to yourself or to your clients.

Robert Fancher: Absolutely.

David: But somebody else, I think, would challenge you and say, well, gee, this ethical thing is a pretty slippery slope, isn't it? Like where do you… how do you know where to stand on this ethical slope? How do you make those decisions?

Robert Fancher: The same way that any other human makes a decision: you try to educate yourself, you try to learn how to think soundly, and you try to be a responsible person with a certain amount of self knowledge and a certain amount of humility in what you suggest and how you suggest it. Certainly, you don't want to… Well, that's the first thing I want to say.

The second thing I want to say - and I'll go back with you - yes, my view is that most of the time when we say something is healthy, we are smuggling in a set of values. Most of the time when we say that doing things one way rather than another is a healthy way, in fact, we are urging on people a set of ethical guidelines which we are not owning as ethical guidelines, and therefore we have not submitted them to the proper sort of examination.

Look, David, I don't like that this is the case. I really don't like it. I went into therapy… I was a Baptist preacher's kid. I wanted to get out from under the thumb of all this ethics bullshit. I wanted to go find some science that was going to tell me how to live. I didn't want to have to be subject to the vagaries of deciding what are my obligations, who do I have to be responsive to, what do I have to do whether it feels good or not. I didn't want any of that to be true, but it is true, and I think that by even pretending to be ethically neutral is itself an ethical position.

I am responsible for my influence in the world, David. I am responsible for the influence that I have. If I help somebody do something more potently, if I help somebody do something with greater effect than they would have been able to do it on their own, I am responsible for my part in their being more effective and powerful. I cannot be neutral. If I help my patient do something more effectively, I am responsible for that effect. If I help my patient feel okay about cheating on their spouse, I am responsible for helping them cheat on their spouse. If I help them ignore ethical rules in their profession, I am responsible for that. That's a basic human principle. We claim exemption for it; the claim of exemption from responsibility for our influence is pretty bizarre. It really is bizarre. The only way to answer would be to say, well, we actually don't have any influence. Well, if you don't have any influence, why are you charging $175 an hour?

David: Yes. Now, do you try to be as transparent as possible about your values and beliefs with the people that you work with?

Robert Fancher: Absolutely.

David: For example, I'm thinking of something like abortion, for example, which is extremely controversial and I believe there are people of good conscience on both sides of that issue. And I think most therapists would feel that, well, they would try to be there for the person that they're working with, but they would not advocate for one side or the other. Where would you be with an issue like that?

Robert Fancher: Well, first thing I would say is that to say anything at all, to choose one sentence rather than another sentence, requires that we have some kind of emotional response, requires that we have some set of values that tells us that saying A is better than saying B. So, when somebody tells me, "Well, I just try to be there for the patient," that is itself an ethical position. That is not a neutral position.

But to go specifically to your thought: I know that we find ourselves in positions that are just heartrending. I do want to say that I don't think we should be authorities in general. I don't think we should be authorities on anything. One of the big arguments in my book is we are not and should not think of ourselves as authorities, and one of the biggest mistakes in our field is to think that we have authority on certain matters. So I don't think we set ourselves up as ethical authorities any more than we set ourselves up as authorities on anything else.

But people hire us to give them advice. I mean, we don't like to admit that that's what happens, but we give them advice under cover of helping them think things through. And we serve as auxiliary minds; we serve as outdoor minds. I am going to help my patients think about all the things that humans have to think about when they are making decisions of the sort that they are making, and that includes the ethical ramifications. So if I have a patient who is debating whether to have an abortion, I have just as much obligation to help them think clearly and correctly about abortion as I do to have them think clearly and correctly about whether they're catastrophizing, maximizing, minimizing or anything else.

It's very bizarre that we will admit that we have an obligation to help people change things, correct things, do things right, except when it comes to the most important kind of right at all, which is mainly doing the right thing, and then all of a sudden we pretend we don't have any expertise, we don't have any responsibility, and we should just ignore it.

So, to stay with your question: you have patients who are in a position like trying to decide what to do about abortion. I think that all you can try to do is be an honest broker. You can be an honest broker about, look, these are things you really need to think through. Here are the places where you may have some obligations, where you may have some commitments, where you're going to have to live stuff.

Just yesterday, I had a patient who was very vexed over his mother wanting some advice from him about what to do about her marriage. The mother's 52 years old. Her husband, which is the stepfather of my patient, has just been diagnosed with Parkinson's disease. She doesn't want to take care of him; she wants out of the marriage because the guy's sick. Now, it seems to me there's some pretty serious issues that need to be taken into account there.

So my patient's saying, "Well, I really think that my position has to be that she has to save her own life, and that may destroy him, but that's his life, that's not hers." I can't support that, and so you find a very adroit way, you find a way of saying… So, eventually, in yesterday's session… so we got around… we're talking about what would it be like for her to be alone - she's 52 years old, what are her prospects, blah blah blah - and it's pretty easy to say, "And what do you think it's going to be like for her to live with the guilt of knowing that her ex-husband is now declining with Parkinson's all alone, and she walked out on him?" So you can bring up ethical sorts of issues like… You know, he may still decide to advise his mother screw the bastard, go have a good life. That may be something he decides. If he does, that's on him, that's not on me.

So I think we try to help people think things through. We do have to know the difference between them and us. We're not authorities, but I do think there are times when the value differences are so great that we ought to just know that and find gracious ways to get out of it.

I had a patient with whom I parted ways literally just last week, very amicably. We worked together for about six weeks. It was very clear that on a couple of fundamental issues we just profoundly differed on what would constitute an acceptable mode of action, and I didn't really want to be responsible for changing her mind, honestly, because in this particular case, I really couldn't see that what she was thinking was a good ideal, was a good idea, but neither could I see that my view on it was so obviously right that I needed to change her view and change her life and have her do something different than she wanted to do.

So I was actually quite relieved when she said, "You know, I think we have such a fundamental difference on values here that I don't really see how we're going to see eye to eye." And I was glad that she said that and I didn't have to, because I was trying to figure out how am I going to say this to this woman without it being narcissistically wounding. How am I going to say to her, "I just can't manage to find a way to get clear to support what you're talking about," without it being wounding to her? So I was very glad that she had the wherewithal and the intelligence to say it herself, and we had a very amicable parting.

David: Well, that speaks to another theme that runs through your book, which is that you see that client and therapist need to swim in the same river, so to speak, that they need to have value systems and belief systems that are pretty much in alignment. And I was happy to see you cite Jerome Frank's 1973 book, Persuasion and Healing. That's a book that had a lasting impact on me and is another good example of a landmark work that deserves to be remembered. And I seem to recall that he makes a point very similar to yours, that therapeutic healing results when client and therapist are operating in the same belief system. That there's a sort of placebo, self healing capacity, that can be triggered if client and healer both believe that the healer can heal. Do I have that right?

Robert Fancher: Yes, and that happens, and it's one of the ways that we kid ourselves is by not knowing that it happens, and here's how it happens. I come out of my training and I believe that I'm all ethically neutral, and I believe that I have this judicious position in which I don't impose my views on other people, and I start seeing patients. And some of those patients get better and some don't. Some of them stay with me for a while; some of them leave after a few weeks. The ones that do well with me tell their friends about me. Then I start meeting people out in the community - doctors, educators, ministers - who are going to be my referral sources. Some of them think well of me, they match up with me on all these important issues, and they send me people. Others don't.

What happens over time is a self-selective process where my clientele is people like me, but if I don't recognize that, if I'm still believing my teaching that, oh, I'm ethically neutral, I don't realize that what I'm doing is I'm socializing people like me to be more like me. And I think that's what happens.

I think that we can be smarter about it; we can be wiser about it; we can therefore, I think, both become more diverse and sophisticated and complicated people ourselves, and then we can work with a wider range of people. And there's also some very good research from back in the '80s and '90s that shows that therapists' values do influence patients, that patients' values shift in the direction of the therapist over the course of therapy.

So, yes, we do better if we're sort of in the same general area. If we're not in the same general area, one of two things is going to happen: the patients are going to leave or else they're going to acquiesce more to thinking like we think so that they can keep working with us because they like us for other reasons.

David: Well, one of the things that I continue to be struck by is… you know, I'm in California, and they're all sorts of very non-traditional practices, practitioners, of people doing things from shamanism to NLP to energy psychology and so on, things that "scientifically" would be maybe very hard to prove. And yet they claim - and I believe them - that they're seeing people and that the people that they see often are getting better and changing and getting the kinds of results that they were looking for. And it seems to me that that fits within the model, within what you're saying, that that's just a different culture of healing.

Robert Fancher: It does fit, David, and this is another one of those things where I wish it were not so. I wish this were not the way it is. I don't like it that you got all these fruits and nuts and weirdos out there practicing strange stuff and people getting better.

There's a woman I know tangentially here in Portland who has three weeks, David, three weeks of psychological training. And she's just hung out a shingle as doing a certain sort of yoga-based counseling. There's this particular organization… the thing they do is actually kind of interesting. They try to integrate the teachings of Carl Rogers with yoga, so you have people get into these yoga poses and then they talk about what they feel and what it brings up for them, and the therapist uses some extremely basic sort of client oriented interventions. Three weeks training and you can be certified in doing this.

I don't like that that's the case, but people get better. I'm enough of a snob; I have a strong belief that there's a difference between truth and falsity. That's why I spent five years getting a Ph.D. and another three years in very arduous training as a psychotherapist, because I believe there's a difference between truth and falsity. And it really bugs me that people can have next to no training and still get some good results, and frequently they're results I don't like. I think there are very complicated issues there, but the fact is I may not like it, but that's how it is.

David: You know, I still hear a Baptist preacher's son in there somewhere.

Robert Fancher: Oh, there's no two ways about that. There's just no two ways about that. And there's some things about that of which I am appreciative. I do think that one of the things that can be the case if you grow up in that kind of religious background is you learn to take ideas very seriously, and you learn to take truth very seriously, because you are in a milieu that tells you that the ideas that you hold will determine your eternal salvation or damnation. So you take ideas seriously and you take truths seriously.

My dad was not particularly happy, of course, that I left the church and ended up as a very virulent atheist for a long time. I'm not a virulent atheist any more; I'm sort of a hopeful agnostic. But Dad and I were talking at one point some years after we got over being mad at each other about this stuff, and he was talking about his disappointment that I had left the church, and I said, "Well, Dad, it's your own fault. You taught me to take ideas seriously, and you taught me to think for myself." He said, "I know, but I was so sure that I was right, that I thought that after you'd learned to think correctly and you thought for yourself, you'd end up agreeing with me."

Well, I appreciate that he said that, and I appreciate that he had the graciousness of it, and frankly I think there's something to be said for growing up thinking that there's a difference between truth and falsity, and it can actually have something to do with whether your life has been worth living or not. So I don't mind that part of the background. I am glad I shed the rest of it; I am glad I got out of the fundamentalist Christian thing. I don't think that's any good for anybody, but I am glad to have had the notion that truth matters drummed into me at an early age.

David: Well, the time has flown by here, and there's just so much more that we could talk about it, and I had thought that we'd get into more of the details of the book, but I think we've hit the high points. I wonder if there are any last words you'd like to say as we wind down here.

Robert Fancher: Well, I would. I am with people who are in pain; they need somebody to talk to. And I think we as professionals need to remember they're looking for somebody to talk to. They're not looking for people who can cite chapter and verse of 43 different RCTs or 27 different process studies, or can say how they think the things they are doing are implications of the character of science. They want somebody to talk to.

And what we need to do is we need to try to become as expert as possible on how life works. And a lot of times what people need to hear from us has next to nothing to do with anything we would ever learn in a psychology course. It has more to do with something we might learn in a sociology course or a history course or by paying attention when we're sitting in the barber shop and overhearing people talk about how to solve their problems.

So I think that we need to realize that we do a very important thing if we are willing to do it, if we are willing to provide someone to talk to. And we need to become expert at the sorts of things that people need to talk about. We need to be very self aware and humble about the values that we are teaching to people, and we need to stop working so damn hard to try to pretend we have some esoteric knowledge that allows us to charge large fees and claim authority, when we're really just trying to be the people that folks talk to when they're in pain. That's my basic view.

David: Okay, well, that's a great wrap-up and it's been a great pleasure speaking with you, Dr. Robert Fancher. Thanks so much for being my guest today on Wise Counsel.

Robert Fancher: Well, I'm very grateful and I really appreciate it, David. Thanks so much.

David: I hope you found this conversation with Dr. Robert T. Fancher as engaging as I did. His book is full of provocative ideas, and by the way, he tells me that the book is now available at Amazon.com and other booksellers under a new title, which is Health and Suffering in America. Also, you might want to visit Dr. Fancher's website at http://therapypdx.com".

You've been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today's show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the Mentalhelp.net home page.

If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at www.shrinkrapradio.com. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.

 

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About Robert Fancher, Ph.D.

Robert Fancher, Ph.D.Bob Fancher earned his Ph.D. in philosophy from Vanderbilt University, with a specialization in action theory-the branch of philosophy that studies how thoughts, feelings, intentions, and choices shape what we do. After teaching for two years, then doing two years of research on education, he went back to school to become a psychotherapist. Bob graduated from The Blanton-Peale Graduate Institute, a psychoanalytic psychotherapy institute in New York. He practiced psychotherapy in New York City for fourteen years. Currently he maintains a counseling practice in Portland, Oregon.

Bob is the author of Cultures of Healing: Correcting the Image of American Mental Health Care (reprinted as Health and Suffering in America: The Context and Content of Mental Health Care ). This critically-acclaimed book has been used as a college text at Princeton, Rutgers, University of Texas, Antioch, University of Oregon, and other places. Bob served on the editorial board of the American Counseling Association's Journal of Mental Health Counseling for three years. Bob has also published books and articles on education, sports psychology, and philosophy, and ghostwritten books, op-eds, and speeches on healthcare, business, ethics, history, psychoanalysis, and cooking.

Among his college teaching experiences, Bob has taught philosophy at Vanderbilt, the University of South Carolina, and New York University; psychology at The New School for Social Research and Marylhurst University; and literature at Sogang University in Seoul, Korea. He has been a Henry Luce Scholar and a recipient of a National Endowment for the Humanities summer fellowship.

Bob is not, and does not wish to be thought of as, a clinical psychologist or any other sort of "licensed mental health professional." He is a person who has spent, and spends, his life trying to understand human suffering, its meanings, and its relief. He has not found the notions of "mental disorders" or "mental health" especially helpful in that quest.

Reader Comments
Discuss this issue below or in our forums.

Small motions lead to big notions - Tim - Feb 8th 2011

Dr. Robert Fancher, I thank you. Though I have not yet fully implemented any of the physical practices,  found in pleasures of small motions (due to rotator surgery).  I have already benefited greatly on several other levels of sound thinking. I just finished chapter 8 so, I'll be working on self image, proper attitude etc. as I go through PT.  I have been enjoying the game for over 40 years and have found myself in most every rut you mentioned.
Shortly after reading the first few chapters, I remembered how I used to enjoy the sound and the feel of a well struck ball,  how the tip of my cue almost felt like a nerve sensor. So, while I have this time (2months+) to recover and re-group could you suggest another book?

Thanks,

Tim

Great Interview - Fiona Holding - Sep 6th 2010

Thanks for a this great interview, I very much enjoyed listening and learning especially with regards to the issue of types of scientific evidence - I found Robert articulated this in a very clear unique way, and with regards to therapist's ethics and interacting with clients. I am now reflecting more on my personal stance as I continue with my training as a psychodynamic psychotherapist

Beaming With Gratitude - mary (student of Counseling) - Apr 9th 2010

I found this interview most inspiring - I'm going to listen to it again!  Robert Fancher is packed with genuine gratitude.  He is so "on fire" about the profession and what he speaks of almost seems to transcend the Ethics we are taught in formal education...a responsibility that goes along with validating others thoughts and decisions.  I know I missed things, initially listening passively whilst at work. Ordering this book today and looking forward to gleaning more wisdom from the pages therein.  Many thanks, Dr Van Nuys!

InLak'esh, Mary

Alpine, Texas

a therapist who falls asleep? - - Apr 4th 2010

And what does one do for a therapist who falls asleep???

Another great interview - Robin - Apr 2nd 2010

Another great interview, Bob raises issues that one seldom acknowledge. I especially liked his ending

"They're not looking for people who can cite chapter and verse of 43 different RCTs or 27 different process studies, or can say how they think the things they are doing are implications of the character of science. They want somebody to talk to."

An old acquaintance of mine, (a guy with what James Gordon refers to as "the numbness", who has seen several therapists) once said something very similar. People have different needs, but I do believe that they all want someone to just talk to when they feel maltreated by life.  

P S
A suggestion for your guest-list: Dr.  Jeffrey Wijnberg, who is involved in Provocative psychology

Always Informative - Grant McGuire - Apr 1st 2010

BOB FANCHER IS ALWAYS THOUGHT-PROVOKING. I HAVE A COPY OF HIS BOOK AND USE IT FOR HELPFUL REFERENCE.

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