2° CONGRESSO S.E.P.I. ITALIA Firenze 24-26 Marzo 2006
Pagina 1
Tullio Carere, 15 Gennaio 2006
Cari amici e colleghi,
Vi propongo un breve dibattito pre-congressuale, cioè preparatorio del Congresso SEPI-Italia del 24-26 Marzo a Firenze, a partire da alcune domande con cui ho cercato di sintetizzare le questioni che mi sembrano più significative per un dibattito attuale sull'integrazione in psicoterapia:
Discutere di integrazione significa occuparsi di ciò che divide gli psicoterapeuti. Perché gli psicoterapeuti sono così divisi, a differenza dei cardiologi o degli endocrinologi? Forse perché la psicoterapia non è veramente una scienza? O forse perché, come sostengono alcuni, non è ancora una scienza, ma lo diventerà quando gli psicoterapeuti si decideranno a uniformarsi alle regole di ogni buona scienza dalla fisica in su, uscendo finalmente dal medioevo come tutte le altre branche della medicina? O piuttosto perché la psicoterapia non è affatto una branca della medicina? Bisognerà forse ammettere che esistono due pratiche diverse, una di tipo medico, basata su diagnosi psicopatologiche e procedure terapeutiche empiricamente supportate, l’altra di tipo umanistico, in cui il significato dei disturbi e dei modi di curarli non è fissato da manuali diagnostici e terapeutici, ma emerge dal contesto e dal dialogo terapeutico? E in questo caso bisognerà arrendersi all’irriducibile diversità dei due approcci, riconoscendo che curare un paziente è cosa diversa dal prendersi cura di un soggetto, o sarà possibile intenderli come i due termini di una polarità al cui interno ogni singolo terapeuta potrà trovare la propria personale collocazione?
Vi prego di inviare a questa minilista un vostro commento in risposta a queste domande, o (in alternativa) di spiegare perché ritenete che queste domande non colgono il centro della questione e di proporre quelle che a vostro parere lo colgono.
Giovanni Liotti, 16 Gennaio 2006
Caro Tullio, cari Colleghi,
rispondo all'invito solo perché ho l'abitudine di rispondere alla corrispondenza.
La mia opinione, conosciuta da alcuni di voi e certamente da pochissimi condivisa e da molti fieramente avversata, è che il processo di integrazione fra le psicoterapie vada avanti per conto suo, indipendentemente cioè dalle iniziative di singoli o di Scuole che tentino di pilotarlo, perché obbedisce a regole sociali, culturali ed economiche molto più potenti delle idee dei singoli o delle Scuole. Se vuole, dunque, ciascuno psicoterapeuta o una singola Scuola di psicoterapia può scegliere di testimoniare e commentare il processo di integrazione delle psicoterapie (magari in modo severamente critico), ma non può determinarlo, pilotarlo o impedirlo. Un poco come l'immigrazione in Europa degli extra-comunitari, che potrebbe travolgerci e cambiare in breve tempo la nostra società e cultura, qualunque cosa cerchiamo di fare per pilotarla o impedirla.
In altre parole: secondo me, quello della progressiva unificazione-integrazione delle psicoterapie è un processo basato su due potenti sviluppi determinati storicamente, culturalmente e soprattutto economicamente, ciascuno dei quali, visibilmente e dimostrabilmente, si rafforza sempre più.
Il primo sviluppo riguarda gli studi di processo e di efficacia delle psicoterapie (che non si limitano agli studi randomizzati controllati: vedi l'articolo di Westen in "Psicoterapia e Scienze Umane" dell'anno scorso). Ne deriva che, come già si vede oggi, vengono sempre più insegnate, nelle Università e nelle Scuole di formazione, le tecniche psicoterapeutiche che hanno superato prove di efficacia. O che vengono venduti con grandi tirature e traduzioni internazionali i libri che presentano modelli di psicoterapia che hanno superato con successo studi in follow-up (esempi, per il trattamento dei pazienti borderline, sono il libro ereticamente "comportamentista" di Marsha Linehan ed il libro altrettanto ereticamente "psicoanalitico" di Bateman e Fonagy).
Il secondo sviluppo riguarda la ricerca di coerenza fra (a) le teorie cliniche delle diverse psicoterapie e (b) quanto emerge dalla ricerca di base nelle discipline più vicine (neuroscienze, epistemologia e antropologia evoluzioniste, psicologia dello sviluppo, etc.). Se misurassimo l'effetto integrativo del richiamarsi ai risultati di queste discipline scientifiche di base, attraverso l'analisi dei contributi alla letteratura di diverse Scuole, potremmo avere qualche risultato interessante, mi sembra. Penso ad esempio al libro più recente di Daniel Stern, che usa il riferimento alla conoscenza implicita, e ai libri di terapeuti cognitivisti che usano lo stesso riferimento. Oppure penso agli scritti di diverse Scuole (sistemiche, psicoanalitiche, cognitiviste) che fanno tutte riferimento agli studi empirici sull'attaccamento, oggi così rilevanti nella ricerca di base della psicologia dello sviluppo. O ancora penso al modo col quale sia cognitivisti che psicoanalisti utilizzano i modelli neuroscientifici di Edelman, di Damasio, di Panksepp. O ai contributi allo studio dell'intersoggettività nella letteratura sperimentale (Trevarthen), nelle neuroscienze (mirror neurons di Rizzolatti e Gallese) e nella letteratura psicoterapeutica (ormai troppi per ricordarli). E molti di voi potrebbero continuare l'elenco, magari pensando agli studi sperimentali sulla teoria della Mente e sulla metacognizione, e al vasto uso che ne fanno psicoterapeuti provenienti da diverse formazioni.
Memore di precedenti malintesi, specifico che non intendo proporre a nessuno di aderire a questa idea (vagamente determinista? avvolta da un certo alone semantico marxista ormai obsoleto?) dell'integrazione in psicoterapia, e meno che mai intendo sostenere che ciascuno psicoterapeuta interessato all'integrazione debba darsi da fare per effettuare personalmente ricerche di processo o di efficacia. Nemmeno credo che gli psicoterapeuti, per interessarsi ad integrazione e differenze fra le psicoterapie, debbano meditare tutti sui risultati delle neuroscienze, o della ricerca nella psicologia dello sviluppo e in altri settori delle scienze contemporanee. Infine, e soprattutto, non nego che insieme a questo processo di unificazione-integrazione delle psicoterapie vada avanti un processo opposto di differenziazione e creativa costruzione di sempre più numerose Scuole, basate appunto sul rifiuto di cercare integrazione-unità attraverso i metodi della ricerca empirica (i soli, mi sembra, che hanno permesso una certa integrazione-unità alle teorie di cardiologi, endocrinologi, chimici, fisici, biologi, etc.).
Se qualcuno dovesse esprimere l'idea che la dialettica fra integranti (scientifici) e differenzianti (umanisti o post-moderni) è buona e salutare, troverebbe il mio sia pur perplesso assenso, ma non ulteriori commenti. Restando fra gli integranti, trovo ogni tanto interessante un scambio con i differenzianti. Spero che lo scambio sia anche per loro fruibile (per me lo è, se preso a piccole dosi), e soprattutto lo sia per i dialettici che tentano (il che a me sembra un paradosso) di integrare in una sintesi le differenze fra differenzianti ed integranti.
Esprimo dunque qui solo un'opinione su qualcosa che a me sembra un processo storico, o un insieme di processi storici e dialettici, indipendente dal nostro apprezzarlo o trovarlo sbagliato. Non ho nulla da obiettare a chi voglia affermare che a suo giudizio questo processo storico non esiste, o che se esiste possa e debba essere avversato.
Spero, ribadendo tutto ciò, che nessuno trovi strano se, memore di infelici esperienze fatte all'interno di dibattiti pre-congressuali passati, dichiaro da parte mia chiuso con questo messaggio ogni contributo personale al dibattito pre-congressuale presente.
Cordiali saluti a tutti, e non considerate, vi prego, scortese il fatto che in nessun caso replicherò ad eventuali messaggi di risposta o commento a questa mail.
Giuseppe Lago, 16 Gennaio 2006
Caro Tullio, cari colleghi
Sono belle domande, non c'è che dire! Non credo che la psicoterapia sia una scienza ma può servirsi della scienza e accostarsi al suo metodo, per meglio operare e riuscire nell'intento che la contraddistingue: curare la personalità degli esseri umani. La psicoterapia è un metodo, infatti, non è una disciplina come lo è la medicina. In quanto metodo, la psicoterapia nasce per organizzare le conoscenze in vista della cura di una realtà umana che scaturisce da un sistema evoluto. Ecco perché l'integrazione non può che essere la via finale comune del metodo psicoterapeutico, in questo concordo con l'idea forse un po' deterministica di Gianni Liotti. Anche se, non credo a una dialettica che si determina in modo automatico. I due approcci citati sono sì poli dialettici ma sono anche i bandoli di una matassa che a fatica cerchiamo di srotolare a partire da Cartesio, per finire a Damasio, ma passando certamente per Matte Blanco. No, colleghi, sono contrario al dualismo degli approcci: nessuno, senza essere un riduzionista di una parte o dell'altra, può collocarsi in campo medico o umanistico pretendendo di fare psicoterapia, seppure polarizzata. I poli o gli steccati lasciamoli nel Novecento, secolo delle grandi contrapposizioni. Oggi, forse è venuto il tempo delle grandi sintesi, le migliori dovrebbero integrare le conoscenze attuali senza minus. E poi, a pensarci bene, la mente è sintesi!
Sergio Benvenuto, 17 Gennaio 2006
Cari colleghi,
sulla scia di Liotti, vorrei anch'io inaugurare il nostro dibattito - se esso avrà mai sviluppo - dicendo che sono profondamente grato ai colleghi psicoterapeuti cognitivi di Roma, città dove opero. Si da' il caso, infatti, che circa il 50% dei pazienti che si riferiscono a me siano passati per qualche tipo di intervento o consulto con psicologi cognitivisti, che godono oggi peraltro di un indiscusso favore mediatico. In molti di questi casi la psicoterapia cognitiva e' semplicemente e puramente fallita, ragion per cui si rivolgono ad uno pseudo-scientifico, mistico e non-sperimentalista come me. Ma nella maggior parte dei casi, va detto, si tratta di persone a cui lo psicoterapeuta cognitivista dice semplicemente "con lei non possiamo farci nulla! vada da un analista!" Uno ha persino la bontà di dare loro il mio nome.... Perché con questi soggetti, spesso molto sofferenti, gli emuli di Liotti non possono fare nulla? "Lei non ha un sintomo preciso!", dicono. Al che l'altro replica: "Ma io soffro! Sono tutto un sintomo!" Niente da fare: per noi lei e' prodotto di scarto per l'analista... Da qui la mia ipotesi: ormai gli psicoanalisti prendono lo scarto dei cognitivisti? Ovvero quello che i cognitivisti - identificati tout court alla scientificità da Liotti - dichiarano intrattabili, o quelli con cui il cognitivista fallisce? La psicoanalisi si occupa degli Scarti della Scienza? Approfitto dell'occasione per chiedere ai cari colleghi se la loro esperienza empirica - bassamente empirica, direi - corrisponde alla mia.
Paolo Migone, 18 Gennaio 2006
Cari amici e colleghi,
sento il bisogno di intervenire dopo la e-mail di Gianni Liotti perché ho l'impressione che potrebbe essere fraintesa da chi non è stato dentro al dibattito avvenuto negli anni scorsi nel nostro piccolo gruppo della SEPI-Italia. Cioè Gianni può essere sembrato un po' troppo sprezzante, quando ad esempio ha detto che non interverrà più ecc., mentre da come lo conosco (e da come sono sicuro lo conoscono tanti altri) so che è sempre molto aperto al dialogo ed entusiasta di potersi confrontare con colleghi di diverso orientamento.
Il fatto è che alcuni di noi si sono confrontati già a lungo (per quasi due anni, dal maggio 2001 al gennaio 2003), nel dibattito pre- e post-congressuale del Primo Congresso SEPI-Italia (Milano, 16-3-2002 - vedi gli Atti a cura di di G.G. Alberti & T. Carere-Comes intitolati "Il futuro della psicoterapia tra integrità e integrazione", pubblicati da Franco Angeli nel 2003, dove a pp. 134-171 è riportata una sintesi del dibattito precongressuale).
La versione integrale del dibattito è pubblicata su Internet, in 6 lunghe parti, che potete trovare linkate al sito:http://www.psychomedia.it/pm-cong/2002/sepi02mi.htm
Mi rendo ben conto che sarebbe assurdo chiedervi di leggerlo perché è veramente molto lungo, e penso nessuno (forse qualche masochista!) riuscirebbe a trovare il tempo e la voglia. In quel dibattito ci confrontammo a fondo, e se da una parte fu molto utile a tutti per gli stimoli ricevuti, dall’altra rimanemmo però con una differenza di opinioni su alcune questioni non da poco: ad esempio su come può essere concepito il “great divide” in psicoterapia, su come e quali "cose" si debbano “integrare”, ecc.
Ad esempio Tullio ha proposto quella che lui chiama “dialettica” per collegare, interfacciare o integrare mondi della psicoterapia che lui ritiene divisi per vari motivi (ma che comunque esistono o hanno una sorta “dignità di esistere”), mentre altri (Gianni ed io, ad esempio) sono molto perplessi su questa “dialettica” e hanno l’impressione che vi siano metodi di verifica (non solo empirica, si badi bene, ma anche concettuale, teorica, logica ecc.) per ritenere un “oggetto” del mondo della psicoterapia (qualunque esso sia) più adatto (o superiore, o migliore ecc.) di un altro per determinati scopi (senza cioè che si debba per forza concepire il confronto tra due cose come una dialettica tra le due, come se ciascuna a modo suo avesse una sua legittimità e andasse in un qualche modo tenuta in una sorta di tensione dialettica con l'altra).
Questo era uno dei problemi affrontati, e a mio parere uno dei principali, per lo meno a mio parere. La differenza di opinioni con Tullio può essere utile perché tiene vivo il dibattito e non lo appiattisce (e il merito va indubbiamente a Tullio, così come il merito di pungolarci da anni come efficace coordinatore della SEPI-Italia), però è anche molto frustrante quando non si riesce mai ad andare d’accordo, e forse anche a capirci fino in fondo. Ma devo dire che Tullio è coerente, se, come mi sembra di capire, concepisce anche le nostre differenze di opinioni come poli di una dialettica, infatti continua indefesso a tentare di mediare e interloquire con noi, testimoniando il suo approccio nell'hic et nunc, per così dire. Però ritengo che questo suo tentativo sia anche la dimostrazione del suo fallimento, infatti Gianni si tira indietro, cioè non vuole starci a questi discorsi (non vuole affatto essere “integrato” da Tullio), e anch'io continuo a non essere convinto della posizione di Tullio. E’ per questo che sento anch’io, come Gianni, l’esigenza di stare un po’ a guardare altri colleghi che eventualmente vogliono battersi nell’arena, infatti da tempo dicevo a Tullio che era meglio allargare il dibattito ad altri, sentire voci nuove (e il Congresso di Firenze può servire anche a questo). Per quanto mi riguarda, mi riservo di dire qualcosa qua e là, se mi viene di dirla, senza farmi coinvolgere di petto nel dibattito come in passato. Spero che possiate capirmi.
Mi farà piacere comunque incontrarci (e perché no, anche “scontrarci”) tutti a Firenze, scambiarci opinioni, sempre nell'amicizia e nel rispetto reciproco di colleghi appassionati al tema della pluralità delle teorie della psicoterapia.
Tullio Carere, 18 Gennaio 2006
Ringrazio coloro che sono intervenuti fino a questo momento in un confronto che mi sembra molto promettente, a patto che si riesca a mantenerlo nei limiti di un dibattito animato ma reciprocamente rispettoso (l¹infiammabilità, sappiamo per esperienza, è il massimo pericolo di questi dibattiti). Intervengo a mia volta solo per commentare un passaggio di Paolo Migone che mi riguarda direttamente.
> Ma devo dire che Tullio è coerente, se, come mi sembra di capire, concepisce
> anche le nostre differenze di opinioni come poli di una dialettica, infatti
> continua indefesso a tentare di mediare e interloquire con noi, testimoniando
> il suo approccio nell'hic et nunc, per così dire. Però ritengo che questo suo
> tentativo sia anche la dimostrazione del suo fallimento, infatti Gianni si
> tira indietro, cioè non vuole starci a questi discorsi (non vuole affatto
> essere "integrato" da Tullio), e anch'io continuo a non essere convinto della
> posizione di Tullio.
Intervengo per dire che Gianni avrebbe perfettamente ragione di non voler essere "integrato" da me, se mai io volessi integrarlo. In realtà io ammetto senza difficoltà che le posizioni che stanno ai due lati del "great divide" - integranti (scientifici) e differenzianti (umanisti o post-moderni), come li definisce Gianni - possano essere considerate incompatibili e incommensurabili, e lo siano sicuramente se sono radicalizzate (con la precisazione che non considero necessariamente un errore la radicalizzazione). Ho il massimo rispetto per chi vuole stare da una parte, magari con qualche saltuario scambio con l'altra, mi sta bene che sia così e non ho alcun sogno di un mondo in cui tutti si integrino con tutti. Mi adopero e mi batto solo perché pur tra mondi distanti e separati ci sia un minimo di comunicazione, di ricerca di un linguaggio comune per aiutarci a capire meglio e rispettare le differenze. E magari a volte anche a vedere che certe dicotomie, se considerate in una prospettiva più ampia, sono in effetti polarità di insiemi che le comprendono. Ma questo sempre nel massimo rispetto delle differenze e delle scelte di starsene per conto proprio. L'integrazione, per come io la intendo, non ha nulla a che vedere con l'integralismo.
Paul Wachtel, 21 Gennaio 2006
In my own view, the matter is not as dichotomous as it can seem to be in some interpretations of the questions posed. I do not think that our divisions are easily explained in terms of simply whether we are a science or not. I say this in part because I think that the term “science” itself is – or should be – a manifold term, not a singular, prescriptive term. I say it as well because some of the divisions, some of our difficulties in achieving consensus are due to the subject matter of our science being extraordinarily ambiguous and difficult to address in very general ways rather than it being intrinsically inaccessible, . (They also derive, as I shall comment on shortly, from the very strong connection of our particular subject matter with values and identity).
To begin with science: To my mind the essence of the scientific method is to take seriously the very things that we, as psychotherapists, particularly should understand. That it is very easy to deceive ourselves, that our memories are suspect, that it is hard to hold onto very much without recording it systematically, that our very perceptions are subject both to motivated and to unmotivated skews and distortions. The scientific method – no, I am already slipping into a singular when it should be a plural; scientific methods are that quite considerable variety of ways in which we try to minimize or reduce those effects (we can never eliminate them, only reduce them).
The problem is that we almost have a variant of the Heisenberg principle operating – not so much in terms of our role as observers changing what we observe (though that, of course, is also true), but in terms of the tradeoff that is entailed. In quantum physics, the more we know about the position of a particle, the less we know about its velocity and vice versa. The very knowing of one reduces our knowing of the other. In psychology, the tradeoff I have in mind is a little different. It is that the more precisely we know something, the more we can use “traditional” scientific methods, often the less useful or comprehensive or directly applicable is that knowledge.
This is not quite as airtight as it is in quantum physics, which is why I said almost a variant of the Heisenberg principle. Sometimes, very precise experimental studies are about very crucially important things, and the refusal to acknowledge that can be a rationalization for laziness or for continuing to do what one is used to rather than responsibly paying attention to the evidence. But all in all, the tradeoffs are significant. The kinds of phenomena that psychoanalytic therapists and theorists are interested in, for example, the subtle issues of affect, conflict, motive, the concern with the edge of experience, with what is not yet expressible, etc – these are hard to address with traditional experimental studies (though even here it is important to acknowledge that some very important work has been done in this regard).
I do believe that sometimes we parrot the models of physics, say, or of medicine, to the detriment of our discipline. We need to find the kinds of disciplined observations and systematic recording of data that are appropriate to the questions we are asking. At our present level of knowledge, for example, one of the technologies that is most relevant is the by now humble one of video and audiotape recorders. This permits several extremely important things to be added to what Freud, say, was able to see, remember, and check on. First, and very important, it allows others to see the same material (though there are of course differences between seeing a tape and actually being there in the affective field with the patient – no solution is perfect). Second, it permits the therapist him or herself to check on what has been remembered. It is striking how different a sequence can be when one watches it on tape from what one has remembered (and the subtle differences are just as important as the dramatic and obvious ones). Third, sometimes we only see something that has, in essence, been lying there waiting for us to notice, after looking at it many times. In one of my very first published papers, concerned with what is communicated by body language, I described a pattern I did not see until I looked at the tape an enormous number of times. But once I finally noticed it, it “jumped out” at me and became rather obvious.
This is just one example of a “scientific” advance over just reporting what one remembers from one’s sessions, often at the end of the day or even days or years later looking back on the case. I mention the tape recorder precisely because (a) these days it is a rather humble instrument, available to most children let alone adults, and yet it is something that Freud simply could not conceive would be available to psychoanalytic research; (b) it is a method that basically retains the usual focus of the intensive psychotherapist. That is, it simply records the effort to be empathically attuned to the patient’s affect state, etc, rather than diverting that effort. It still requires a good deal of inference and interpretation to maintain certain views, but the argument has a somewhat more solid foundation. (Some people argue that to record a session totally changes the configuration of what is transpiring. I believe that to be a self-serving rationalization for not exposing either one’s clinical skills or one’s ideas to this kind of scrutiny).
More complicated or technologically advanced ways of improving on what we can know just from sessions are, of course, also available, often in the form of some kind of physiological or neurological recording, but consisting of many other methods as well. There, we quickly find ourselves on the slippery slope of tradeoffs I referred to above. But although we may not be able to completely resolve that dilemma, I believe we do a better job of zeroing in on what we need to know by shifting back and forth to some degree from one end of the tradeoff slope to the other. That is, sometimes shifting away from our “intuition” toward considering what a particular experimental finding suggests, even if its ecological validity can be in question; sometimes, shifting away from what the “findings” are that seem to emerge from certain studies because one is paying attention to what one’s affects, interpersonal and empathic connections, etc are telling us. After all, Luborsky has shown that usually the researcher’s own orientation comes out ahead even in carefully conducted studies of therapy that seem “objective.” Giving credence to what the physicist and philosopher Polanyi called the “tacit” dimension or tacit knowledge is an important corrective to ideologically driven scientism.
So again, in my view, the biggest problem is falling into an either-or dichotomy. And, in my view, there is a danger that the seemingly ecumenical “both-and” stance can itself be an unwitting falling into dichotomy because it implies that the two sides being equally considered and valued are two totally different sides.
So, to return to the main set of questions, I do not think “ there exist two quite different practices, one of medical type, based on psychopathological diagnoses and empirically supported therapeutic procedures, the other of humanistic type.” And I say this even though I am a very strong critic of the ideology that “empirical validation” means manuals. In my work with patients, and in my theorizing, I sometimes am going along paying attention to my subjective experience of being with someone when a “finding” occurs to me that alters what I am doing and how I am seeing and experiencing what is going on between us. And in my reading of the research literature, I am attentive to the methodology, and (apropos what I just said) am seriously respectful of the content of the findings, but I am also simultaneously thinking about it in terms of what my experience in life has been of what it is to be a human being, to be in a relationship with another person, etc.
I guess maybe that is why I am a SEPI person. I am not a dichotomist by and large (you could certainly find some places where I am, especially in the realm of politics). I tend to look at both sides not just in terms of theories (psychodynamic, cognitive-behavioral, family systems, experiential, etc.) but also in terms of methodologies and perspectives (empathic immersion, controlled experiments, etc.)
I look forward to exchanging ideas with my Italian colleagues about matters such as this.
Daniela Maggioni, 22 Gennaio 2006
Faccio un po' di fatica a tenere ferme quasi per forza le dicotomie, seppure come polarità utili a far emergere fondamenti e assunti comuni: tra psicoterapia e psicoterapia, tra medicina e psicoterapia, tra pratica medica e pratica umanistica (e quindi tra scienze della natura e scienze dello spirito? tra scienze nomotetiche ed eidetiche, scienze "dure" e scienze "soft", e così via? Ancoraaa???). Non tanto e non solo per assetto mentale personale, quanto perché credo che la filosofia della scienza abbia molto ridotto queste dicotomie e sia pervenuta ad una definizione di scienza molto meno dicotomica e più complessa, e per noi finalmente meno squalificante, nella quale anche i dati ed i fondamenti della pratica psicoterapica hanno poco da arrossire, a certe condizioni, rispetto a quelli "di ogni buona scienza dalla fisica in su". Mi pare, cioè, che dal Medioevo siamo usciti, quanto a "scientificità", a detta di chi "decide" che cosa è scienza e che cosa non lo è.
La questione, mi pare, è oggi prevalentemente un'altra, ed è in casa nostra: è lo scarso interesse delle diverse comunità scientifiche alle quali gli psicoterapeuti appartengono a
1) denunciare i fondamenti delle loro pratiche e dimostrarne il collegamento con le pratiche stesse;
2) fornire dati relativi ai trattamenti, sviluppare ed applicare metodologie di ricerca sul processo e sull'esito (anche studi di caso singolo) e contribuire all'individuazione e verifica dei fattori di efficacia delle singole pratiche e tecniche;
3) condurre costantemente la ricerca sui fondamenti della/e psicoterapie (quale psicopatologia? quale cambiamento? quale modello di sviluppo? ecc.)
4) riflettere e dialogare sul rapporto tra teorie, modelli e "paradigmi", impliciti ed espliciti, e pratica psicoterapica da una parte e formazione dall'altra (ah, che questione, quella delle "scuole", delle scuole riconosciute per l'esercizio della psicoterapia,e degli Istituti "ufficiali", soprattutto ma non solo in Italia!);
5) coltivare e stimolare il dialogo con le scienze della mente, del cervello e dello sviluppo e le ricerche relative, straordinariamente ricche e promettenti anche per i fondamenti del nostro agire terapeutico nelle sue diverse declinazioni e che a noi chiede, nelle sue posizioni più serie, di fornire quesiti, dati osservativi, ipotesi esplicative (ricordo solo gli arcinoti articoli di E. Kandel , al riguardo).
Non sto a citare, per ciascun punto, la ricca letteratura degli ultimi decenni. Forse sono troppo pessimista, in questo senso, perché guardo in casa mia, innanzitutto, cioè nell'area psicoanalitica. Unicuique suum.
Peraltro, mantenere le dicotomie meta-cognitive -per così dire- per favorire l'integrazione delle pratiche non è detto che sia la strada migliore. Anche se forse non lo è nemmeno quella che in qualche modo sto proponendo, che è un po' un tornare indietro a dichiarare e confrontare fondamenti e riferimenti di base...
Credo che non sia possibile essere per l'integrazione o per la dicotomia, ma che la dialettica -di cui anche questo dibattito può essere prova- richieda la chiarezza/separatezza delle posizioni e dei loro fondamenti. Per dirla nei termini con i quali l'instancabile Tullio Carere ci ha proposto di scendere nell'arena, curare un paziente può essere cosa diversa o non dal prendersi cura di un soggetto, a seconda di come si dichiara e si dimostra di concepire e trattare il paziente/soggetto e quindi e comunque di essere psicoterapeuti. Al di là dei termini e dell'area culturale ed ideologica entro la quale, per storia e cultura e affezione, ciascuno di noi si colloca. E senza determinismi e riduzionismi forzati, ma anche senza eclettismi e narcisistici ed anti-scientifici richiami alla propria soggettiva pratica ed esperienza come unico e non esportabile/confrontabile fondamento.
Comunque, per farla breve (ed in parte sono stata preceduta dal chiaro e ricco intervento di Liotti), ritengo fondamentali alcuni compiti per noi e per i figli dei nostri figli:
- confronto serio su che cosa facciamo/insegniamo davvero come psicoterapia per individuare modelli chiari e studiarne o confrontarne l'efficacia alla luce, se non di nostri studi/ricerche, di quanto altri hanno già fatto o stanno facendo (io credo che l'idea di "psicoterapia su misura" sia un paradigma ormai comune, ma anche pericoloso);
- lavoro, interno alle varie "scuole" e comune, per sviluppare adeguate e misurabili e confrontabili teorie cliniche (mi pare siamo abbastanza incerti, ancora, in questo senso);
- esplicitazione di quanto/che cosa condividiamo oggi (ed una mini-ricerca sulle voci bibliografiche citate negli articoli e libri degli autori più rappresentativi dei diversi indirizzi, diciamo negli ultimi 10 anni, darebbe suggestivi spunti) dei contributi dell'Infant research e delle Neuroscienze.
Anch'io credo, come Liotti, che molto di comune ci sia già, ma che più che esserne travolti come dalle nuove inarrestabili migrazioni del terzo millennio noi ne siamo attori e prodotto e non lo dichiariamo, nelle sedi ufficiali, contribuendo ad una confusione che alimenta l'eclettismo o l'individualismo e non certo alla costruzione di un dominio scientificamente e culturalmente solido, per l'opinione pubblica, per il panorama scientifico e per i nostri pazienti.
Per finire -e chiedo scusa anche per la prolissità, poco avvezza come sono ai dibattiti in rete- lancio una proposta: se tutti perseguiamo con metodi diversi il cambiamento con la pratica della psicoterapia, che cosa ci proponiamo di cambiare? struttura, patologia, adattamento, gradi di adattamento, disagio relazionale, difese, pattern comportamentali, rappresentazioni....
Forse si può partire da qui.
Paolo Migone, 22 Gennaio 2006
Daniela Maggioni ha scritto:
>...ritengo fondamentali alcuni compiti:
>-confronto serio su che cosa facciamo/insegniamo davvero come psicoterapia per individuare >modelli chiari e studiarne o confrontarne l'efficacia alla luce, se non di nostri studi/ricerche, di >quanto altri hanno già fatto o stanno facendo (io credo che l'idea di "psicoterapia su misura" sia >un paradigma ormai comune, ma anche pericoloso);
>- lavoro, interno alle varie "scuole" e comune, per sviluppare adeguate e misurabili e >confrontabili teorie cliniche (mi pare siamo abbastanza incerti, ancora, in questo senso);...
Colgo l'occasione di quanto detto da Daniela per ricordare a tutti coloro che ancora non lo sapessero che recentemente è partito un grosso e complesso progetto internazionale di ricerca sull'efficacia della psicoterapia e sui corsi di formazione degli psicoterapeuti, guidato da Robert Elliott e Alberto Zucconi (nello Steering Committee ci sono anche D. Orlinsky, F. Caspar, L. Castonguay, G. Parry e B. Strauss), l'International Project on the Effectiveness of Psychotherapy and Psychotherapy Training (IPEPPT). Si propone di studiare trasversalmente tutti gli approcci, utilizzando sistemi che traducono le diverse scale di valutazione in griglie comuni, e soprattutto si propone di studiare l'efficacia del training delle varie scuole psicoterapeutiche. Questo progetto è aperto a tutti i colleghi psicoterapeuti eventualmente interessati e agli organismi pubblici e privati di formazione e ricerca (scuole di psicoterapia ecc.).
Per informazioni, vedi il website www.ipeppt.net
Tullio Carere, 23 Gennaio 2006
Cara Daniela, colgo l'occasione del tuo prezioso messaggio e di quello di Paul Wachtel, entrambi nettamente anti-dicotomici, per chiarire un punto che forse nelle domande di partenza non era abbastanza chiaro. La dicotomia scientifico-umanistica in psicoterapia prima di essere una cosa rispetto alla quale essere pro o contro è un dato di fatto, icasticamente descritto da B. Carey nell’incipit di un noto articolo del 2004 sul New York Times che cito spesso per ricordare un’evidenza che forse non a tutti appare così evidente:
Good therapists usually work to resolve conflicts, not inflame them. But there is a civil war going on in psychology, and not everyone is in the mood for healing.
On one side are experts who argue that what therapists do in their consulting rooms should be backed by scientific studies proving its worth.
On the other are those who say that the push for this evidence threatens the very things that make psychotherapy work in the first place.
Se riconosciamo questo dato di fatto, il passo successivo consiste nel decidere che farne. Lo si può liquidare come un semplice errore che dimostra l'arretratezza complessiva del nostro campo e l'incapacità di cogliere gli sviluppi più recenti del metodo - o dei metodi, come postmodernamente preferisce dire Paul - della ricerca scientifica, oppure lo si può accettare come il riflesso di una contraddizione non ancora pervenuta a un'articolazione dialettica, restando per il momento ancorata al livello della semplice opposizione. Pur consapevole del fatto che la semplice parola "dialettica" scatena in non pochi amici e colleghi reazioni che vanno dall'irritazione al furore, proverò a dire perché per me la seconda opzione è preferibile. Come lucidamente osserva Paul,
<<The problem is that we almost have a variant of the Heisenberg principle operating – not so much in terms of our role as observers changing what we observe (though that, of course, is also true), but in terms of the tradeoff that is entailed. In quantum physics, the more we know about the position of a particle, the less we know about its velocity and vice versa. The very knowing of one reduces our knowing of the other. In psychology, the tradeoff I have in mind is a little different. It is that the more precisely we know something, the more we can use "traditional" scientific methods, often the less useful or comprehensive or directly applicable is that knowledge.>>
I metodi scientifici "tradizionali" sono quelli applicati dalla gran parte della ricerca empirica in psicoterapia: si definisce una procedura, la si manualizza e la si sottopone a test in uno studio clinico randomizzato, per vedere se funziona in una certa popolazione di pazienti. La pretesa che i risultati di questi studi siano applicati nella pratica clinica, avanzata in modo abbastanza bellicoso dai sostenitori delle EST, Empirically Supported Therapies, è rigettata in modo non meno deciso da coloro (come Levant, presidente dell'APA) che vedono in essa essenzialmente un'aberrazione. Questo è il "dato di fatto". Secondo la mia ipotesi questo dato non è altro che il prodotto del principio di indeterminazione citato da Paul, e che io enuncerei in questi termini: quanto più pretendiamo di conoscere "oggettivamente" i fenomeni che accadono in una relazione psicoterapeutica, tanto più ci sfugge il lato "soggettivo" di questi fenomeni - affetti, significati, valori. Ai due lati del "great divide" stanno rispettivamente coloro che privilegiano l'oggettività (e quindi vorrebbero una psicoterapia simile alla medicina, capace di curare disturbi correttamente diagnosticati con procedure empiricamente supportate) e coloro che privilegiano la soggettività (e hanno scarso interesse per diagnosi e procedure, ma molto per i significati che via via emergono nel corso di un processo).
Sanare questa frattura significa per me recuperare una dialettica del soggetto e dell'oggetto, trasformando quindi la dicotomia in una polarità in cui non si privilegia a priori né un lato nell'altro, ma si cerca di cogliere la globalità di un processo integrando i dati di ordine soggettivo con quelli di ordine oggettivo. In questa prospettiva cambia il modo di intendere la ricerca. Da un lato la ricerca psicoanalitica tradizionale, che privilegia nettamente i dati soggettivi, dall'altro la ricerca empirica in psicoterapia (soprattutto quella di impianto cognitivo-comportamentale sui cui si basano le EST) che privilegia altrettanto nettamente i dati sperimentalmente riproducibli e misurabili, hanno creato una situazione di stallo e di reciproca incompatibilità. Su queste basi il divario è incolmabile e la dicotomia insuperabile - indubbiamente un gran numero di psicoterapeuti, da una parte e dall'altra della barricata, non mostra alcuna intenzione di schiodarsi da queste basi.
Mi sembra che questa sterile contrapposizione possa essere superata partendo da due punti nodali. Il primo è il riconoscimento da parte dei terapeuti della necessità di documentare il loro lavoro non con semplici note cliniche, ma con registrazioni audio o video (come preferisce Paul, con molti altri) o con questionari post-seduta (come preferisco io, con non molti altri). In questo modo l'oggetto di studio è la psicoterapia reale, non un artefatto di laboratorio, e i dati ottenuti sono di tipo documentale, e non sperimentale. Il secondo riguarda il modo di elaborare questi dati. Trattandosi di documenti di processo, l’elaborazione dei dati dovrebbe seguire le linee guida dell'elaborazione di tutti i documenti processuali, siano essi di tipo storico, giuridico o psicologico. I dati processuali o storici poco o nulla si prestano a elaborazioni di tipo matematico-statistico, ma richiedono di essere interpretati. In sostanza, una ricerca in psicoterapia che superi la dicotomia soggetto/oggetto dovrebbe integrare l'interpretazione dei vissuti in seduta (dati soggettivi) con l'interpretazione dei documenti processuali (dati oggettivi). E' quello che nel mio piccolo io faccio nel mio minuscolo gruppo di ricerca, ma è quello che a mio parere ogni singolo terapeuta potrebbe e forse dovrebbe fare, recuperando lo Junktim freudiano: il legame inscindibile fra teoria, pratica e ricerca.
John Norcross, 25 Gennaio 2006
To understand the psychotherapies, one must appreciate both the robust commonalties that unite them and the enduring differences that separate them. To appreciate only the undifferentiated, lowest-common denominator mass is to miss the clear distinctions among component parts. To appreciate only the precise distinctions of the components is to miss the larger gestalt. We should strive to integrate the differentiated parts into the whole at a higher level. Here, we can understand the unity and the complexity of psychotherapy. It is to this level, I believe, that psychotherapy should aspire.
In clinical work, we can combine the power of the common factors and the specificity of the differences. In fact, many of the differences among the psychotherapies are complimentary when working with patients. Disparate treatment content and goals of the psychotherapies, for example, can be prescriptively matched to the clinical needs and treatment preferences of individual patients. Different psychotherapeutic methods have been shown to be differentially effective for patients in different stages of change, for another example. The insight-oriented and motivation-enhancement methods are indicated for patients in precontemplation and contemplation stages, while more cognitive and behavioral methods are indicated for patients in the action stage. And highly directive and paradoxical methods have been shown to be more effective for high-resistance patients, for a third example. Different strokes for different folks.
Finally, I am deeply concerned about the tendency to bifurcate the field of psychotherapy into bipolar camps: insight vs action therapies, objective vs. subjective therapies, or, as implied in the stimulus question, medical model vs. contextual model. It serves neither our discipline nor our clients. The alternative is not to deny real differences; the alternative is to avoid dichotomous experiences and to appreciate both the unity and complexity of psychotherapy, using the real differences to enhance outcome by tailoring psychotherapy to the individual client and the singular situation.
Tullio Carere, 25 Gennaio 2006
Thank you John for sharing with us your deep concern "about the tendency to bifurcate the field of psychotherapy into bipolar camps: insight vs action therapies, objective vs. subjective therapies, or, as implied in the stimulus question, medical model vs. contextual model", and your belief that "it serves neither our discipline nor our clients", coupled with the belief that "the alternative is to avoid dichotomous experiences and to appreciate both the unity and complexity of psychotherapy, using the real differences to enhance outcome by tailoring psychotherapy to the individual client and the singular situation."
I myself am a believer in the unity and complexity of psychotherapy (although I do not believe in the uselessness of the bipolar perspective). Of course you are aware that we live in a world of infidels who don't believe in the unity of psychotherapy. For instance, in psychoanalysis the believers in a common ground are called the "common grounders" and are said to be one of the five or six major psychoanalytic tribes living in a reserve, watched over with suspicion or open hostility by all the other tribes. According to the First Law of Discussions among Psychotherapists, whenever a psychotherapist says that psychotherapy has the X property (e.g., it has robust commonalities), there always is another therapist who says that his or her thing does not have the X property (e.g., there are at most family resemblances). Our field produces dichotomies as other fields produce daisies. But it seems to me that there are many more people allergic to dichotomies than to daisies.
In my view nothing is wrong with dichotomies, mostly. To the contrary, dichotomies are there to correct therapists' and theorists' one-sidedness. Behavior therapy was born to expose psychoanalysis' one-sidedness. Insight vs. action therapies is a useful dichotomy, because it exposes the one-sidedness of both. It is good, but not good enough. The really good thing is when someone transforms the dichotomy into a polarity. That is, when someone understands that insight and action are not two definitively and insuperably different things, but the two terms of a "cyclical dynamics", as Paul called it in his pioneering work. This is how dialectics works: the apparent separateness and one-sidedness of the two terms of a contradiction is transcended (aufgehoben) when the relation connecting the two is seen and implemented. In the same vein, the current dichotomy between practice and research can be transformed into a polarity if the two are no longer seen as two separate things made by different operators with different competences, but as the two sides of an integrated enterprise, as I have tried to sketch in a previous posting.
I stop here, because allergy to dichotomies is nothing, compared to the almost anaphylactic crises unchained by dialectics in some friends and colleagues, and I don't want to stress their immune system.
George Stricker, 25 Gennaio 2006
I'm not sure that John and Tullio really disagree, but whether they do or not, let me indicate where I stand on this. I agree with John that the creation of bipolar camps is not constructive, and often the polarities are given life and exclude the other. However, I agree with Tullio as to the value of a dialectic process, and that begins with opposing views that then can be reconciled for a higher order solution (which, in turn, gives way to further opposition and resultant syntheses, in a continuing process). As for science and practice, my views are in my writing on the Local Clinical Scientist, a formulation that has the clinician acting as a scientist in a laboratory with the patient, maintaining attitudes of skepticism and inquiry, and learning from each encounter. This requires the systematic record keeping that Tullio discussed earlier in order to be effective.
Allan Zuckoff, 25 Gennaio 2006
Dear Tullio,
I’ve enjoyed reading this exchange, and have been glad to see a reemergence of substantive discussion on this listserv. I join the discussion as a psychologist trained in empirical-phenomenological research methods who has spent much of the past decade involved in controlled trials of psychotherapy interventions, and thus as someone who has sympathies for both sides of the dichotomy (or poles of the dialectic, if you prefer).
In one of your posts to Paul, you wrote:
<<I believe that the impasse can be overcome starting from two basic points. The first is the acknowledgment by the therapists of the necessity of documenting their work not just with clinical notes, but also with audio- or video recording (as you prefer) or post-session questionnaires (as I prefer). In this way the object of study is real therapy, not a laboratory artifact, and the data obtained are of a documental, not experimental type.>>
I agree that the object of psychotherapy research should be, as you put it, “real therapy.” I gather, though (based on past listserv posts), that you do not consider time-limited, protocol-guided therapy provided in the context of a research study to fit that description. If I’m correct in this understanding (and I apologize in advance if I have misconstrued you), then this is perplexingly dismissive of the powerful effects such therapies have been repeatedly demonstrated to have (as well as of the “reality” of the therapeutic encounters I have experienced in doing such therapies). It would also deprive us of excellent sources of the data that I think interests both of us the most: live, meaningful interactions between therapist and client.
Relatedly, I am also perplexed by your suggestion of an equivalence between recordings of therapy sessions, and post-session questionnaires. From an empirical perspective, research on training of therapists in motivational interviewing (the area with which I am most familiar) has shown that the gap between what therapists think they are doing, and what recordings show them to have been doing, is rather substantial (especially with regard to expressed empathy). From a psychoanalytic perspective, this should hardly be surprising: no matter how well-analyzed, therapists have their defenses, and their own assessment of what has happened and what they have done in a session should reliably be expected to be distorted in various ways. For access to the rich intersubjectivity of therapeutic process, it seems to me that there can be no substitute for recording of sessions.
I’ve chosen to address two of your specific points, rather than the overarching theoretical and conceptual issues, because I think it’s in such points that the challenges of psychotherapy integration become most clear. If agreement is impossible on points such as this, then it’s hard for me to see how the rifts you have highlighted can be healed. If synthesis can be achieved on such questions, however, perhaps there is more hope.
Hilde Rapp, 26 Gennaio 2006
Tullio observes/ asks:
<<Dealing with integration means to deal with what divides the psychotherapists. Why are psychotherapists so much divided, in comparison to cardiologists or endocrinologists?>>
Hilde replies:
All knowledge, as Bion so astutely observed, requires linking that which is similar and separating that which is dissimilar or different – all thought and all language depends on making distinctions. Psychotherapy has in common with the natural sciences that part of the activities of practitioners of psychological therapies consist in observing the client’s behaviour, noticing regularities or patterns, and finding ways of systematizing these observations through description, where possible measurement, and through searching for regularities and consistencies in the relations between observations – something akin to formulating rules, laws and theories. Psychiatric classification depends on such systematizing work, including certain behaviours, signs or symptoms in the description of clients disordered thoughts, feelings and behaviours and excluding others in order to arrive at a differential diagnosis.
Psychotherapy is dissimilar from the natural sciences and similar to the Geisteswissenschaften ( sciences of the mind – what anglosaxons call Human sciences and the arts), in that it also enquires into subjective and cultural acts of meaning making by exploring with clients through questioning and spontaneous self report , their own efforts after assigning meaning and significance to the content of their consciousness. This activity draws on culturally mediated symbols and metaphors as well as subtle distinctions between affect states such as regret, remorse, repentance, shame or guilt and culturally mediated story grammars or forms of narrative. The negotiation of such intersubjective meaning and perhaps even transpersonal experience can be tapped by methods of measurement as for instance in discourse analysis, both of key words and of non verbal signs, such as hesitation patterns, inflection and so forth. More usually, therapists draw on their own capacity for artistic appreciation and, significantly, for empathic understanding of the client’s communications, whether verbal or nonverbal, whether in the form of reports of dreams and fantasies or of reports of social or natural events, in ways akin to those used by writers, poets, dramatists, film makers and visual artists.
Tullio poses the questions:
<< Maybe because psychotherapy is not a science? Or because, as some maintain, it is not yet a science, but it will become one when psychotherapists will decide to submit to the rules of all good science, from physics upwards, getting out of the medieval darkness like all other branches of medicine? Or rather because psychotherapy is not at all a branch of medicine?>>
Hilde replies:
I largely agree with the points already made eloquently by Paul and by John. Although these questions are common, and although I very much like questions, I do not think that we should be seduced into providing dichotomous answers!. As you will see from my contribution to the conference which also reflects the structure of my forthcoming book, my understanding of integration depends on respecting that human beings have only partial access to what may be known about ourselves and the world. We do not have a coherent theory of everything- and, Wilber not withstanding, in some ways I rather hope we never will. Furthermore, we are prisoners of language when it comes to what can be said about what we know, and therefore we express what we know according to different traditions of enquiry. Paradigms, epistemologies and traditions arise in ways that are the best fit for the purpose of examining, describing, measuring or classifying the phenomena we wish to understand at a given time in history. Each age brings revisions, redecisions and innovations, some clearly advances, others cul de sacs born of fad or fashion – whether often only time can tell which is which.
In my view the task of integration is to establish correspondences or links between the way we describe ( what we hope is) the same phenomenon in one paradigm and how we describe it in another. .
I use four simple distinctions to map the field- each of which connects into a particular tradition of enquiry:
I. Exploring subjective experience
II. Exploring cultural patterns of meaning making
III. Examining and measuring bio-social determinants
IV. Investigating the effects of the social-political- environmental- economic regulation of society
For instance: We may become curious about correspondences between physiological events such as hormone function, brain transmitter activity ( III) and thoughts, feelings, dreams or motivational events etc ( I ). We may want to track such patterns, insofar as we understand them through the life span- how do they change with age and experience (III) ? Whatever we do will be subject to interpretation (I), and our interpretations of any findings are culturally situated (II). Furthermore, they tend to have political implications, in that moneys will be allocated ( or not) to research further, and recommendations will be made via guidelines to regulate access to treatments or resources (IV). Integrative therapists need to negotiate the different ways in which communities of enquiry, meaning, interest or practice use epistemologies and language to share their knowledge and also to mark it off from the discourses of other disciplines with a related but different focus of enquiry. This requires adopting a meta-perspective and , alas, a good deal reading and thinking outside the box without loosing one’s humility in the face of the complexity of what we are trying to understand, and crucially to apply to responsible practice with often vulnerable clients.
Tullio asks:
<<Shall we admit that there exist two quite different practices, one of medical type, based on psychopathological diagnoses and empirically supported therapeutic procedures, the other of humanistic type, in which the meaning of the disorders and of the ways to cure them does not come out of diagnostic and therapeutic manuals, but of therapeutic dialogue and context?>>
Hilde replies;
Yes there are different traditions which are linked to different practices which serve different social functions. Traditionally diagnostically driven psychiatry is designed to observe, diagnose, and then treat socially divergent behaviour. Its aim is to restore the client or patient to a socially adapted/ adaptive state in which his or her behaviour fits within normal parameters. It is a corrective practice and can be and has been on occasion coercive, but it can be and often is simply normalizing, helping the client to reintegrate into the social order and maintaining the necessary emotional stability to function in relation to life’s tasks.
The more humanistic type of practice tends to aim in the opposite direction, namely to help the client to stand back from convention and to choose freely how he or she wants to actualize their potential which may currently be hemmed in by unsuccessful attempts at trying to fit into a conventional social framework. It may help people to break free from unproductive relationships with significant others or to liberate their creativity from humdrum and unfulfilling jobs.
In practice, most good, and most integrative psychotherapist would see a positive value in both these endeavours; to help someone to have the social skills and emotional stability to play their part as a citizen on the one hand, and to have enough resources to make responsible and rewarding decisions on the other: human beings need both, the capacity for forming and maintaining meaningful relationships within the social and cultural framework of their society and to find novel and creative forms of self expression in the face of the challenges of ( post) modernity so that they can carry out tasks which draw on both these capabilities.
Tullio asks:
<<In that case, shall we surrender to the irreducible diversity of the two approaches, acknowledging that treating a patient is incomparable with caring for a subject, or shall we understand them as the two terms of a polarity, inside which every therapist can conveniently locate himself or herself according to temperament and preferences? >>
Hilde replies:
To an extent, as Paul and especially John, have already observed, it is the client’s need which should determine what therapeutic tasks need to be undertaken, and the nature of the task will to a large measure determine the method or approach used by the therapist at a particular point in the evolution of the treatment. To an extent most therapists will be more interested in or more skilled at a particular way of working – more or less scientifically or more or less artistically. If the therapist is self aware and responsible, such preferences will be reflected in the kind of client groups a therapist chooses to work with, which clients he or she refers on to a colleague, more skilled in the empirically validated treatment recommended by any national or international guidelines or protocols insofar as these exist, are relevant or trustworthy. Integrative therapists may be more versatile and able to function competently over a wider range of treatment modalities and approaches than so called ‘pure form therapists’, but this is a matter for scientific research to decide, where therapist orientation is matched with client outcome…
Tullio Carere, 27 Gennaio 2006
Dear Allan,
I am very happy that you make the points below:
<<I agree that the object of psychotherapy research should be, as you put it, “real therapy.” I gather, though (based on past listserv posts), that you do not consider time-limited, protocol-guided therapy provided in the context of a research study to fit that description. If I’m correct in this understanding (and I apologize in advance if I have misconstrued you), then this is perplexingly dismissive of the powerful effects such therapies have been repeatedly demonstrated to have (as well as of the “reality” of the therapeutic encounters I have experienced in doing such therapies). It would also deprive us of excellent sources of the data that I think interests both of us the most: live, meaningful interactions between therapist and client.>>
To begin with, for the First Law of DAP (Discussions among Psychotherapists), your belief in "the powerful effects such therapies have been repeatedly demonstrated to have" can be matched against the belief of others that the effect of time-limited, protocol-guided therapies is almost irrelevant. Consider, for instance, the results of Luborsky et al's 2002 mega-analysis (meta-meta-analysis). Comparing active treatments, these authors found a non significant effect size of .20 based on 17 meta-analyses, which further shrank to .12 when corrected for researcher allegiance (see also Messer 2001, Messer & Wampold 2002). Secondly, most efficacy studies are based on a set of assumptions (namely, that psychological symptoms are highly malleable, discrete, and relatively independent of long-standing personality processes, that the primary focus of treatment can be readily identified, that the elements of efficacious treatment are dissociable and additive, that these techniques can be implemented in a relatively brief span as prescribed in a manual), assumptions that are not theory-neutral - if theory-neutrality ever exists - but theory-specific of the behaviorism of the 1960s and 1970s. Most of these assumptions are empirically testable, and many of them have either never been adequately tested or have been empirically falsified to one degree or another (Westen et al. 2004). You cannot expect that a process-oriented therapist takes such studies in great consideration.
Real therapy, to me, is what really happens in the relationship between a patient and a therapist, not what the therapist believes to happen as a consequence of his/her allegiance to a theory or a protocol. But you are well aware of the difference:
<<Relatedly, I am also perplexed by your suggestion of an equivalence between recordings of therapy sessions, and post-session questionnaires. From an empirical perspective, research on training of therapists in motivational interviewing (the area with which I am most familiar) has shown that the gap between what therapists think they are doing, and what recordings show them to have been doing, is rather substantial (especially with regard to expressed empathy). From a psychoanalytic perspective, this should hardly be surprising: no matter how well-analyzed, therapists have their defenses, and their own assessment of what has happened and what they have done in a session should reliably be expected to be distorted in various ways. For access to the rich intersubjectivity of therapeutic process, it seems to me that there can be no substitute for recording of sessions.>>
Does audio- or video- recording permit us to understand what really happens in a therapy? Yes and no, in my view - more no than yes. Too often have I seen videotapes of therapists proudly showing them in the conviction that everybody should see what they see - namely, the efficacy of their method - whereas what I usually see is different to totally different from what they see (not truer, just different). Tapes don't record meanings, just behaviors whose meaning has to be interpreted - and of course the meanings change according to the theory of the interpreter. If you let go of the idea that a tape as such shows the reality of a session, and accept that all you have is a material that must be interpreted according to a theory that will be extolled by some and rejected by others, your enthusiasm for such material could rather fall off, especially if you consider that its processing is extremely time-consuming.
In this state of affairs, you might consider the convenience of post session questionnaires vs. recordings. For instance, the questionnaire that we have devised in our small research group asks the patients to rate on a 7-point scale the session outcome and 15 items describing typical session experiences, like "I felt understood", or "I have seen alternatives to my usual behavior" on two columns (respectively, "This is what happened in the session", "This is what I expected in the session"). The questionnaire does not yields numbers to sum to other numbers to make statistics (a game you can play, yet of poor relevance), because the ratings are very context-dependent (a short discussion of the questionnaire at the beginning of the next session is mandatory - it takes very little time and generally is very useful). It is a simple and efficacious tool to monitor and document the process, in the perspective of George's Local clinical scientist (to be dialectically balanced with the Local clinical artist). Much more practical and economical than any recording, as far as I know. And, last but not least, it heals the rift between practice and research, in the spirit of Freud's Junktim.
Tyler Carpenter, 28 Gennaio 2006
For me I suspect that I am less interested clinically in what divides psychotherapists. People make distinctions by nature and may argue over their respective validity. I find I'm more interested in integrating what I know of what is known, in the patient and what they present for help with. In this respect I find my self drawing on a lot about humans that present itself in the context and conditions I am faced with. Because my patients are currently typically seriously disturbed sex offenders, this requires an integration of medicine-criminology-religion-developmental psychopathology-culture. I see no distinctions between medicine-meaning-treatment-science, except for the purposes of discussion with others or articulating to myself what seems to be intuitively true and clinically effective, or requires more investigation and thought together with the patient and the context of treaters and security. To me to be therapeutic is simply to say I got the mix right this time with this person. I don't think that I'm idiosyncratic in this approach, for by the canons of our respective professions and the nature of who we work with, I suspect we make the distinctions which our patients present us with for treatment in the settings we choose to work. Or said another way, I think any well trained clinician who undertakes to treat psychotic and character disordered criminals in a correctional context in which the realities of getting a favourable result (and preventing tragic and fatal ones) dictates that we take meaning, context, level of systems, empirical knowledge, and medicine seriously or not work successfully with those folks. Deviations from such an "integration" seem to me to be more about experience. In this light physics, chemistry, brain science, sociology, anthropology, religion, psychology, etc. all have their place and can be articulated in those meaningful moments and periods when we and our patients can breathe "aha" as the elements come together in the therapeutic ebb and flow. When we work this way, severity becomes less severe and more treatable. More like a difficult problem in the process of becoming a less difficult one. If one perseverates and is rigid in ones thinking, the question of the extent to which this stuckness is state or trait, reflective of damage-development-context (or most likely an admixture) drives the moment and the therapeutic response. To split such things into meaning-medicine-technique, except for the purposes of teaching or discussion, is to miss a complete understanding of the entire phenomenon at hand. It's a little like hardening the categories, when in fact that is the problem to be understood and developed and processed in the moment. Why make such a moment projective identification-cognitive distortion-perseveration, when the solution is to standback and address the issue in one of the numerous ways the patient, environment and tools might address?! As to our relationship to doctors, that division seems to be less distinct to me as the practice seems more consumer driven and multi-disciplinary. To me some behavior and cognitive therapy seems more like some types of medicine, but when I reflect further or consult another practitioner or reflect on all that is happening in my consult with my doctor, it seems that he is drawing on a wider understanding of therapeutics where there is much overlap in what he and I think that the problem is.
Zuckoff Allan, 29 Gennaio 2006
Dear Tullio,
It seems to me that, if “integration” means anything when it comes to the methodology of psychotherapy research, it must involve finding some common ground between “process-oriented” and ”outcomes-oriented” perspectives. While I am far from an uncritical proponent of controlled psychotherapy outcomes research, and I believe that questions about what the cumulative evidence shows thus far are of great importance, your dismissal of this entire body of research as “almost irrelevant” does not, I think, bode well for the project of integration.
But let us stay, as you prefer, within the realm of process research. You write:
<<Real therapy, to me, is what really happens in the relationship between a patient and a therapist, not what the therapist believes to happen as a consequence of his/her allegiance to a theory or a protocol.>>
Here we are in complete agreement. Which makes the critical question: how can we best research, and thus understand, “what really happens in the relationship between a patient and a therapist”? Your claim is that recordings of sessions are less valuable for this purpose than I believe, due to the inevitable conflict of interpretations.
<<Tapes don't record meanings, just behaviors whose meaning has to be interpreted - and of course the meanings change according to the theory of the interpreter. If you let go of the idea that a tape as such shows the reality of a session, and accept that all you have is a material that must be interpreted according to a theory that will be extolled by some and rejected by others, your enthusiasm for such material could rather fall off…>>
This, I would argue, is not only wrong, but highly ironic and (if it were true) ultimately destructive of any meaningful research process. The position you articulate would leave us all trapped in the hermeneutic circle—and thus forced in every case to insist that any one construal of meaning is “not truer, just different” from another. The irony comes from the fact that, by claiming that “behaviors” have no inherent meaning, you are echoing a key (and mistaken) element of the behaviorist position you otherwise reject. The destructiveness derives from the fact that, like all post-structural positions, yours fetches up in relativism and the death of truth.
Fortunately, one need not be a positivist to escape this trap. Merleau-Ponty showed us how: phenomena (including behavior) are both autochthonously organized (and thus inherently meaningful) and intrinsically ambiguous (and thus open to multiple interpretations). Varying perspectives may be more or less accurate—but some are truer than others, and it is possible (and, if research is to be something other than an endless circle, necessary) to adjudicate between them.
Thus, the problem of recordings does not lie in either their multivocity or their capturing of only a part of the “reality” of a session—but rather, in finding (one or more) methods that can allow them to speak their truth (which is, of course, not “the whole truth” but one part thereof). The method I have used begins with the phenomenological reduction—impossible to complete, yet vital to undertake. I have no doubt that other methods could be viable, as well.
I believe that the approach I am pointing towards speaks to your own concern about interpretations of therapeutic process being contaminated by the theoretical (and other) biases of those who offer them as demonstrations of their therapy’s power. At the same time, it shares the one virtue of controlled outcomes research that I most admire: it allows for the possibility of falsification of claims of efficacy through public (i.e., intersubjective) evaluation, which is as close as we can come to true objectivity in this realm. Post-session questionnaires, while of some interest, cannot come close either to revealing the richness of therapeutic process, or to putting one’s claims for the power of one’s form of therapy to the test.
Tullio Carere, 29 Gennaio 2006
Dear Allan, you write:
<<It seems to me that, if “integration” means anything when it comes to the methodology of psychotherapy research, it must involve finding some common ground between “process-oriented” and ”outcomes-oriented” perspectives. While I am far from an uncritical proponent of controlled psychotherapy outcomes research, and I believe that questions about what the cumulative evidence shows thus far are of great importance, your dismissal of this entire body of research as “almost irrelevant” does not, I think, bode well for the project of integration.>>
I strongly endorse a dialectic between "process-oriented" and "procedure-oriented" perspectives (though I don't share your enthusiasm for most efficacy studies so far). I do not dismiss an "entire body of research as 'almost irrelevant'", but others do. Some are enthusiastic of that sort of research, others dismiss it (both on the base of robust empirical data: First Law of DaP). Empirical research is necessary, and just because it is necessary it must be criticized (as Westen does) for the way it has been done so far, with so many unjustified and unwarranted assumptions and biases. Above all, I agree with Westen that empirical research should return to real therapy as a natural laboratory in the first place, in order to draw from the observation of real processes the hypotheses to put to test (as opposite to the "Popperian" trend in empirical research, which only emphasizes hypotheses testing), with a much more balanced mix of observation and experiment. I personally believe that empirical research in psychotherapy should be much more of the correlational, and much less of the experimental type.
<<… the critical question: how can we best research, and thus understand, “what really happens in the relationship between a patient and a therapist”? Your claim is that recordings of sessions are less valuable for this purpose than I believe, due to the inevitable conflict of interpretations… This, I would argue, is not only wrong, but highly ironic and (if it were true) ultimately destructive of any meaningful research process. The position you articulate would leave us all trapped in the hermeneutic circle—and thus forced in every case to insist that any one construal of meaning is “not truer, just different” from another. The irony comes from the fact that, by claiming that “behaviors” have no inherent meaning, you are echoing a key (and mistaken) element of the behaviorist position you otherwise reject. The destructiveness derives from the fact that, like all post-structural positions, yours fetches up in relativism and the death of truth. Fortunately, one need not be a positivist to escape this trap. Merleau-Ponty showed us how: phenomena (including behavior) are both autochthonously organized (and thus inherently meaningful) and intrinsically ambiguous (and thus open to multiple interpretations). Varying perspectives may be more or less accurate—but some are truer than others, and it is possible (and, if research is to be something other than an endless circle, necessary) to adjudicate between them. Thus, the problem of recordings does not lie in either their multivocity or their capturing of only a part of the “reality” of a session—but rather, in finding (one or more) methods that can allow them to speak their truth (which is, of course, not “the whole truth” but one part thereof). The method I have used begins with the phenomenological reduction—impossible to complete, yet vital to undertake. I have no doubt that other methods could be viable, as well. >>
I surely am an adversary of scientism, i.e. the belief that science is the ultimate key to crack open the mysteries of life and existence. All scientific enterprise is based on some indemonstrable belief or subjective choice (even mathematic, as Goedel saw and showed). The death of truth is rather a consequence of the hubris that claims that truth can be objectively known. All objective knowledge is the result of some epistemological choices of the subject (which the subject is usually not aware of). This awareness, though, does not make of me a post-modernist relativist. On one hand, this makes me try to recoup the dialectic of the subject and the object wherever it gets lost (in positive sciences it usually does) - which means that I always try to uncover the hidden presuppositions, choices and beliefs behind any "objective" knowledge. On the other, I don't believe that we are fatally trapped inside our subjective points of view - or hopelessly conditioned by the conditions of our lives. To the contrary, the liberation of the subject from whatever traps or conditions his or her existence is to me the very goal of any psychotherapeutic effort, from the shamans on. Bion's formula "freedom from memory and desire" epitomizes well this basic thrust, and the phenomenological reduction is an important aspect of this freedom - at least its first step. I am glad to read that your method "begins" with it. You must be aware, though, that it is not enough to begin with it. To become aware of all one's presuppositions, judgments and expectations, and to suspend them continuously, is a very hard discipline, and I would not say that it is the bread and butter of most of those who devote themselves to empirical research - who therefore quite often remain stuck with their unsuspended and uncriticized presuppositions. But maybe we could agree on this point: science has a good chance of not corrupting into scientism to the extent that the scientist practices a good enough epoché from the start to the end of his or her work.
<<I believe that the approach I am pointing towards speaks to your own concern about interpretations of therapeutic process being contaminated by the theoretical (and other) biases of those who offer them as demonstrations of their therapy’s power. At the same time, it shares the one virtue of controlled outcomes research that I most admire: it allows for the possibility of falsification of claims of efficacy through public (i.e., intersubjective) evaluation, which is as close as we can come to true objectivity in this realm. Post-session questionnaires, while of some interest, cannot come close either to revealing the richness of therapeutic process, or to putting one’s claims for the power of one’s form of therapy to the test.>>
I don't admire most controlled outcome research for the too many unwarranted assumptions on which it is based. But I do believe that empirical (above all correlational) research can be done in a much more critical and useful way. For instance I admire the work of Stern's group (the Boston Change Process Study Group) on audiotaped transcripts, in which they illustrate how much " sloppiness" (fuzzy intentionalizing, unpredictability, improvisation, variation, and redundancy) generates unpredictable and potentially creative elements that contribute to psychotherapeutic change. I think the Dodo bird would appreciate that his (her?) verdict receives one more empirical support. Post-session questionnaires might be less useful for such purposes, but I value them a lot as precious tools for monitoring and documenting the process at disposal of the local scientist. There is a great deal of unpredictability in the psychotherapeutic process, and I believe it is an "inherent property of intersubjective systems" (as the BCPSG puts it) in spite of those who believe in manualized treatments. If this is the case, let the therapy go its own way, but let us produce objective material (questionnaires are literally objects that can be intersubjectively examined, like audiotaped transcripts) to document the process.
Tullio Carere, 2 Febbraio 2006
Thank you dear Hilde for your rich response, which reflects your vision of psychotherapy as art and science - which is also my vision. Medicine too is art and science, but psychotherapy is such in a very special way, given its kinship with natural sciences on one side and human sciences on the other. Our field has not yet been able to find a viable integration between these two sides. You acknowledge that there are "different traditions which are linked to different practices", one "diagnostically driven", and the other of "more humanistic type". But the difference you underscore is between two opposite thrusts, one adaptive/normalizing, and the other actualizing/self-realizing. If this were the point, your observation that "most good, and most integrative psychotherapist would see a positive value in both these endeavors" would solve the problem, and the integration between the two traditions would already have been happily realized. In my view this unfortunately is not the case.
As a matter of fact, there is a big rift between the two sub-fields. Here is how I describe the relevant difference: Those "diagnostically driven", as you fittingly name them, apply the simple principle of diagnosing a disorder, a problem, a need, or a phase, and prescribing the (empirically supported) procedures to fix the disorder or the problem, or to meet the need or the phase. This frame of mind is commonly called "medical model", because it corresponds to the medical treatment as it is conceptualized in our time. On the other side, the adherents to the adversarial perspective, often called "contextual model", maintain "that psychotherapy is incompatible with the medical model and that conceptualizing psychotherapy in this way distorts the nature of this effort" (Wampold, 2001). They propose as an alternative a holistic/contextual approach, in which common factors are emphasized to the detriment of procedures (which are reduced to mere placebo). Both sides support their views with enormous amounts of empirical research; both sides maintain that the approach of their side is the one that best meets the needs of the clients; and both sides dismiss the other as simply wrong if not harmful. As Westen put it, "the intensity of the acrimony, the distaste, has never been so high."
If we want to come to terms with this split, we might start with a few things. To begin with, we should not deny its existence. A way both sides have to dismiss the other is to simply deny their existence as a partner of a dialogue or a negotiation. If the other does not exist, why should we waste our time with dichotomies or polarities? It is pointless. Secondly, we should get rid of the myth of scientific neutrality. If X and the opposite of X are both empirically supported, we cannot ask empirical research to solve the problem (I am not saying that empirical research is useless, but only that it cannot solve this problem). Thirdly, it is clear that no reconciliation is possible between the medical and the contextual model. But do we really need them? They are both abstractions far from everyday practice. In the "common sense" model every therapist makes use of some procedures which they deem useful - therefore they are not contextualist. But nobody applies them in a protocol mode: they use heuristic, rule-of-thumb procedures, and adapts them to the present circumstances - and every patient responds to their therapist's procedures according to the way they understand them and the way they need them. Everything happens out of a great deal of improvisation and "sloppyness". Therapy works when there is a good enough working alliance, which is not the result of protocols, but of ongoing negotiations. In the common sense perspective there is room for both procedures and context: at this level integration is possible, whereas what we get from the protocol-driven and the contextual perspective is the split of the field.
In the common sense perspective it is not so important to separate the procedures from the context. What is crucial instead is to correlate process and outcome, i.e. to understand what transpires in the clinical (not the experimental) setting that explains the progress, or the lack of progress. It seems to me that empirical research is much more useful when it tries to illuminate this matter, than when it claims to prove or disprove the efficacy of procedures independently of the context. This is my response to my own questions.
Hilde Rapp, 6 Febbraio 2006
Tullio wrote:
<<You acknowledge that there are "different traditions which are linked to different practices", one "diagnostically driven", and the other of "more humanistic type". But the difference you underscore is between two opposite thrusts, one adaptive/normalizing, and the other actualizing/self-realizing. If this were the point, your observation that "most good, and most integrative psychotherapist would see a positive value in both these endeavors" would solve the problem, and the integration between the two traditions would already have been happily realized. In my view this unfortunately is not the case.
As a matter of fact, there is a big rift between the two sub-fields. Here is how I describe the relevant difference: Those "diagnostically driven", as you fittingly name them, apply the simple principle of diagnosing a disorder, a problem, a need, or a phase, and prescribing the (empirically supported) procedures to fix the disorder or the problem, or to meet the need or the phase. This frame of mind is commonly called "medical model", because it corresponds to the medical treatment as it is conceptualized in our time. On the other side, the adherents to the adversarial perspective, often called "contextual model", maintain "that psychotherapy is incompatible with the medical model and that conceptualizing psychotherapy in this way distorts the nature of this effort" (Wampold, 2001). They propose as an alternative a holistic/contextual approach, in which common factors are emphasized to the detriment of procedures (which are reduced to mere placebo). Both sides support their views with enormous amounts of empirical research; both sides maintain that the approach of their side is the one that best meets the needs of the clients; and both sides dismiss the other as simply wrong if not harmful. As Westen put it, "the intensity of the acrimony, the distaste, has never been so high.">>
I entirely agree with you, Tullio, that the field at this present moment is divided and that debates are acrimonious. However, I would want to argue that it is precisely because of this situation that integrative psychotherapy- where the emphasis is on the syllable –ative- ie an ongoing process- is necessary, and that this was, indeed, the stimulus for the origination of the ‘movement’ for exploring the integration of psychotherapies. We have had four recognized waves, the last being accommodative- assimilative integration.
I am, however not describing the status quo, but rather I am actively and passionately pleading for a fifth wave- as I believe are you- which advocates for meta- integration. Meta- integration can accommodate the historically existing differences because increasingly integrative therapists set store by and are skilled in ‘negative capability’- i.e. the capacity to tolerate paradox, uncertainty, contingencies and ambiguity as inevitable properties of complex living systems.
With this comes the recognition that any integrative ‘solutions’ will be local and specific and are likely to relate to single lines of conflict. There are echoes here of Bion’s dream that there could be a grid that would allow us to specify a problem quite precisely- that we might be able to formulate a coherent question by means of which to interrogate reality. But there is also the recognition that in fact we really proceed in a much more random fashion, making use of unexpected windows of opportunity, leaps of the imagination, the availability of new descriptive and analytic tools as information technology improves, victims of the vagaries of intellectual fashion and the vicissitudes of everyday life as it presents populations with new anxieties, new challenges and both news defenses (beliefs in panaceas, distractions etc) and new solutions, real or imagined.
The new skill is not so much the capacity to deliver sweeping answers which unify a universe of discourse- this would be my ‘quarrel’ with Ken Wilber’s ‘integral psychology’ as an attempt at a new ‘theory of everything’. The new skill would be to have a methodology for transforming conflicts between assertions and positions by focusing on common needs and goals- perhaps also common factors- but more strongly on common functions: What is the function of the client’s defenses or resistances? How do they aim to meet the client’s needs- and which ones? - and what are their priorities in terms of the client’s assumptive world and value system? Is it bread or honor? as it were. Echoes of Maslow would figure here and the contemporary expansion of his model into a more differentiated hierarchy of needs in Spiral Dynamics. It is an enterprise that is both modest and bold.
Tullio wrote:
<<If we want to come to terms with this split, we might start with a few things. To begin with, we should not deny its existence>>.
Agreed. We need to bear the pain of its existence and accept splitting and polarization as a part of the human condition and hence also the professional landscape, and we need to endeavor to understand the psychological pressures which maintain these splits and conflicts.
Tullio wrote:
<< A way both sides have to dismiss the other is to simply deny their existence as a partner of a dialogue or a negotiation. If the other does not exist, why should we waste our time with dichotomies or polarities? It is pointless. Secondly, we should get rid of the myth of scientific neutrality. If X and the opposite of X are both empirically supported, we cannot ask empirical research to solve the problem (I am not saying that empirical research is useless, but only that it cannot solve this problem). Thirdly, it is clear that no reconciliation is possible between the medical and the contextual model. But do we really need them? They are both abstractions far from everyday practice>>.
I am reading this as description of the arguments advanced in the split field rather than as statements of your position- I am right in this? As you can see from the previous response, I entirely agree that the problem arises and is maintained by the fact that both positions are ‘abstractions from practice’.
Tullio wrote:
<<In the "common sense" model every therapist makes use of some procedures which they deem useful - therefore they are not contextualist. But nobody applies them in a protocol mode: they use heuristic, rule-of-thumb procedures, and adapts them to the present circumstances - and every patient responds to their therapist's procedures according to the way they understand them and the way they need them. Everything happens out of a great deal of improvisation and "sloppyness". Therapy works when there is a good enough working alliance, which is not the result of protocols, but of ongoing negotiations. In the common sense perspective there is room for both procedures and context: at this level integration is possible>>
Hhmm… Yes I agree that at the pragmatic level, as confirmed by Lisa Najavits’ research, senior and/or successful practitioners tend to be responsive to clients needs and hence use whatever heuristic approach moves the client on with respect to insight and desired change. Experienced therapists from widely different orientations are therefore more similar to each other with respect to their practice and their ‘theory in use’, what ever their ‘espoused theory’, than they are, by and large, to their more junior colleagues from the same theoretical orientation. It seems much more important to ask in the first instance: what do you do? What does your praxis look like? What are you aiming to achieve, what are your goals? And only then to ask for theory informed explanations of these praxis choices…
Tullio wrote:
<< whereas what we get from the protocol-driven and the contextual perspective is the split of the field>>
I raise this in my chapter about research- the protocol driven perspective tends to have its home in the research community, in that it is – for many- a favored vehicle for formulating and testing researchable questions in a reliable and consistent way. We need ask population focused questions: Does this approach work at all and if so how does it compare to its competitors? Does this intervention really work? For whom does it work? Does the change last? Obviously, unless there is as much standardization as possible there is no possibility to compare what therapist A does with client A to what therapist B does with client B. I don’t believe there is a serious expectation that therapy in natural environments should be carried out in such formalized ways.
Once there is evidence that a particular protocol does seem to deliver the desired clinical change reliably, it would seem foolish, in a cash strapped service, not to offer such treatments. The issue then becomes what to do with clients or types of clients who do not seem to respond to generally effective approaches designed to target the kinds of problems these clients bring. Most researchers and clinicians are modest enough to recognize that such clients exist and that other forms alternative help may be needed. Even though advocates for a particular approach may not see it as part of their brief to find out what needs to be done, the extraordinary changes in which cognitive behavior therapy is now conceptualized and delivered, including both relationship and mindfulness focused approaches, testifies to the openness of researchers and practitioners to exploring new ways of working in order to reach clients” that other beers don’t reach”.
Once there is evidence that something does work in principle, we want to ask process questions concerning how (perhaps even why?) it might do so. Within ‘hard science’ approaches this is done through experimental methods, which focus on observable and measurable variables.
So called ‘contextual’ approaches do not (or should I say should not?) Make any claims that the ‘soft’ science variables, which underlie their practice, are (with some exceptions) researchable by certain ‘hard science’ means and they should not be expected to produce equivalent outcomes. This is not to say that they should be exempt from the public health related question as to whether their approach is capable of producing reliable clinical change, i.e. works in principle and works for particular populations, and whether it works as well as its competitors, or whether it has a competitive advantage in relation to specific populations, and should therefore be publicly funded.
Historically, contextual approaches have struggling with descriptive case histories and analytical formulations which address how or why certain kinds of therapist behaviors might successfully address certain kind of client behaviors, such as defenses, thought /feeling/behavior patterns (schemas) and how unconscious pressures and relationships might play a role in both. They have largely done so anecdotally, but in a way, which is recognized as a sizable body of expert clinical opinion capable of guiding practice. There are good reasons for these differences in epistemology and methodology, which I will come back to below.
Tullio wrote:
<<In the common sense perspective it is not so important to separate the procedures from the context. What is crucial instead is to correlate process and outcome, i.e. to understand what transpires in the clinical (not the experimental) setting that explains the progress, or the lack of progress. It seems to me that empirical research is much more useful when it tries to illuminate this matter, than when it claims to prove or disprove the efficacy of procedures independently of the context. This is my response to my own questions>>.
I suppose the ‘common sense’ perspective is actually still an ‘uncommon sense’ perspective. I agree, see above, that it is a ‘both-and’ scenario, where the real challenge for my proposed meta-integrative approach is one of humility and cooperation in the face of the complexity of the human condition and the marvelous achievements of the moral imagination we are capable of on a good day and the awesome depths of depravity we seem to be able to sink to on a fearsome day. We need people who will examine the outer landscape of how human beings negotiate their conflicting needs through social contracts of one sort or another, and for this behavior focused ‘ normalizing’ approaches are extremely useful.
We equally need people who plumb the inner landscape of how we attribute meaning to our passions, dreams and fears. The kinds of measurement that are fit for calibrating a psychic plumb line that reaches into the depths of meaning making are not the same as those fit for regulating socially adaptive behavior by means of guidelines that map our social skills.
However, social skills without the attribution of meaning are empty, mechanical and soulless, and efforts after meaning without the social skills to share them with others, leave people isolated, without role or relationships on the margins of the social world.
Only by each bringing to the table the best we can offer by way of tools for enquiry, ways of reaching out to lonely, frightened, lost, confused and deeply troubled fellow human beings, and ways of satisfying our social institutions that taxpayers money is invested ethically and effectively, can we move forward: in other words only by integrating the fragments of what we know and know how to do well, can we serve humanity as psychotherapists and mental health professionals…
This means loosing our fear both of healthy competition and of accountable co-operation…
Ken Benau, 7 Febbraio 2006
Hilde wrote:
<<However, social skills without the attribution of meaning are empty, mechanical and soulless, and efforts after meaning without the social skills to share them with others, leave people isolated, without role or relationships on the margins of the social world>>.
I simply want to say, bravo! Having worked with many developmentally challenged children and adults who have deficits in social skills, but usually lack an appreciation for the reason, i.e. one that gives them meaning/purpose, to apply said taught skills in the first place. The "depth" folks and the "behavioral skills" folks have much to teach each other, if we can only listen.
As a serendipitous aside: an Asperger adult client of mine recently ended a session telling me why he believes there is a link (in Asperger's/high functioning Autism) between deficits in mirror neuron functioning and executive functions... I don't know his theory yet, but he's obviously been doing his reading and I am very curious... So I should add, if we can listen to our clients, too.
Hilde Rapp, 7 Febbraio 2006
Dear Ken,
Thank you for your feedback. I also have some experience of working with people suffering from neurological or developmental deficits and learning difficulties. I am struck by the level of insight some people do have into their difficulties and how imaginatively they talk about them by making use of metaphors where they lack access to – or the capacity to understand- relevant scientific research. We can often help by amplifying their ‘naïve theory’ with research, where we ourselves know any. This seems to help clients make sense of their difficulty better. It helps them to normalize and accept it and it encourages them to co-develop and practice relevant coping mechanisms with the therapist.
From a practical perspective even a ‘superstitional’ pseudo theory can function like this because any explanation that makes subjective sense to the client will lessen anxiety and hence lower the threshold for responding to therapeutic help…
I tend to translate into appropriate language that a client can understand something to the effect of “ Given what is going on in your brain/ nervous system/endocrine system…etc it is to be expected that you should have this difficulty. It is a normal consequence of your impairment. Let us look in detail at how this makes your life difficult and let us work out together what you might do to make it easier to function despite your impairment…
This can be learning to breathe, speak in a particular rhythm to overcome dysarthria and speech problems which seriously get in the way of communication. Or it can mean helping a client learn to understand the anxiety reducing effect of gaze avoidance in intimate situations ( Michael Argyle studied this in Oxford in the seventies), and to help a client to use gaze avoidance with awareness by learning to say to an interlocutor: I am sorry I have difficulty looking you in the eye while I talk to you because it makes me loose my thread…. And so forth…
All this develops out of the therapist’s deep respect for the client’s wish and need to make meaning of their difficulties through listening ‘deeply’ as Rogers once put it. Our task is to accept, amplify, clarify, and transform what the client knows about themselves and then to add, as necessary, new skills and understanding which enrich the client’s repertoire.
It helps enormously if we understand enough about normal and abnormal human development and physiology and the effect of adverse events and environments on both. To know something about 1) normal responses to abnormal circumstances or 2) normal sequelae of abnormal development, or conversely, 3) abnormal (neurotic or psychotic) responses to normal environments, and of course, 4) developmentally normal responses to normal situations is very helpful. It empowers the therapist to convey to clients that their experience is understandable and expected in the light of research. This provides a sound basis for helping people to drop developmentally superseded defenses and to develop more age appropriate ones, to overcome abnormal defenses to’ objectively’ non threatening stimuli, and or to explore ways of using the plasticity of the brain to bypass a current loss or distortion of function.
Here it is the ‘contextualists’, especially within psychoanalysis and constructivism have rekindled the passionate interest Freud had in understanding the links between the physiological ( phi) and the psychic ( psy) as he explored this and theorized this in his project for a scientific psychology by participating in neuroscientific research. In addition, especially analysts, have been revisiting and working collaboratively with academic experimental cognitive and social developmental psychology, while cognitive behavior therapists have from the outset been grounded in academic research that focuses on the connections between beliefs, attitudes, emotions and behavior. The difference seems to be largely one of language, what is impulsivity in one quarter becomes lack of mentalisation in an other and what might be time out and thought stopping in one tradition might become reflective functioning in another…
It is all out there for the taking if we are not too frightened to leave our silos…