Pythagorean Theoretical vs. Hippocrates’ Empirical Approach in Relation to Clinical Psychology
Early in this semester, our class spent a lecture with Pythagoras, an ancient Greek philosopher, mathematician, and theoretician who is widely known for his theorem of right triangles (a²+b²=c²) since high school. This lecture quickly drew my attention to it because he was also mentioned in my clinical psychology class. At first glance, this connection between a philosopher/mathematician and clinical psychology was unexpected and strange, for it was not immediately clear how the Pythagoreans’ contribution to mathematics and music relate to mental wellness. Indeed, it turns out that Pythagoras’ influences in clinical psychology don’t have a lot to do with what he did. Rather, it is the overarching theme of theoretical thinking in the Pythagorean tradition that is being actively studied and applied in clinical psychology. This theoretical manner of conducting clinical psychology is often contrasted with a more empirical manner of helping patients, which is often conceived of as the approach that focuses on the prescription of psychological medication.
The overarching goal of this article, therefore, aims to bridge between both philosophy and clinical psychology by exploring the legacy of the Pythagorean way of thinking in clinical psychology along with the discussion on the empirical/medical approach. Like various other disciplines of studies, psychology branches out from philosophy, yet there hasn’t been a lot of focus on the connection between clinical psychology and philosophy. Worth notably, some scholars have argued that Socrates, through his cooperative way of helping another individual to deliver a deeper understanding of the world, was the first psychotherapist (Overholser, 1993, 2010). More, there are some approaches to clinical treatments that explicitly follow a philosophical theory. For example, existential psychotherapy and humanistic-existential theories are influenced by the work of existential philosophers such as Kierkegaard, Heidegger, and Sartre (p.128, Watson & Schneider, 2016). It is therefore to find the influence of philosophical thoughts throughout the history of clinical research development in psychology.
In this article, I will first introduce how the Pythagoreans influence the way psychologists set up individual psychotherapy. I will then introduce the medical approach to psychological diagnosis, and how this approach is different from individual psychotherapy. Next, I will introduce some historical context in psychology concerning when the theorist’s (Pythagorean) way of clinical practice and the medical approach began to view each other almost as opposites. An imbalance between these two streams seemed to serve as the driving force for the subsequence radical focus on only behavioural/medical approaches to clinical research and practice for almost 30 years. This radical shift impacted clinical psychology in its subsequent reliance on psychiatric medications, some of which present many problems in terms of their effectiveness.
Finally, I will discuss some of the misconceptions many people have against the contemporary form of psychoanalytic/psychodynamic psychotherapy, which settles its philosophical underpinnings on the Pythagorean way of theoretical thinking. There are a variety of different psychotherapies available in the market: psychodynamic therapy, cognitive-behavioural therapy, emotion-focused therapy, existential therapy, and interpersonal therapy. It must be noted that the last point mentions only the psychoanalytic orientation of treatment because of its often-ridiculed reputation due to much of what Sigmund Freud speculated about a century ago. Psychodynamic treatments have shifted away from a lot of what Freud proposed at his time. Evidently (and controversially), contemporary research and replication studies suggest that outcomes from different psychotherapies are essentially equivalent (Baardseth et al., 2013; Rosenzweig, 1936; for a review, see Shedler, 2010). This is also known as the Dodo Bird verdict, which references the conclusion of the dodo bird in Alice in Wonderland: “Everybody has won, and all must have prizes.”
The Pythagoreans and Hippocratic Thinking
The Pythagoreans’ influence on the development of clinical psychology comes from their characteristic way of theoretical thinking. Psychologists borrow these theoreticians’ “hypothetical-deductive” mode of thinking to set up their treatments. Through this premise, clinicians formulate hypotheses about the possible cause of a patient’s psychological problems through exploration of the patient’s current and past inner and external life (p.112, Liden & Hewitt, 2018). In other words, psychologists attempt to infer the theoretically potential cause of the psychological problems from the patient’s life experience. These clinicians argue that psychotherapy should strive to find and treat the cause of the presenting mental problem so that symptoms can be fully resolved. More, because the clinician and the patients have worked together to gain positive insights that can unravel the problem, the patient can leave the therapist better equipped to cope with potential future difficulties (p.270, Weiner, 2016). This stream of clinical practice can be thought of as seeking underlying cause as the focus (p.91, Linden & Hewitt, 2018).
At the same time, clinical psychologists also receive influence from Hippocrates, the ancient Greek physician who is best known as the “father of modern medicine”. Since Hippocrates is a physician, this means that this stream of psychological practice assumes psychological problems can be treated as physiological diseases and responses, such as the flu or a fever. Hippocrates’ school of thought advocates for the importance of objective observations and systematic processes of diagnosis in medicine. Psychologists’ adoption of this tradition of thinking is evident in the publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the application of medication for symptom relief according to this manual. This stream of clinical practice can be thought of as taking symptoms as the focus (p.91, Linden & Hewitt, 2018).
There wasn’t really a distinct divide between these two streams of thought. Hippocrates, for example, believed that taking care of the well-being of the soul and the inner peace of man also heal the body (p.3, Kleisiaris, 2014). It was when psychologists began a monumental dispute on how to best study the human mind began in the 1940s that this divide between theoretical focus and observation focus widened.
In the 1900s, Freud’s psychoanalytic theory swept the world (p.369, *textbook OpenStax). His practice of psychotherapy underlined the importance to explore unconscious processing and internal mental life, such as unconscious defence mechanisms and early life adversity, which still are the main focus of today’s psychodynamic stream. Even before Freud, there were already many other thinkers and psychologists who proposed that psychology is about the study of the mind’s inner mechanism. Our mind cannot be studied directly, so the only way to go about it is often by asking for self-reports. In an attempt to develop a more scientific and systematic way of self-reporting, scientists associated with structuralism in the 1890s proposed that psychology should be about tracking and collecting detailed, exhaustive accounts of what a person senses, feels, and think each moment in a given task (p.9). However, psychology did not go too far with this method of exhaustive recording. It provided a limited understanding of the human mind as the accounts were still highly subjective, making it impossible to establish agreement across people. Yet, as a reader in the contemporary time, in hindsight, if there is a seesaw of ‘good science’ on which one end sits the theorists and the other end sits the empiricists, we can see that this balance was tilting toward the theorists during this period.
Frustrated by the stagnation in the field in the 1930s, psychologists such as John B. Watson and B. F. Skinner (famously known for his work on operant conditioning), argued that the previous models for studying the mind were flawed and impossible. Instead, they proposed that psychology should only examine and study observable behaviours in experimentally controlled conditions in laboratory settings. According to Watson (1930),
“Psychology, as the behaviourist views it, is a purely objective, experimental branch of natural science which needs introspection as little as do the sciences of chemistry and physics.”
This radical paradigm shift toward behaviouralism changed the focus in psychology from drawing theoretical inferences about the mind to studying observable behavioural changes. Behaviouralists dominated psychological studies for the next 30 years, during which internal events like emotions and thoughts were completely driven out of the main stage of psychological research until the 1960s. If we are to continue with our previous analogy of the seesaw of ‘good science’, the balance was tilting to the empiricist side, which solely focuses on dealing with observable phenomena without recourse to inner mental events. Although the theoretical approach and empirical approach have come to terms with the return of cognitive psychology to psychological studies as a whole, this disparity still manifests in the subdiscipline of clinical psychology.
How did behaviourism influence the subsequent development of clinical psychology?
The focus on objectively observable phenomena in clinical psychology has been a persistent endeavour in clinical psychology to help patients with mental health problems, and it was fueled by the behaviourist movement (Taschereau-Dumouchel et al., 2022). Perhaps from an introductory class to psychopathology, a video, or an article about certain mental health problems, the chances are you have heard about the DSM, short for the Diagnostic and Statistical Manual for Mental Disorder. The DSM is a detailed classification of psychological disorders that provide specific criteria for the diagnosis of specific mental disorder and other information relevant to understanding the nature of various mental disorders from current research. This manual is currently in its fifth edition (DSM-5).
The DSM-5 is used by many licenced clinical practitioners to classify patients’ mental disturbances into specific categories when their reported symptoms meet a certain number of descriptor criteria. For example, if a person suspects that he has depression and goes to a clinician for a diagnosis, the clinician will use the checklist of diagnostic criteria for major depressive disorder (MMD see Table 1, DSM-5). For the patient to be clinically diagnosed with MMD, Items A, B, and C must be met. In Item A specifically, 5 of the 9 criteria from this section must be present for 2 weeks.
At the same time, however, if the person has 4 of the 9 criteria, it means that he will not be getting the diagnosis. While this can be seen as a safeguard against prescribing subclinical depressed patient medications that have serious side effects, this sometimes gives the false impression that the person is not suffering from depression. This is false. Not being able to meet the criteria sufficient for a formal diagnosis of clinically significant depression does not suggest that the person is not experiencing any of the psychological distress associated with their depression. Rather, researchers have found that individuals with subthreshold depression have an increased risk of developing major depression (Cuijpers & Smit, 2008; Fergusson et al., 2005).
Medical Approach and the DSM
The DSM approach conducts diagnoses according to observable signs and symptoms. Hence, this is the “taking symptoms as the focus” approach as we’ve previously mentioned. We saw how the orientation of focusing on the symptoms originate from the ancient Greek physician Hippocrates, so does this orientation in clinical psychology has anything with what a physician would normally do, such as prescribing medications? The answer is yes. DSM diagnosis can inform clinicians and patients about psychological medications, and general partitions can use the DSM to guide medication prescription (Fleury et al., 2012). As a result, about 50% of patients receive psychotropic medication without having a formal assessment and diagnosis by mental health professionals (Rhee & Rosenheck, 2019; Jonas et al., 2013). Indeed, since the DSM-5 operates in a checklist fashion, a diagnosis can be done relatively easily.
However, it’s necessary to note that research has suggested that, in individuals with mild to moderate depressive episodes, antidepressant medications are no more effective than placebo, which are sugar pills that are given as a sham medication (Kirsch, 2008; Kirsch, 2019; Pigott et al., 2010). In patients who are severely depressed (persistent depression that remains relatively unchanged over long periods, sometimes 20 to 30 years), the analyses suggest that the medications are effective. However, some have found that the drugs are effective only because the placebo has lost effect (Ioannidis, 2008).
At the same time, antidepressants also have substantial side effects, including blurred vision, dry mouth, constipation, difficulty urinating, drowsiness, weight gain (at least 13 pounds on average), and, sometimes, sexual dysfunction. As many as 40% of patients taking these medications may stop taking the drug, thinking the drug is worse than the disease (p.252, Barlow, 2018).
According to the NMIH, the lifetime prevalence of experiencing at least one MMD is 8.4% in the U.S. adult population, meaning that 8.4% of the U.S. population experience MMD at least once in their life. The more severe form of depression has a much lower prevalence of around 1.5% in the U.S. In other words, more individuals experience a mild or moderate form of depression, many of whom receive antidepressant medications that do not provide more benefit than a sham antidepressant sugar pill. In addition to minimal benefits, they would also be experiencing serious side effects associated with the drug.
However, this inefficacy of medications seems to be the particular case with antidepressants only, which are used for alleviating symptoms of the physiological reaction associated with distress. This has an important implication. Contrary to what most people might think, psychotropic medications are not a cure. Medication helps with symptom management, but it cannot get rid of the mental disorder such that it may not come back ever again. Treating mental disorders is not like a physician treating a bacterial infection in the body which can be effectively targeted with anti-biotics. Anxiety and mood disorders in particular cannot be uprooted by simply taking more medications unless the disorder resolves spontaneously on its own. This seems to bring a gloomy picture to the prospect of psychological treatment; however, there is an alternative.
Alternative to Psychological Medical Treatment
Psychotherapy may be better understood in its traditional sense as a talking cure (p.1, Weiner, 2016). As we’ve previously alluded to, psychotherapy follows the Pythagoreans’ way of theoretical thinking by drawing inferences from the patient’s current and past life for the cause of the mental distress. The clinicians strive to formulate a model of the individual patient that reflects the patient’s individualized psychological profile. Importantly, these inferences are not based on the subjective opinion of the clinician only. Instead, these inferences are based on the theoretical orientation of the clinicians and established theories in the field. Psychotherapeutic theories that are backed by empirical evidence and research are the most practiced ones.
The most widely practiced forms of psychotherapy include but are not limited to psychodynamic, cognitive-behavioural, emotion-focused, and integrative therapy. In the psychodynamic orientation, the clinicians pay most attention to the patten of their patient’s (1) past and current relationships, including how they interact with the therapist and (2) defence, anxiety, and underlying impulse (Barber & Solomonov, 2016). To the psychodynamic practitioners, these psychological components are what theoretically constitute mental disturbances and distress. Hence, they strive to formulate an individual model of their according to these components, drawing a hypothesis about what might be troubling the patients and working with their patients to confirm whether their hypothesis was accurate. This process of building an individualized model of the patient is known as formulation. Along with that, their practice emphasizes the importance of listening and creating a safe environment for the patient to freely express themselves. Unfortunately, this side of psychodynamic therapy in the modern era is often underrepresented.
But didn’t we mention that the theorist and the empiricist clinical psychologists are almost seeing one another as opposite? Why are these psychologists with a theoretical orientation using empirical methods? As we’ve previously discussed, psychology as a whole has been coming together as more integral, striving to conduct the best science possible. Unlike other subdisciplines in psychology, clinical psychology is especially unique due to its clinical practice component in addition to conducting research (this is also why clinical psychology is a competitive field to get into!) Hence, it is necessary to demonstrate the effectiveness of psychotherapy systematically in the interest of good science and for patients who are suffering from psychological disturbances and paying for their therapy sessions. This is also why empirically validated psychotherapies are sometimes referred to as evidence-based psychotherapy.
Psychotherapy can provide many more benefits to patients with mental disorders especially because research generally shows that they are more effective than medications and maintained benefits even after termination of the treatment. Although some may argue that medication is cheaper than enrolling in psychotherapy, considering psychotherapy’s aim to treat the cause and its higher effectiveness but not providing temporary alleviation of symptoms, psychotherapy may be more cost-effect (Shelder, 2010; Cook et al., 2017). Therefore, psychotherapy treatments seem to be both effective and sustained even after the therapy ends.
Importantly, in the review done by Shelder (2010), the researcher compared the effect size (a unitless standard measure of outcome effectiveness) across various types of psychotherapy and medication. In psychology, an effect size above 0.8 is considered large, between 0.5–0.8 is medium, and below 0.5 is considered small (Cohen, 1988). In Shelder’s (2010) review, he showed that antidepressant medication has an effect size that ranges from 0.17–0.31. For general psychotherapy, the effect size has an average of around 0.80. For cognitive-behavioural therapy (CBT), 0.62–1.0. For psychodynamic therapy, 0.69–1.17.
There are many myths about psychodynamic therapy which are often the result of misunderstanding and false portrayals much due to what Sigmund Freud had outlandishly speculated a century ago. The current psychodynamic paradigm has been reshaped and changed, diverging a lot from the kind of psychoanalysis Freud was doing, though the focuses on unconscious mechanisms and interpersonal relationships are still the centrepiece. As shown in Shelder’s (2010) review, contemporary psychodynamic therapy produces outcomes that are as effective as other forms of psychotherapies. This is true even when psychodynamic therapy is compared with CBT, a therapeutic orientation that is most famous for having been developed from rigorously empirical research (DiGiuseppe & Venezia, 2016). This equivalence in therapeutic benefits and outcomes across different types of psychotherapy is also known as the “Dodo bird effect”, alluding to the conclusion of the dodo bird in Alice in Wonderland: “Everybody has won, and all must have prizes” (Carroll, 2000).
In this article, I suggest that the Pythagoreans’ theoretical approach to thinking has served the current landscape of psychological research and clinical psychological practice as a fundamental premise. Alongside the influence of the theorists, the empiricist/ medical approach that originates way back to Hippocrates shapes the development of clinical psychology. The imbalance between the theorist and the empiricist in the 20th century rapidly changed how clinical practice is conducted.
Clinical psychologists and general practitioners who see the importance of objective observations and studies emphasize a focus on symptoms and symptom relief of psychological problems through medications and diagnosis. Meanwhile, psychotherapists see the importance of resolving the underlying cause of psychological difficulties and emphasize formulation, creating a theoretical model for each patient for individualized treatment. The psychotherapists, as opposed to those who only advocate for psychotropic medication as treatment, seem to have embraced both the empirical and theoretical traditions. The outcome effectiveness and cost-effectiveness of psychotherapy also seem to be superior to medications.
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