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Pragmatism and Therapeutic Practice

Although pragmatic sensibilities have shaped the course of therapeutic practice across the foundational schools of thought over the years, philosophically minded practitioners are rare, and there has been surprisingly little treatment of American pragmatism in the clinical literature. A series of writers have noted the absence of interest in pragmatic thought, proposing that it offers fundamental if largely unexamined principles and ethical perspectives for clinicians engaged in therapeutic practices (Borden, 1998, 1999; Brendel, 2006; Goldberg, 2002; Raposa, 2015; Strenger, 1997).

I first found myself speaking of a “clinical pragmatism” three decades ago in my seminar on Donald Winnicott and the Independent Tradition in British psychoanalysis, moved by unexpected points of connection with the work of James and Dewey. The Independent Tradition had emerged as a pragmatic voice in the 1940s, challenging the theoretical orthodoxy of Melanie Klein and Anna Freud. The clinicians who refused to embrace the purist paradigm of either thinker formed what is known as the “Middle Group,” preserving an independence of mind, drawing on ideas and methods from divergent perspectives. Following the example of Winnicott, they were committed to a theoretical pluralism, emphasizing the ambiguities, complexities, and contingencies of the clinical situation, approaching their practice from multiple points of view without recourse to notions of absolute truth.

Like James and Dewey, they rejected objective or rational conceptions of knowledge, arguing that we can never know the truth of the whole, and they remained uneasy with sweeping assertions about personality, psychopathology', or the therapeutic endeavor, realizing the dangers of presuming to know too much. Their theoretical formulations originate in the concrete particulars of everyday practice, shaped by close observation and careful description of experience in accord with their empirical disposition. In line with James and Dewey, they emphasize the practical outcomes of ideas and methods, searching for what proves useful in the given case (see Borden, 1994, 1998, 2009; and Phillips, 1988, for expanded accounts of Winnicott and the Independent Tradition).

Carlo Strenger and Arnold Goldberg have offered valuable treatments of pragmatic philosophy and ethics in their writings on contemporary psychoanalysis and comparative psychotherapy.

Strenger explores the tension between purist approaches and pragmatism in his account, introducing a position he describes as “critical pluralism” (1997). In working from a purist point of view, Strenger argues, “the risk is that patients come to feel that they have been tied onto a Procrustean bed and cut or stretched to fit its size” (1997, p. 123). Although he does not engage American pragmatism, he draws on the pragmatic philosophy of John Stuart Mill and Isaiah Berlin in articulating a range of clinical and ethical concerns. Pragmatic thinkers reject “big ideologies and singlemindedness in the pursuit of One Truth” (p. 123) and embrace a “critical pluralism,” realizing that “human understanding is intrinsically limited; that no conceptual framework can capture all possible perspectives on reality... and that the coexistence of competing conceptual frameworks is in itself of enormous value” (p. 128).

From a pragmatic perspective, Strenger explains, we do not deal with theory for theory’s sake but “ultimately with a craft committed to helping people,” rejecting purity of approach, relying on different ways of understanding, common sense, and flexibility as we search for what works. The defining feature of pragmatism, he writes, is our insistence that “the map must never be confused with the territory. It sees theory as a tool rather than as a mirror of reality, and hence judges its validity by its usefulness” (1997, p. 123).

Goldberg draws on James, Dewey, and Charles Sanders Peirce in his essay, presenting pragmatism as “a philosophy of instrumentalism or one devoted to the tools of a trade,” regarding theory' not as a rendering of objective knowledge about human behavior but as a tool for dealing with the complexities of clinical practice (2002, p. 236). He emphasizes the “effectiveness of diversity'” in his discussion of theoretical pluralism and proposes that beneficial outcomes are more likely to follow from flexible use of ideas from divergent schools of thought rather than from a “final, unifying, overarching theory' that puts it all together in a neat package” (p. 246). Only' the test of effectiveness, he argues, should move us to choose one theory' over another.

David Brendel, trained as a psychiatrist and philosopher, shows how pragmatic principles help clinicians negotiate fundamental tensions between science and humanism in his trenchant critique of psychiatry (2006). In the domain of science, clinicians draw on a range of heuristics, explanatory' concepts, and empirical findings that carry’ the potential to deepen understanding of problems in functioning and inform treatment options. Yet reductive or rigid application of scientific research may restrict the range of help and care. Humanistic approaches focus on the person as an individual, taking account of the complexities of subjective experience, relational life, and existential concerns. The clinician must join scientific reasoning and humanistic values in efforts to care for the whole person, drawing on multiple perspectives that bridge both domains of understanding.

The pragmatic perspective he outlines in his book, informed by close readings of Peirce, James, and Dewey, is organized around what he calls the “four P’s,” emphasizing: 1) the practical dimensions of all scientific inquiry'; 2) the pluralistic nature of the phenomena studied by' science; 3) the participatory' role of individuals with different perspectives in the social process of scientific inquiry'; and 4) the provisional nature of scientific understanding and explanation (Brendel, 2006, p. 28). In his pragmatic approach, taking account of scientific reasoning and humanistic values, he challenges “the longstanding tendency to split the patient in to an objective specimen for scientific study,” regarding the individual as a “complex human subject” whose experience evokes empathy, respect, compassion, and wonder (2006, p. 24).

Like Strenger and Goldberg, Brendel views the core ethical value of clinical pragmatism as “the primacy of practical results for individual persons in the everyday' life world” (2006, p. 142). We do not think of beneficial outcomes “from an abstract or objective vantage point,” he explains, “but rather in terms of the deliberations and negotiations among people working toward those goals” (2006, p. 142). I return to these accounts as we explore pragmatic conceptions of therapeutic action.

 
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